Highly Structured Therapies Prove Their Efficacy in BPD

Any structured, symptom-focused treatment for borderline personality disorder is likely to be better than the unstructured care patients typically get in the community.

That would appear to be the message from two randomized studies comparing psychotherapies specifically designed for treatment of borderline personality disorder (BPD)—dialectical-behavior therapy (DBT) and mentalization-based treatment (MBT)—with other therapies.

The two studies appeared in the December 2009 American Journal of Psychiatry.

Both studies confirm the efficacy of the specialized psychotherapies. The findings are noteworthy because while both MBT and DBT have been shown in previous studies to be superior to “treatment as usual” in the community—which may be unstructured and fragmented—they had not been tested against more-focused treatments.

In recent years a number of studies have shown that several forms of psychotherapy—including MBT and DBT—that focus intensely on the specific symptoms of BPD are effective and superior to the usual care patients receive in the community.

DBT is a manualized psychotherapy developed for BPD by Marcia Linehan, Ph.D, that combines learning theory, Eastern philosophy, a dialectic form of therapy focusing on the pervasive emotional dysregulation that patients with BPD experience, and the development of more-effective coping strategies.

In the recent DBT-related study, 180 patients diagnosed with BPD who had at least two suicidal or nonsuicidal self-injurious episodes in the previous five years were randomly assigned to receive one year of DBT or general psychiatric management. The latter was based on the APA Practice Guideline for the Treatment of Patients With Borderline Personality Disorder and consisted of case management, dynamically informed psychotherapy, and symptom-targeted medication management.

Pharmacotherapy was based on the symptom-targeted approach as presented in the APA guideline.

The primary outcome measures, assessed at baseline and every four months over the treatment period, were frequency and severity of suicidal and nonsuicidal self-harm episodes.

Both groups showed improvement on the majority of clinical outcome measures after one year of treatment, including significant reductions in the frequency and severity of suicidal and nonsuicidal self-injurious episodes and significant improvements in most secondary clinical outcomes. Both groups had a reduction in general health care utilization, including emergency visits and psychiatric hospital days, as well as significant improvements in BPD symptoms, symptom distress, depression, anger, and interpersonal functioning.

No significant differences across any outcomes were found between groups.

“This study provides further evidence that borderline personality disorder significantly benefits from specific well-defined psychotherapeutic approaches,” Shelley McMain, Ph.D., of the Centre for Addiction and Mental Health in Toronto and the University of Toronto Department of Psychiatry, told Psychiatric News. “Based on previous research supporting the superiority of DBT, we predicted that patients treated with DBT would achieve better outcomes than patients receiving general psychiatric management.

“Our findings indicate that DBT and a specialized general psychiatric management approach involving psychodynamic therapy and symptom-targeted pharmacotherapy were associated with positive treatment outcomes,” McMain said. “Clinicians who are trained in an approach based on a sound theory and principles of effective psychotherapies for BPD can expect to achieve better treatment outcomes than those utilizing nonspecific generic approaches.”

In a second report in the same issue of the journal, Andrew Bateman, M.D., and Peter Fonagy, Ph.D., of St. Ann's Hospital, London, compared an 18-month MBT treatment with a structured clinical management (SCM) approach.

MBT is a manualized psychodynamic therapy rooted in attachment and cognitive theory. It aims to improve patients' capacity to understand their own and others' mental states in order to address their difficulties with affect, impulse regulation, and interpersonal functioning. For the purposes of the study, it consisted of 18 months of combined individual and group psychotherapy provided by two therapists.

The outpatient SCM protocol was based on best generic practice for BPD within psychiatric services settings in the United Kingdom. (These are based on criteria from that country's National Institute on Clinical Excellence.)

Regular individual and group sessions were offered with appointments every three months for psychiatric review; therapy was based on a counseling model closest to a supportive approach, with case management, advocacy support, and problem-oriented psychotherapeutic interventions.

In the study, 134 patients consecutively referred to a specialized personality disorder treatment center were randomly allocated to MBT or SCM. The primary outcome was the occurrence of crisis events, a composite of suicidal and severe self-injurious behaviors and hospitalization. Secondary outcomes included social and interpersonal functioning and self-reported symptoms.

Bateman and Fonagy found substantial improvements after both treatments across all outcome variables. However, patients randomly assigned to MBT showed a steeper decline of both self-reported and clinically significant problems, including suicide attempts and hospitalization.

Six-month periods free of suicidal behaviors, severe self-injurious behaviors, and hospitalization frequency improved from 0 percent to 43 percent in the SCM group and from 0 percent to 73 percent in the MBT group

“Both conditions were associated with substantially reduced suicidality, self-harm, and hospitalization, and improvement on measures of symptoms and social and interpersonal functioning by the end of treatment,” Bateman and Fonagy noted. “The rate of improvement in both groups was higher than spontaneous remission of symptoms of borderline personality disorder.”

However, they pointed out that MBT was superior to outpatient SCM in terms of effects on suicide attempts, severe incidents of self-harm, and on self-reported measures, suggesting that “psychotherapy focusing on psychological functions relevant to symptoms of borderline personality disorder … can enhance a structured, integrated treatment program providing generic psychological support.”

Joel Paris, M.D., a professor of psychiatry at McGill University and an expert on BPD who reviewed the articles, said the study of DBT shows that while it may be superior to treatment as usual, and somewhat superior to treatment by community experts, it is no better when compared to another well-structured program.

Paris said the relative superiority of MBT may be due to the fact that the comparator treatment used in that study is more akin to treatment as usual than the general psychiatric management used in comparison to DBT.

He said the take-home message from both studies is that “any well structrured psychotherapy for BPD is better than the usual unstructured approach that these patients get.” He will be publishing commentary on both studies in an upcoming issue of Current Psychiatry Reports.

“A Randomized Trial of Dialectical Behavior Therapy Versus General Psychiatric Management for Borderline Personality Disorder” is posted at <http://ajp.psychiatryonline.org/cgi/content/full/166/12/1365>. “A Randomized Controlled Trial of Outpatient Mentalization-Based Treatment Versus Structured Clinical Management for Borderline Personality Disorder” is posted at <http://ajp.psychiatryonline.org/cgi/content/full/166/12/1355>.