Evidence Tables for Additional Studies Reviewed
Appendix GStudy characteristics and main results of rTMS compared with sham
Study characteristics and main results of AP compared with TAU
Study characteristics and main results of SFT compared with TAU
Study characteristics and main results of SFT alone compared with SFT with extra phone support
Study characteristics and main results of CR compared with psychoeducation
Study characteristics and main results of CT compared with RST
Study characteristics and main results of MOTR compared with GPM
Study characteristics and main results of PIT compared with E-PDT
Study characteristics and main results of mechanism-based group psychotherapy compared with nonspecific supportive psychotherapy
Study characteristics and main results of other psychotherapy compared with TAU
Study characteristics and main results of service delivery approaches
Repetitive Transcranial Magnetic Stimulation Versus Sham
| Author (year) and/or trial name | Study characteristics | Participants, N; interventions; duration | Study population, including main inclusion and exclusion criteria | Sample demographics | Primary outcome; main results; attrition | Risk of bias |
|---|---|---|---|---|---|---|
Cailhol et al. (2014) | Design: Double-blinded RCT Setting: Outpatient, single center Country: France Funding: University Hospital of Toulouse | N = 9 G1 (4): Sham rTMS G2 (5): rTMS frequency: 10 Hz, 80% of motor threshold, total 2,000 pulses per session; 10 sessions Duration: 2 weeks | Inclusion: Ages 20–45 years; DSM-IV and DIB-R criteria for BPD Exclusion: Bipolar I disorder, alcohol dependency, current MDE or PTSD; contraindication to rTMS | Mean age, years (SD): NR Female: 89% Race/ethnicity: NR | Primary outcome: BPDSI at 3 months No significant differences in BPDSI, MADRS, SCL-90, GAS Incidence of AEs: NR Withdrawal due to AEs: NR Attrition: 0% Differential attrition: 0% | Moderate |
AE = adverse event; BPD = borderline personality disorder; BPDSI = Borderline Personality Disorder Severity Index; DIB-R = Diagnostic Interview for Borderlines–Revised; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th Edition; G1 = Group 1; G2 = Group 2; GAS = Global Assessment Scale; Hz = hertz; MADRS: Montgomery-Åsberg Depression Scale; MDE = major depressive episode; N = sample size; NR = not reported; PTSD = posttraumatic stress disorder; RCT = randomized controlled trial; rTMS = repetitive transcranial magnetic stimulation; SCL-90 = Symptom Checklist–90; SD = standard deviation.
Abandonment Psychotherapy Versus Treatment as Usual
| Author (year) and/or trial name | Study characteristics | Participants, N; interventions; duration | Study population, including main inclusion and exclusion criteria | Sample demographics | Primary outcome; main results; attrition | Risk of bias |
|---|---|---|---|---|---|---|
Andreoli et al. (2016) | Design: RCT Setting: Outpatient, single center Country: Switzerland Funding: NR | N = 170 G1 (30): TAU: intensive community treatment G2 (70): Manualized AP: Two sessions per week delivered by nurses with experience in management of patients with BPD, plus antidepressant medications Duration: 3 months | Inclusion: Ages 18–60 years; DSM-IV BPD and MDD diagnoses Exclusion: DSM-IV psychotic disorder, bipolar I disorder, SUD, or intellectual disability; inability to speak French | Mean age, years (SD): 32 (10.1) Female: 84% Race/ethnicity: NR | Primary outcome: Suicidal relapse, rehospitalization, clinical remission (GAS > 60) at 3 months G2 significantly more effective than G1 to reduce suicidal relapse (12.9% vs. 40.0%, P <0.005) and rehospitalization (14.3% vs. 36%, P <0.01), to achieve 50% reduction in Ham-D (65.7% vs. 33.3%, P <0.005), and improve GAS (62.7 vs. 36.7, P <0.01) Incidence of AEs: G1: 100% (30/30) G2: 100% (70/70) Withdrawal due to AEs: NR Attrition: 12% Differential attrition: G1: 37% (11/30) G2: 6% (4/70) | Moderate |
AE = adverse event; AP = abandonment psychotherapy; BPD = borderline personality disorder; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th Edition; G1 = Group 1; G2 = Group 2; GAS = Global Assessment Scale; Ham-D = Hamilton Rating Scale for Depression; MDD = major depressive disorder; N = sample size; NR = not reported; RCT = randomized controlled trial; SD = standard deviation; SUD = substance use disorder; TAU = treatment as usual.
Schema-Focused Therapy Versus Treatment as Usual
| Author (year) and/or trial name | Study characteristics | Participants, N; interventions; duration | Study population, including main inclusion and exclusion criteria | Sample demographics | Primary outcome; main results; attrition | Risk of bias |
|---|---|---|---|---|---|---|
Farrell et al. (2009) | Design: RCT Setting: Outpatient, multicenter Country: United States Funding: Government, NIMH | N = 32 G1 (16): TAU: Weekly individual psychotherapy in community G2 (16): SFT plus TAU: 30 weekly group sessions, each lasting 90 minutes; combination of emotional awareness training, BPD psychoeducation, distress management training, and schema-focused change work; sessions consisted of discussing homework from previous session, presenting new information, a question-and-answer session, experiential or cognitive work, and homework assignment Duration: 8 months Follow-up: 6 months | Inclusion: Females; age 18–65 years; met criteria for BPD from DIPD-R and BSI; in individual psychotherapy of ≥ 6 months duration and stable Exclusion: Axis I diagnosis of psychotic disorder or presence of psychosis; below-average IQ (89) on Shipley Institute of Living Scale | Mean age, years (SD): G1: 36 (8.08) G2: 35 (9.30) Female: 100% Race/ethnicity: NR | Primary outcome: NR G2 significantly more effective than G1 at 14-month follow-up (6 months after end of treatment) for BPD diagnosis (measured by DIB-R; 0% vs. 83%, P < 0.001), BPD symptoms (measured by BSI; 15.75 vs. 33.08, P < 0.001), global severity of psychiatric symptoms (measured by SCL-90; 0.96 vs. 1.93, P < 0.001), and improved global functioning (measured by GAF; 66.19 vs. 48.25, P < 0.001) Attrition: 12.5% (4/32) G1: 25% (4/16) G2: 0% (0/16) | Moderate |
Leppänen et al. (2016) | Design: RCT Setting: Outpatient, multicenter Country: Finland Funding: NR | N = 71 G1 (47): TAU; treatment in accordance with current practices of Oulu city mental health care services; treatments vary widely, from supportive weekly psychotherapy sessions to visits every few weeks and from occasional appointments for medication control to home rehabilitation G2 (24): SFT-based psychoeducational group integrated into individual therapy: 45- to 60-minute individual therapy sessions once a week, a total of forty 90-minute psychoeducational group sessions (approximately once a week), and materials for patients to practice therapy exercises at home Duration: 12 months | Inclusion: Age ≥ 20 years; fulfilled SCID-II criteria for BPD; severe symptoms of BPD, including parasuicidal behavior (e.g., cutting, other forms of self-harm, impulsive overdosing of medicines); attempted suicide; considerable emotional instability affecting social and professional life; previous unsuccessful treatments (one or more) Exclusion: Schizophrenia spectrum diseases/psychoses, bipolar disorder (type I), neuropsychiatric disorder, severe substance abuse problem, Axis I disorders diagnosed according to SCID-I, or presence of neuropsychiatric disorder | Mean age, years (SD): G1: 32 (8.8) G2: 32 (8.3) Female: 86% Race/ethnicity: NR | Primary outcome: Borderline symptoms on BPDSI-IV No difference between groups on BPD outcomes Attrition: 26.8% (19/71) G1: 31.9% (15/47) G2: 16.7% (4/24) | High |
Hilden et al. (2021) | Design: RCT Setting: Outpatient, single center Country: Finland Funding: Helsinki University Hospital | N = 42 G1 (14): TAU; psychiatrist visits and 45-minute therapy sessions once monthly; both pharmacotherapy and some form of psychosocial support or psychotherapy for most patients G2 (28): SFT; 20 weekly 90-minute sessions Duration: 20 weeks | Inclusion: Adults; BPD using DSM-IV SCID-II criteria (included those who had previously received treatment) Exclusion: Psychotic symptoms, suicide risk, principal diagnosis of uncontrollable SUD, or illness or symptoms affecting participation; those undergoing specific psychotherapy | Mean age, years (SD): G1: 27 (3.7) G2: 31 (8.8) Female: 83% Race/ethnicity: NR | Primary outcome: Intra-individual change in borderline personality symptoms No difference between groups on BPD outcomes Attrition: 16.7% (7/42) G1: 14.3% (2/14) G2: 17.97% (5/28) | Moderate |
BPD = borderline personality disorder; BPDSI-IV = Borderline Personality Disorder Severity Index-IV; BSI = Borderline Syndrome Index; DIB-R = Diagnostic Interview for Borderlines–Revised; DIPD-R = Diagnostic Interview for Personality Disorders–Revised; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th Edition; G1 = Group 1; G2 = Group 2; GAF = Global Assessment of Functioning; IQ = intelligence quotient; N = sample size; NIMH = National Institute of Mental Health; NR = not reported; RCT = randomized controlled trial; SCID-I = Structured Clinical Interview for DSM-IV Axis I Disorders; SCID-II = Structured Clinical Interview for DSM-IV Axis II Disorders; SCL-90 = Symptom Checklist–90; SD = standard deviation; SFT = schema-focused therapy; SUD = substance use disorder; TAU = treatment as usual.
Schema-Focused Therapy Versus Schema-Focused Therapy With Extra Phone Support
| Author (year) and/or trial name | Study characteristics | Participants, N; interventions; duration | Study population, including main inclusion and exclusion criteria | Sample demographics | Primary outcome; main results; attrition | Risk of bias |
|---|---|---|---|---|---|---|
Nadort et al. (2009) | Design: RCT Setting: Outpatient, multicenter Country: The Netherlands Funding: Other, public benefit organization | N = 62 G1 (30): 45-minute sessions of SFT twice a week in year 1 and once a week in year 2 G2 (32): 45-minute sessions of SFT twice a week along with extra phone support outside office hours Duration: 18 months | Inclusion: Ages 18–60 years; DSM-IV BPD diagnosis; BPDSI-IV score > 20 Exclusion: Psychotic disorders, bipolar disorder, DID, ASPD, or ADHD; addiction of such severity that clinical detoxification was indicated; psychiatric disorders secondary to medical conditions | Mean age, years (SD): G1: 32.13 (9.01) G2: 31.81 (9.24) Female: 96.8% Race/ethnicity: NR | Primary outcome: BPDSI-IV at 18 months No significant differences between G1 and G2 on BPD severity and burden as well as outcomes of global psychological problems, quality of life, and dysfunction Incidence of AEs: NR Withdrawal due to AEs: G1: 0% (0/30) G2: 3% (1/32; suicide after treatment allocation, but before treatment additional crisis support was provided) Attrition: 21% Differential attrition: ≤ 10 percentage points | Moderate |
ADHD = attention-deficit/hyperactivity disorder; AE = adverse event; ASPD = antisocial personality disorder; BPD = borderline personality disorder; BPDSI-IV = Borderline Personality Disorder Severity Index-IV; DID = dissociative identity disorder; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th Edition; G1 = Group 1; G2 = Group 2; N = sample size; NR = not reported; RCT = randomized controlled trial; SD = standard deviation; SFT = schema-focused therapy.
Cognitive Rehabilitation Versus Psychoeducation
| Author (year) and/or trial name | Study characteristics | Participants, N; interventions; duration | Study population, including main inclusion and exclusion criteria | Sample demographics | Primary outcome; main results; attrition | Risk of bias |
|---|---|---|---|---|---|---|
Pascual et al. (2015) | Design: RCT Setting: Outpatient, multicenter Country: Spain Funding: Government, Centro de Investigación Biomédica en Red de Salud Mental, Instituto de Salud Carlos III, Fondo de Investigación Sanitaria | N = 70 G1 (36): CR; twice-weekly group sessions G2 (34): Psychoeducation; weekly group sessions Duration: 16 weeks | Inclusion: Ages 18–45 years; outpatient; BPD diagnosis according to DSM-IV-TR and evaluated by SCID-II and DIB-R; CGI-BPD > 4; GAF < 65 Exclusion: Severe physical conditions that could affect neuropsychological performance; IQ < 85; MDD or substance misuse within past 6 months; schizophrenia, severe psychotic disorder, or bipolar disorder; previous participation in any psychoeducation or cognitive rehabilitation | Mean age, years (SD): G1: 32 (6.04) G2: 33 (8.8) Female: 74.3% Race/ethnicity: NR | Primary outcome: Psychosocial functioning at 6 months No significant difference between G1 and G2 on psychosocial functioning including on BSL-23, FAST, BIS, Ham-A, or MADRS at 6 months Incidence of AEs: NR Withdrawal due to AEs: NR Attrition: 40% Differential attrition: < 10 percentage points | High |
AE = adverse event; BIS = Barratt Impulsiveness Scale; BPD = borderline personality disorder; BSL-23 = Borderline Symptom List–23; CGI-BPD = Clinical Global Impression Scale for Borderline Personality Disorder; CR = cognitive rehabilitation; DIB-R = Diagnostic Interview for Borderlines–Revised; DSM-IV-TR = Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision; FAST = Functioning Assessment Scale Test; G1 = Group 1; G2 = Group 2; GAF = Global Assessment of Functioning; Ham-A = Hamilton Rating Scale for Anxiety; IQ = intelligence quotient; MADRS = Montgomery-Åsberg Depression Rating Scale; MDD = major depressive disorder; N = sample size; NR = not reported; RCT = randomized controlled trial; SCID-II = Structured Clinical Interview for DSM-IV Axis II Disorders; SD = standard deviation.
Cognitive Therapy Versus Rogerian Supportive Therapy
| Author (year) and/or trial name | Study characteristics | Participants, N; interventions; duration | Study population, including main inclusion and exclusion criteria | Sample demographics | Primary outcome; main results; attrition | Risk of bias |
|---|---|---|---|---|---|---|
Cottraux et al. (2009) | Design: RCT Setting: Outpatient, multicenter Country: France Funding: Other | N = 65 G1 (32): Weekly individual RST for 6 months then biweekly individual RST for 6 months G2 (33): Weekly individual CT for 6 months then biweekly individual RST for 6 months Duration: 1 year | Inclusion: DSM-IV BPD diagnosis (confirmed by DIB-R score of ≥ 8) Exclusion: Age < 18 or > 60 years; living too far from centers; psychotic disorders with current delusions; significant drug or alcohol addiction in foreground; antisocial behaviors; not following psychotherapy at time of the study | Mean age, years (SD): G1: 32.6 (8.3) G2: 34.3 (10.2) Female: 76.9% Race/ethnicity: NR | Primary outcome: Combined response (score ≤ 3 on CGI and Hopelessness score < 8) at 24 weeks No significant differences between G1 and G2 on CGI-I, Hopelessness scale, Ham-D, or BAI at 24 weeks G2 significant improvement in BDI scores at 24 weeks (13.0 vs. 21.7, P =0.01) Harms: NR Attrition: Week 24: 22% Week 104: 68% Differential attrition: ≤ 10 percentage points | Moderate |
BAI = Beck Anxiety Inventory; BDI = Beck Depression Inventory; BPD = borderline personality disorder; CGI = Clinical Global Impression Scale; CGI-I = Clinical Global Impression–Improvement; CT = cognitive therapy; DIB-R = Diagnostic Interview for Borderlines–Revised; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th Edition; G1 = Group 1; G2 = Group 2; Ham-D = Hamilton Rating Scale for Depression; N = sample size; NR = not reported; RCT = randomized controlled trial; RST = Rogerian supportive therapy; SD = standard deviation.
Motive-Oriented Therapeutic Relationship Versus General Psychiatric Management
| Author (year) and/or trial name | Study characteristics | Participants, N; interventions; duration | Study population, including main inclusion and exclusion criteria | Sample demographics | Primary outcome; main results; attrition | Risk of bias |
|---|---|---|---|---|---|---|
Kramer et al. (2011) | Design: RCT Setting: Outpatient, single center Country: Switzerland Funding: NR | N = 25 G1 (14): 10 session TAU with manual-based psychiatric and psychotherapeutic approach G2 (11): 10 sessions of MOTR along with TAU Duration: Seven therapy sessions | Inclusion: Ages 16–60 years; DSM-IV BPD diagnosis; speaks fluent French Exclusion: Organic disorder or persistent substance abuse or dependence that might affect brain function; psychotic disorder implying pronounced break in reality testing, including schizophrenia, delusional disorder, and bipolar I disorder; acute risk of suicide; severe cognitive impairment | Mean age, years (SD): 31 (10.59) Female: 77% Race/ethnicity: NR | Primary outcome: Psychotherapeutic results on OQ–45 after seven therapy sessions No significant differences between G1 and G2 on psychotherapeutic results after seven therapy sessions Attrition: 42% Differential attrition: G1: 57% (8/14) G2: 18% (2/11) | High |
Kramer et al. (2014) | Design: RCT Setting: Outpatient, single center Country: Switzerland Funding: Government, Swiss National Science Foundation | N = 85 G1 (43): 10 sessions of GPM G2 (42): 10 sessions of GPM plus MOTR use of plan analysis Duration: 3 months | Inclusion: Ages 18–65 years; DSM-IV BPD diagnosis Exclusion: DSM-IV psychotic disorders, intellectual disability, or substance abuse | Mean age, years (SD): G1: 31 (11.00) G2: 35 (9.97) Female: 68.9% Race/ethnicity: NR | Primary outcome: Psychotherapeutic results on OQ-45 at 3 months G2 significantly greater improvement on OQ-45 at 3 months (76.0 vs. 86.1, P < 0.01) No significant differences between G1 and G2 on IIP and BSL at 3 months Attrition: 29% Differential attrition: ≤ 10 percentage points | Moderate |
BPD = borderline personality disorder; BSL = Borderline Symptom List; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th Edition; G1 = Group 1; G2 = Group 2; GPM = general psychiatric management; IIP = Inventory of Interpersonal Problems; MOTR = motive-oriented therapeutic relationship; N = sample size; NR = not reported; OQ-45 = Outcome Questionnaire–45; RCT = randomized controlled trial; SD = standard deviation; TAU = treatment as usual.
Psychoanalytic-Interactional Therapy Versus Psychodynamic Therapy by Experts
| Author (year) and/or trial name | Study characteristics | Participants, N; interventions; duration | Study population, including main inclusion and exclusion criteria | Sample demographics | Primary outcome; main results; attrition | Risk of bias |
|---|---|---|---|---|---|---|
Leichsenring et al. (2016) | Design: RCT Setting: Inpatient, single center Country: Germany Funding: Other | N = 168 G1 (46): WL/TAU; 80% of patients continued usual treatment and remainder did not receive any treatment during WL period G2 (64): PIT; one or two weekly individual sessions and three weekly group therapy sessions; art or body therapy and consultations with a social worker (on needs basis) G3 (58): E-PDT; one or two weekly sessions of non-manualized individual therapy and three weekly sessions of group therapy; art or body therapy and consultations with a social worker (on needs basis) Mean duration, days (SD): G1: 89.69 (105.31) G2: 106.7 (41.71) G3: 76.78 (21.07) | Inclusion: Ages 18–65 years; Cluster B personality disorder diagnosis according to SCID-II (DSM-IV) Exclusion: Psychotic and acute substance-related disorders, acute (uncontrollable) risk of suicide, or organic mental disorders; severe medical conditions (according to ICD-10) | Mean age, years (SD): G1: 31 (9.4) G2: 29 (8.7) G3: 30 (9.1) Female: 69% Race/ethnicity: NR | Primary outcome: BPI, GSI of SCL-90-R at end of treatment (duration varies by treatment) G2 and G3 significantly more effective than G1 for improving BPD outcomes (measured by BPI [G2 vs. G1: 18.76 vs. 26.39, P = 0.004; G3 vs. G1: 19.41 vs. 26.39, P = 0.0004]), depression (BDI [G2 vs. G1: 17.44 vs. 27.80, P = 0.0001; G3 vs. G1: 15.20 vs. 27.80, P = 0.0001]), and global functioning (GSI of SCL-90-R [G2 vs. G1: 0.99 vs. 1.65, P = 0.0001; G3 vs. G1: 0.96 vs. 1.65, P = 0.0001]) No significant differences between active arms (G2 and G3) and G1 for anxiety (BAI) Incidence of AEs: NR Withdrawal due to AEs: NR Attrition: 18.0% (22/122) Differential attrition: ≤ 10 percentage points | High |
AE = adverse event; BAI = Beck Anxiety Inventory; BDI = Beck Depression Inventory; BPD = borderline personality disorder; BPI = Borderline Personality Inventory; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th Edition; E-PDT = psychodynamic therapy by experts in personality disorder; G1 = Group 1; G2 = Group 2; G3 = Group 3; GSI = Global Severity Index; ICD-10 = International Classification of Diseases, 10th Revision; N = sample size; NR = not reported; PIT = psychoanalytic interactional therapy; RCT = randomized controlled trial; SCL-90-R = Symptom Checklist–90–Revised; SCID-II = Structured Clinical Interview for DSM-IV Axis II Disorders; SD = standard deviation; TAU = treatment as usual; WL = wait-list.
Mechanism-Based Group Psychotherapy Versus Nonspecific Supportive Psychotherapy
| Author (year) and/or trial name | Study characteristics | Participants, N; interventions; duration | Study population, including main inclusion and exclusion criteria | Sample demographics | Primary outcome; main results; attrition | Risk of bias |
|---|---|---|---|---|---|---|
Herpertz et al. (2020) | Design: RCT Setting: Outpatient, single center Country: Germany Funding: Other, German Research Foundation | N = 59 G1 (29): Mechanism-based anti-aggression psychotherapy; highly manualized program starting with one individual 1-hour session followed by 6 weeks of group therapy with two 1.5-hour sessions per week (a total of 18 hours) G2 (30): Nonspecific supportive psychotherapy similar to DBT with same dosage as G1 Duration: 6 months | Inclusion: Ages 18–55 years; outpatients meeting ≥ 4 BPD criteria according to IPDE Exclusion: Additional non-study psychotherapy; pregnancy; epilepsy; bipolar I disorder, schizophrenia, or current substance abuse or addiction as well as change in medication in past 3 weeks | Mean age, years (SD): G1: 33 (8.8) G2: 30 (9.5) Female: 64% Race/ethnicity: NR | Primary outcome: MOAS at 6 months No difference between groups at end of treatment G2 significantly greater improvement in overt aggression on the MOAS at 6 months (10.60 vs. 22.95, P = 0.02) Incidence of AEs: G1: 6.9% (2/29) G2: 0% (0/30) Withdrawal due to AE: G1: 3.4% (1/29) G2: 0% (0/30) Attrition: 24% Differential attrition: ≥ 10 percentage points G1: 31% (9/29) G2: 17% (5/30) | High |
AE = adverse event; BPD = borderline personality disorder; DBT = dialectical behavior therapy; G1 = Group 1; G2 = Group 2; IPDE = International Personality Disorder Examination; MOAS = Modified Overt Aggression Scale; N = sample size; NR = not reported; RCT = randomized controlled trial; SD = standard deviation.
Other Psychotherapy Versus Treatment as Usual
| Author (year) and/or trial name | Study characteristics | Participants, N; interventions; duration | Study population, including main inclusion and exclusion criteria | Sample demographics | Primary outcome; main results; attrition | Risk of bias |
|---|---|---|---|---|---|---|
Amianto et al. (2011) | Design: RCT Setting: Outpatient, single center Country: Italy Funding: Government, other | N = 35 G1 (17): TAU: Supervised team management G2 (18): Supervised team management plus sequential brief Adlerian psychodynamic psychotherapy Duration: 12 months | Inclusion: Ages 20–50 years; DSM-IV-TR BPD diagnosis; heavy use of MHS throughout prior year Exclusion: Acute comorbid Axis I disorder requiring hospitalization; current SUD; intellectual disability; previous psychotherapy interventions | Mean age, years (SD): 40 (9.4) Female: 49% Race/ethnicity: NR | Primary outcome: High mental health use (more than six emergency interventions in prior year) No significant differences between G2 and G1 in CGI, SCL-90, and GAF at 12 months Attrition: 5.7% (2/35) G1: 5.9% (1/17) G2: 5.6% (1/18) | Moderate |
Gratz et al. (2014) | Design: RCT Setting: Outpatient, single center Country: NR Funding: Government, NIMH | N = 61 G1 (30): TAU; ongoing outpatient treatment, with most participants (> 70%) receiving supportive or dynamic individual therapy and others (19%) receiving CBT G2 (31): ERGT; Weekly 90-minute group sessions over 14 weeks (six patients per group) Duration: 14 weeks | Inclusion: Females; age 18–60 years; threshold or subthreshold diagnosis of BPD; history of repeated deliberate self-harm, with one or more episodes in past 6 months; having an individual therapist, psychiatrist, or case manager; diagnostic interview for DSM-IV Exclusion: Diagnoses of primary psychotic disorder, bipolar I disorder, or current (past month) SUD | Mean age, years (SD): G1: 33 (0.9) G2: 33 (11.0) Female: 100% Race/ethnicity: Racial/ethnic minority: 21% | Primary outcome: NR G2 significantly more effective than G1 for improving self-harm (measured using SHI; 16.05 vs. 29.40, P < 0.05), emotion dysregulation (DERS; 95.27 vs. 113.62, P < 0.05), BPD severity (ZAN-BPD; 4.35 vs. 12.03, P < 0.05), and quality of life (QLI; 0.31 vs. - 0.50, P < 0.05) No significant differences between G2 and G1 on measures of BPD-related severity and symptoms (measured by composite of IIP, BEST, AAQ, BDI, and SDS) Attrition: 13.1% (8/61) G1: 10% (3/30) G2: 16.1% (5/31) | Moderate |
Reneses et al. (2013) | Design: RCT Setting: Outpatient, multicenter Country: Spain Funding: Government, Ministry | N = 53 G1 (28): TAU; conventional treatment without specific additional psychotherapy for 6 months, psychopharmacological treatment in accordance with standard applied in hospital clinic G2 (25): PRFP along with conventional care: 20 face-to-face, 45-minute, consecutive weekly PRFP sessions plus conventional outpatient psychiatric treatment Duration: 12 months | Inclusion: Ages 18–50 years; clinical diagnosis of BPD using DSM-IV-TR and SCID-II; clinical situation of outpatient treatment Exclusion: Active suicide risk symptoms, violent or unmanageable heteroaggressive behaviors; comorbidity with diagnosis of eating behavior disorder on Axis I, toxic dependence disorder, or current severe physical disease; interrupting patients’ psychotherapy for more than four consecutive sessions without justification or for more than six sessions in any case | Mean age, years (SD): 34 (7.5) Female: 71% Race/ethnicity: NR | Primary outcome: Severity of general symptoms (GSI of SCL-90-R) and impulsivity (BIS, SASS) G2 significantly more effective than G1 for improving BPD severity (measured by ZAN-BPD; 13.0 vs. 19.1, P < 0.001) and symptoms (SCL-90 [1.2 vs. 1.7, P < 0.001]; MADRS total [15.9 vs. 22.8, P < 0.001]; BIS [52.5 vs. 68.2, P < 0.01]; and SASS [35.4 vs. 27.6, P < 0.001]) No significant differences between G2 and G1 for STAI state score or CGI Attrition: 13% (7/53) G1: 14% (4/28) G2: 12% (3/25) | High |
Leichsenring et al. (2016) | Design: RCT Setting: Inpatient, single center Country: Germany Funding: Other | N = 168 G1 (46): WL/TAU; 80% of patients continued usual treatment and remainder did not receive any treatment during WL period G2 (64): PIT; one or two weekly individual sessions and three weekly group therapy sessions; art or body therapy and consultations with a social worker (on needs basis) G3 (58): E-PDT; one or two weekly sessions of non-manualized individual therapy and three weekly sessions of group therapy; art or body therapy and consultations with a social worker (on needs basis) Mean duration, days (SD): G1: 89.69 (105.31) G2: 106.7 (41.71) G3: 76.78 (21.07) | Inclusion: Ages 18–65 years; Cluster B personality disorder diagnosis according to SCID-II (DSM-IV) Exclusion: Psychotic and acute substance-related disorders, acute (uncontrollable) risk of suicide, or organic mental disorders; severe medical conditions (according to ICD-10) | Mean age, years (SD): G1: 31 (9.4) G2: 29 (8.7) G3: 30 (9.1) Female: 69% Race/ethnicity: NR | Primary outcome: BPI, GSI of SCL-90-R at end of treatment (duration varies by treatment) G2 and G3 significantly more effective than G1 for improving BPD outcomes (measured by BPI [G2 vs. G1: 18.76 vs. 26.39, P = 0.004; G3 vs. G1: 19.41 vs. 26.39, P = 0.0004]), depression (BDI [G2 vs. G1: 17.44 vs. 27.80, P = 0.0001; G3 vs. G1: 15.20 vs. 27.80, P = 0.0001]) and global functioning (GSI of SCL-90-R [G2 vs. G1: 0.99 vs. 1.65, P = 0.0001; G3 vs. G1: 0.96 vs. 1.65, P = 0.0001]) No significant differences between active arms (G2 and G3) and G1 for anxiety (BAI) Incidence of AEs: NR Withdrawal due to AEs: NR Attrition: 18.0% (22/122) Differential attrition: ≤ 10 percentage points | High |
AAQ = Acceptance and Action Questionnaire; AE = adverse event; BAI = Beck Anxiety Inventory; BDI = Beck Depression Inventory; BEST = Borderline Evaluation of Severity Over Time; BIS = Barrat Impulsivity Scale; BPD = borderline personality disorder; BPI = Borderline Personality Inventory; CBT = cognitive-behavioral therapy; CGI = Clinical Global Impression; DERS = Difficulties in Emotion Regulation Scale; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th Edition; DSM-IV-TR = Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision; ERGT = emotion regulation group therapy; E-PDT = psychodynamic therapy by experts in personality disorders; G1 = Group 1; G2 = Group 2; G3 = Group 3; GAF = Global Assessment of Functioning; GSI = Global Severity Index; ICD-10 = International Classification of Diseases, 10th Revision; IIP = Inventory of Interpersonal Problems; MADRS = Montgomery-Åsberg Depression Rating Scale; MHS = mental health services; N = sample size; NIMH = National Institute of Mental Health; NR = not reported; PIT = psychoanalytic-interactional therapy; PRFP = psychic representation focused psychotherapy; QLI = Quality of Life Inventory; RCT = randomized controlled trial; SASS = Social Adaptation Self-evaluation Scale; SCID-II = Structured Clinical Interview for DSM-IV Axis II Disorders; SCL-90 = Symptom Checklist–90; SCL-90-R = Symptom Checklist–90 Revised; SD = standard deviation; SDS = Sheehan Disability Scale; SHI = Self-Harm Inventory; STAI = State-Trait-Anxiety Inventory; SUD = substance use disorder; TAU = treatment as usual; WL = wait-list; ZAN-BPD = Zanarini Rating Scale for Borderline Personality Disorder.
Service Delivery Approaches
| Author (year) and/or trial name | Study characteristics | Participants, N; interventions; duration | Study population, including main inclusion and exclusion criteria | Sample demographics | Primary outcome; main results; attrition | Risk of bias |
|---|---|---|---|---|---|---|
Bartak et al. (2011) | Design: Prospective cohort study Setting: University hospital and mental health care centers Country: The Netherlands Funding: None | N = 245 G1 (59): Outpatient individual or group psychotherapy sessions for up to two sessions per week G2 (99): At least one session per week of psychotherapy in day-hospital but slept at home G3 (87): Stayed at institution for 5 days per week and received different forms of psychotherapy Duration: 18 months | Inclusion: Participants with Cluster B personality disorders diagnosed with DSM-IV Personality Exclusion: Organic cerebral impairment, intellectual disability, or schizophrenia | Based on N analyzed: Mean age, years (SD): 31 (8.5) Female: 71% Race/ethnicity: NR 77% with BPD | Primary outcome: GSI at 18 months No significant differences in GSI and EQ-5D Incidence of AEs: NR Withdrawal due to AEs: NR Attrition: 16% Differential attrition: ≤ 10 percentage points | Moderate |
Laporte et al. (2018) | Design: Prospective cohort Setting: Outpatient, multicenter Country: Canada Funding: McGill University | N = 681 G1 (479): 12 weekly sessions of individual therapy and 12 of group therapy G2 (138): Extended care clinic with weekly sessions of two types of group therapy, weekly sessions of individual therapy, and pharmacological management Duration: G1: 12 weeks G2: 6–24 months | Inclusion: DSM-5 BPD diagnosis; ≥ 8 on DIB-R for current BPD Exclusion: NR | Mean age, years (SD): G1: 27 (7.8) G2: 36 (10.4) Female: 93% Race/ethnicity: NR | Primary outcome: NR Significant reductions in both groups but no reporting on between-group comparisons Incidence of AEs: NR Withdrawal due to AEs: NR Attrition: 32% Differential attrition: G1: 29% (137/479) G2: 43% (59/138) | High |
Sinnaeve et al. (2018) | Design: RCT Setting: Community mental health centers Country: The Netherlands Funding: GGZ Rivierduinen | N = 84 G1 (42): Standard, outpatient DBT G2 (42): Step-down DBT consisting of 3 months of residential DBT plus 6 months of outpatient DBT Duration: G1: 12 months G2: 9 months | Inclusion: DSM-IV BPD diagnosis; ages 18–45 years; ≥ 24 on the BPDSI-IV and one or more episodes of SIB Exclusion: Chronic psychotic disorder, bipolar I disorder, intellectual disability, or SUD requiring detoxification; involuntary psychiatric treatment | Mean age, years (SD): G1: 26 (7.5) G2: 26 (6.2) Female: 95% Race/ethnicity: NR | Primary outcome: NR Significant reductions in both groups but no reporting on between-group comparisons Incidence of AEs: NR Withdrawal due to AEs: NR Attrition: 44% Differential attrition: ≤ 10 percentage points | High |
Smits et al. (2020; 2022) | Design: RCT Setting: Outpatient, multicenter Country: The Netherlands Funding: ZonMw | N = 114 G1 (70): MBT, day-hospital setting G2 (44): MBT, IOP setting Duration: 18 months | Inclusion: BPD diagnosis; age ≥ 18 years Exclusion: ASD, chronic psychotic disorder, or organic brain disorder, intellectual disability (IQ < 80), or ASPD with history of physical violence | Mean age, years (SD): G1: 31 (10.6) G2: 30 (9.2) Female: 83% Race/ethnicity: NR | Primary outcome: GSI of BSI at 18 months Significant improvements on all outcomes (GSI, SSHI, PAI-BOR, EQ-5D, IIP, SIPP) at 18 months and no significant between-group difference except on IIP and SIPP No significant differences between groups at 36 months Incidence of AEs: NR Withdrawal due to AEs: NR Attrition: 78% at 18 months Differential attrition: 18% | High |
AE = adverse event; ASD = autism spectrum disorder; ASPD = antisocial personality disorder; BPD = borderline personality disorder; BPDSI-IV = Borderline Personality Disorder Severity Index-IV; BSI = Brief Symptom Inventory; DBT = dialectical behavior therapy; DIB-R = Diagnostic Interview for Borderlines–Revised; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, 4th Edition; DSM-5 = Diagnostic and Statistical Manual of Mental Disorders, 5th Edition; EQ-5D = European Quality of Life–5 Dimension; G1 = Group 1; G2 = Group 2; G3 = Group 3; GSI = Global Severity Index; IIP = Inventory of Interpersonal Problems; IOP = intensive outpatient; IQ = intelligence quotient; MBT = mentalization-based treatment; N = sample size; NR = not reported; PAI-BOR = Personality Assessment Inventory-Borderline Features Scale; RCT = randomized controlled trial; SD = standard deviation; SIB = self-injurious behavior; SIPP = Severity Indices of Personality Problems; SSHI = Suicide and Self-Harm Inventory; SUD = substance use disorder.
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The American Psychiatric Association Practice Guideline for the Treatment of Patients With Borderline Personality Disorder
November 2024
©American Psychiatric Association Publishing
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