Psychotherapies Combat Prominent BPD Symptoms

Three structured forms of psychotherapy appear to be successful in patients with borderline personality disorder (BPD).

A randomized, controlled trial found transference-focused psychotherapy, dialectical behavior therapy (DBT), and supportive therapy were all associated with change in several measures of outcome. Transference-focused therapy was most successful, with significant improvement reported in multiple areas across six different measures of outcome.

A report on the trial appeared in the June American Journal of Psychiatry.

The study is the latest in a string of reports appearing in the psychiatric literature in the last two to three years validating the efficacy of psychotherapy in treating BPD.

Several forms of psychot herapy— including DBT, cognitive-behavioral therapy (CBT), transference-focused therapy, and mentalization-based therapy—have been found effective for BPD and have been or are being replicated (Psychiatric News, January 19).

In the new study, 90 patients who were diagnosed with BPD were randomly assigned to transference-focused psychotherapy, DBT, or supportive treatment and received medication when indicated. Prior to treatment and at four-month intervals during a one-year period, blind raters assessed six domains of outcome— suicidal behavior, aggression, impulsivity, anxiety, depression, and social adjustment.

Results showed that patients in all three treatment groups showed significant positive change in depression, anxiety, global functioning, and social adjustment across one year of treatment. Both transference-focused and DBT were significantly associated with improvement in suicidality.

In this study, only transference-focused psychotherapy and supportive treatment were associated with improvement in anger, and only transference-focused psychotherapy was significantly predictive of change in irritability and verbal and direct assault. Transference-focused psychotherapy and supportive treatment were each associated with improvement in facets of impulsivity.

“To our knowledge, this is the first randomized, controlled trial design that examines three well-described (manualized) treatments for borderline personality disorder, one of which (dialectical behavior therapy) is considered by many to be a standard treatment in the field...,” wrote study authors John Clarkin, Ph.D., and colleagues. “The general equivalence of outcome across the three treatments studied suggests that there may be different routes to symptom change in patients with borderline personality disorder.”

Clarkin is at New York Hospital Cornell Medical Center in White Plains, N.Y. Colleagues in the study were Kenneth Levy, Ph.D., Mark Lenzenweger, Ph.D., and Otto Kernberg, M.D., also of Cornell Medical Center.

Joel Paris, M.D., an expert on the treatment of personality disorders and BPD in particular, said the superiority of transference-based therapy would have to be replicated by other studies. Nonetheless, he said that the success of DBT and supportive therapy in the study “clearly shows that there is more than one way to treat BPD.”

Paris is a professor and chair of the Department of Psychiatry at McGill University in Montreal and editor in chief of the Canadian Journal of Psychiatry. He is also a past president of the Association for Research in Personality Disorders.

He noted that past studies by Marcia Linehan, Ph.D., on DBT were pioneering, but that manualized therapy in most of those studies was compared with treatment as usual. “A lot of things are better than treatment as usual,” Paris told Psychiatric News.

Paris added that one study by Linehan and colleagues published in the July 2006 Archives of General Psychiatry showed that DBT was also superior to psychotherapy conducted by mental health professionals with a special interest in BPD.

“But it is also important to compare different forms of manualized therapy to each other,” Paris said. “The Clarkin study is important because it is the first to compare these treatments with each other and to show that all are beneficial.

“A well-structured therapy works for these patients and isn't limited to one method,” he said. “That's good news for psychiatry, because most patients can't get access to DBT—it's too long and expensive—and we might otherwise think there are no other evidence-based therapies. But there are now perhaps four or five therapies that work with these patients.”

In fact, all of the tested therapies for BPD tend to be extensive and expensive, Paris noted.

“I believe that none of these methods is going to be available to a large number of patients in their original form,” he said. “No one will be able to pay for it. What I think is necessary is to find a way to streamline these treatments and provide them in briefer forms, just as brief therapies have been adapted for treatment of depression and other conditions.”

“Evaluating Three Treatments for Borderline Personality Disorder: A Multiwave Study” is posted at<http://ajp.psychiatryonline.org/> under the June issue. ▪