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Psychotherapy for Borderline Personality Disorder: A Multiwave Study 

Psychotherapy for Borderline Personality Disorder: A Multiwave Study
Chapter:
Psychotherapy for Borderline Personality Disorder: A Multiwave Study
Author(s):

David Grunwald

, Erica Robinson

, and Sarah Fineberg

DOI:
10.1093/med/9780190625085.003.0031
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The general equivalence of outcome across the three [psychotherapy] treatments suggests that there may be different routes to symptom change in patients with Borderline Personality Disorder.

Clarkin et al.1

Research Question:

How does transference-focused psychotherapy (TFP), supportive therapy, and dialectical behavioral therapy (DBT) compare in the treatment of borderline personality disorder (BPD)?

Funding:

The Borderline Personality Disorder Research Foundation

Year Study Began:

1998

Year Study Published:

2007

Study Location:

Three academic sites in the New York area

Who Was Studied:

Patients 18 to 50 years old meeting DSM-IV criteria for BPD.

Who Was Excluded:

Patients with psychotic disorders, bipolar I disorder, delusional disorder, delirium, dementia, and/or amnestic or other cognitive disorders were excluded. People with comorbid active substance dependence were also excluded.

How Many Participants:

90

Study Overview:

See Figure 31.1 for a summary of the study design.

Figure 31.1 Summary of Study Design

Figure 31.1 Summary of Study Design

Notes: TFP = transference-focused psychotherapy. DBT = dialectical behavioral therapy.

Study Intervention:

Patients with BPD were randomly assigned to TFP, DBT, or supportive treatment.

TFP is a psychodynamic-informed therapy that focuses on “borderline” psychological organization. Treatment examines patterns in outside life through the lens of situations occurring between patient and therapist. Individual TFP sessions were offered twice weekly.

DBT is a behavioral therapy that treats symptoms as maladaptive behaviors arising when a sensitive person is in an invalidating environment. Treatment teaches skills to regulate emotions; the therapist is highly supportive. Weekly individual and group sessions and as-needed telephone consultation were provided.

Supportive therapy provides emotional support and the therapist offers advice on practical problems. Supportive treatment involved 1 weekly session plus additional sessions as needed.

In all study arms, subjects were evaluated before study onset and medicated as needed by separate blinded study psychiatrists. At baseline and at 4-month intervals, raters assessed suicidal behavior, aggression, impulsivity, anxiety, depression, and social adjustment.

Follow-Up:

4, 8, and 12 months

Endpoints:

Primary outcomes (measure used listed in parentheses): suicidality (Overt Aggression Scale–Modified), aggression (Anger, Irritability, and Assault Questionnaire), and impulsivity (Barratt Impulsiveness Scale II). Secondary outcomes: anxiety (Brief Symptom Inventory), depression (Beck Depression Inventory), and social adjustment (Global Assessment of Functioning Scale and Social Adjustment Scale).

Results

  • All three treatments significantly improved depression, anxiety, global functioning, and social adjustment.

  • TFP showed significant improvement across 10 of 12 domains versus 6 of 12 domains in the supportive treatment, and 5 of 12 in the DBT groups.

  • Suicidality significantly decreased with both TFP and DBT.

  • Anger significantly decreased with TFP and supportive treatment.

  • Only TFP significantly decreased motor impulsivity, irritability, verbal assault, and direct assault.2

  • Only supportive therapy significantly improved self-control.2

  • None of the groups significantly improved on attention-based impulsivity.2

  • 62 of 90 enrolled subjects continued 9+ months. Intent to treat analysis suggested that attrition did not substantially alter the findings (Table 31.1).

Table 31.1 Summary of BPD Multiwave Study’s Key Findings

Outcome

TFP

P value

DBT

P value

Supportive treatment

P Value

Suicidality

0.33

0.01

0.44

0.01

0.18

>0.05

Anger

0.44

0.001

0.25

>0.05

0.28

0.05

Irritability

0.33

>0.05

0.11

>0.05

0.16

>0.05

Verbal assault

0.43

0.001

0.21

>0.05

0.19

>0.05

Impulsivity

0.36

0.005

0.05

>0.05

0.31

>0.02

Anxiety

0.37

0.004

0.50

0.001

0.48

0.001

Depression

0.50

0.001

0.38

0.003

0.49

0.001

Social adjustment

0.28

0.03

0.44

0.001

0.59

0.001

Notes: The data presented here represents the effect size regarding improvement relative to baseline. A higher value represents a larger effect. P values represents the outcome measure post-treatment and at baseline. BPD = borderline personality disorder. TFP = transference-focused psychotherapy. DBT = dialectical behavior therapy.

Criticisms and Limitations:

The study had limited statistical power for assessing differences between the treatment groups, so it is not possible to know whether the study interventions are significantly better than no intervention. Also, the study population (92% female) differed from epidemiologic data on BPD3 (50% female). These factors limit the ability to generalize the findings.

Also, ethical constraints prevented the authors from including a control group that did not receive any intervention, so it is not possible to know whether the study interventions are significantly better than no intervention. Although the supportive treatment arm was intended to approximate usual care, study therapists likely had more support than many typical community clinicians.

Treatment dose also differed among the groups: the TFP group had two visits per week, the DBT group had three visits per week, and the supportive treatment group had one visit per week. Therefore, therapy dose rather than content may have driven study outcomes.

Though there are no FDA-approved medications for BPD, many subjects in this study received pharmacologic therapy. Rates of pharmacotherapy also differed among groups, and information about specific medications, classes, and numbers of medications is not reported. Subgroup analysis suggested that medicated subjects had similar outcomes to the full study cohort.

Other Relevant Studies and Information:

  • A 2012 Cochrane Systemic Review found that both comprehensive (defined as therapy that includes one-to-one treatment) as well as noncomprehensive psychotherapeutics for BPD show beneficial effects on core pathology and associated general psychopathology.3 DBT has been studied most extensively, followed by mentalization-based treatment (MBT), TFP, schema-focused therapy and systems training for emotional predictability and problem-solving for BPD (STEPS).

  • Polypharmacy is common in BPD despite evidence only for mood stabilizers, second generation antipsychotics, and symptom-focused use of selective serotonin reuptake inhibitors.4 There are no FDA-approved medications for BPD, and no evidence for using benzodiazepines.

  • American Psychiatric Association (APA) guidelines for BPD promote psychodynamic or DBT approaches and treating co-occurring psychiatric diagnoses with therapy and/or medications.4 A 2017 meta-analysis supports this approach, finding significant but modest and unstable benefits of the main evidence-based psychotherapies for BPD.5

Summary and Implications:

This study was the first randomized controlled trial that examined and compared three manualized psychotherapeutic treatments for BPD. Each of the three therapies led to significant improvement in multiple symptoms over one year of outpatient treatment relative to baseline. Notably, patients treated with TFP improved in more domains than did those assigned to other treatment groups.

Clinical Case: Psychotherapies for BPD

Case History

A 43-year-old man with BPD including mood instability, irritability, and chronic passive suicidality was sent to a local emergency department after describing increasing suicidal urges to his therapist. The patient was discharged from the ED, and at a follow-up therapy session two days later, asked for a referral to a new clinician. The patient now presents to a new outpatient psychiatrist for treatment.

Based on the results of this study, what modality of psychotherapy should the psychiatrist choose?

Suggested Answer

This and other studies contributed to APA guidelines supporting DBT or psychodynamic psychotherapy (e.g. TFP, MBT, etc.) to treat BPD.

The patient in this vignette is typical of patients in this study, and thus any of the three psychotherapies may be appropriate. Considering the patient’s suicidality and irritability, a trial of TFP should be strongly considered if logistically feasible. In this study, TFP was the only treatment with significant improvement in both suicidality and irritability. However, psychoeducation about the format and content of various treatment options (such as the 3 modalities described in this chapter) will be important to help connect the patient to an appropriate care setting where he is likely to follow through.

References

1. Clarkin, J. F., Levy, K. N., Lenzenweger, M. F., & Kernberg, O. T. (2007). Evaluating three treatments for borderline personality disorder: A multiwave study. American Journal of Psychiatry, 164(6), 922–928.Find this resource:

2. Stoffers, J. M., Völlm, B. A., Rücker, G., Timmer, A., Huband, N., & Lieb, K. (2012). Psychological therapies for people with borderline personality disorder. Cochrane Database of Systematic Reviews, 8, CD005652.Find this resource:

    3. Grant, B. F., Chou, S. P., Goldstein, R. B., Huang, B., Stinson, F. S., Saha, T. D., . . . Ruan, W. J. (2008). Prevalence, correlates, disability, and comorbidity of DSM-IV borderline personality disorder: Results from the Wave 2 National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Clinical Psychiatry, 69(4), 533–545.Find this resource:

    4. Oldham, J. M., Gabbard, G. O., Goin, M. K., Gunderson, J., Soloff, P., Spiegel, D., . . . Phillips, K. A. (2001). Treatment of patients with borderline personality disorder. American Psychiatric Association Practice Guidelines. American Journal of Psychiatry, 158(10 Suppl), 1–52.Find this resource:

      5. Cristea, I. A., Gentili, C., Cotet, C. D., Palomba, D., Barbui, C., & Cuijpers, P. (2017). Efficacy of psychotherapies for borderline personality Disorder: A systematic review and meta-analysis. JAMA psychiatry, 74(4), 319–328.Find this resource: