Drawing the borderline: Predicting treatment outcomes in patients with borderline personality disorder

Patient-related factors associated with patient retention and non-completion in psychosocial treatment of borderline personality disorder: A systematic review

The potential efficacy of psychosocial interventions in the treatment of borderline personality disorder (BPD) is impacted by significant treatment non-completion (TNC), with meta-analytic studies reporting rates of attrition of between 25% and 28%. Increasing patient retention could facilitate outcomes and improve resource utilization, given limited healthcare services. A systematic search of PsycINFO, CINAHL, EMBASE, CENTRAL, and Web of Science Core Collection identified 33 articles that met the criteria for inclusion. Although substantial heterogeneity in terms of methodology and quality of analysis limited conclusions that could be drawn in the narrative review, a few consistent patterns of findings were elucidated, such as Cluster B personality disorder comorbidities and lower therapeutic alliance were associated with TNC. Interestingly, the severity of BPD symptoms was not a predictor of TNC. These findings are discussed in terms of their potential theoretical contribution to TNC. Clinically, there may be value in applying mindfulness and motivational interviewing strategies early on in treatment for individuals who present uncertainty about engaging in treatment. Further research to develop this empirical landscape includes focusing on high-powered replications, examining burgeoning lines of research, and investigating dynamic predictors of TNC.

Comparison of 8-vs-12 weeks, adapted dialectical behavioral therapy (DBT) for borderline personality disorder in routine psychiatric inpatient treatment-A naturalistic study

Dialectical behavior therapy (DBT) is widely acknowledged as an effective treatment for individuals with borderline personality disorder (BPD). However, the optimal treatment duration within DBT remains a topic of investigation. This retrospective, naturalistic non-randomized study aimed to compare the efficacy of 8 week and 12 week DBT interventions with equivalent content, focusing on the change of BPD-specific symptomatology as the primary outcome and depressive symptoms as the secondary outcome. Overall, 175 patients who participated in DBT and received either 8 week or 12 week intervention were included in the analysis. Routine inpatient treatment was adapted from standard DBT with the modules: skill training, interpersonal skills, dealing with feelings, and mindfulness. Measurements were taken at baseline, mid-point, and endpoint. The borderline symptom list-23 (BSL-23) was used for the assessment of borderline-specific symptoms, while the Beck depression inventory-II (BDI-II) was used for the assessment of depressive symptoms. Statistical analysis was conducted using linear mixed models. Effect sizes were calculated for both measures. The results of the analysis indicated an improvement in both groups over time. Effect sizes were d = 1.29 for BSL-23 and d = 1.79 for BDI-II in the 8 week group, and d = 1.16 for BSL-23 and d = 1.58 for BDI-II in the 12 week group. However, there were no differences in the change of BPD-specific symptoms or the severity of depressive symptoms between the 8 week and 12 week treatment duration groups. Based on these findings, shorter treatment durations, like 8 weeks, could be a viable alternative, offering comparable therapeutic benefits, potential cost reduction, and improved accessibility. However, further research is needed to explore factors influencing treatment outcomes and evaluate the long-term effects of different treatment durations in DBT for BPD.Trial registration: drks.de (DRKS00030939) registered 19/12/2022.

Maladaptive defense mechanisms moderate treatment outcome in 6 months versus 12 months dialectical-behavior therapy for borderline personality disorder

OBJECTIVE

We investigated whether defense mechanisms in patients with borderline personality disorder (BPD) predict treatment response of dialectical behavior therapy (DBT) and whether they moderate outcome in different treatment lengths.

METHOD

We analyzed a subsample of 60 outpatients with BPD, randomized into either 6 (n = 30) or 12 (n = 30) months of DBT. The average level of defensive adaptiveness, assessed with observer-rated overall defensive functioning (ODF) and "immature" (i.e., maladaptive) defenses were used as predictors and moderators of self-reported frequency of self-harm. We conducted a Generalized Linear Mixed Model (GLMM).

RESULTS

A lower ODF at treatment onset predicted smaller reductions in self-harm, irrespective of treatment length (IRR = 0.92, 95% CI = [0.86, 0.99], p = .020). Lower order "immature" ("major image distorting") defenses showed significantly smaller (IRR = 1.13, 95% CI = [1.06, 1.21], p < .001) and higher order "immature" ("minor image distorting") defenses showed significantly larger (IRR = .91, 95% CI = [.85, .97], p = .006) reductions in self harm in the 6-month but not in the 12-month treatment.

CONCLUSION

Even though the results have to be regarded as preliminary due to the small sample size, findings might indicate that patients with BPD and lower average defensive adaptiveness may benefit from individualized treatment plans including specific interventions targeting defense function.

Therapeutic alliance and dropout in patients with borderline pathology receiving residential dialectical behavior therapy

BACKGROUND

This study focused on the impact of therapeutic alliance on therapy dropout in a naturalistic sample of patients with borderline pathology receiving dialectical behavior therapy (DBT) in a residential setting. We assumed that low therapeutic alliance shortly after admission would be associated with elevated dropout.

METHODS

44 participants with borderline pathology (≥ 3 DSM-5 borderline personality disorder criteria) in a residential DBT program completed a quality assurance questionnaire set assessing demographic information, pretreatment psychopathology and therapeutic alliance during the first seven days of their residential stay. Predictors of dropout were investigated using binary logistic regression analyses.

RESULTS

The dropout rate was 34.1% (n = 15). In binary logistic regression analyses with variables covering demographic and clinical characteristics, comorbidities and childhood trauma history, only the therapeutic alliance significantly predicted dropout (z = -2.371, p = .018).

CONCLUSIONS

This study supports the importance of therapy process variables, here the therapeutic alliance at the beginning of treatment, as predictors of therapy dropout in borderline pathology. If this finding is replicated, it shows the potential importance of monitoring the therapeutic relationship throughout the therapeutic process.

CLINICALTRIALS

gov Identifier: NCT05289583, retrospectively registered on March 11, 2022.

Latent classes of symptom trajectories during partial hospitalization for major depressive disorder and generalized anxiety disorder

BACKGROUND

A variety of treatments have been empirically validated in the treatment of major depressive disorder and generalized anxiety disorder. Researchers commonly evaluate symptom change during treatment using single model curves, however, modeling multiple curves simultaneously allows for the identification of subgroups of patients that progress through treatment on distinct paths.

METHODS

Latent growth mixture modeling was used to identify and characterize distinct classes of symptom trajectories among two samples of patients with either MDD or GAD receiving treatment in a daily partial hospital program.

RESULTS

Four depression symptom trajectories were identified in the MDD sample, and three anxiety symptom trajectories were identified in the GAD sample. Both samples shared symptom trajectory classes of responders, rapid responders, and minimal responders, while the MDD sample demonstrated an additional class of early rapid responders. In both samples, low symptom severity at baseline was associated with membership in the responder class, though few other patterns emerged in baseline characteristics predicting trajectory class membership. At treatment discharge, those in the minimal responder class reported poorer outcomes on every clinical measure. Patients within each class reported similar scores at discharge as compared to each other class, indicating that class membership affects clinical measures beyond symptom severity.

LIMITATIONS

Patient demographic characteristics were relatively homogeneous. Group-based trajectory modeling inherently involves some degree of uncertainty regarding the number and shape of trajectories.

CONCLUSIONS

Identifying symptom trajectories can provide information regarding how patients are likely to progress through treatment, and thus inform clinicians when a patient deviates from expected progress.

[Evidence-based inpatient psychotherapy in borderline personality disorder]

BACKGROUND

Borderline personality disorder (BPD) is frequent (prevalence in Germany between 0.7% and 4.5%) [11] and is associated with a high level of psychological stress and frequent emergency inpatient admissions. The provision of disorder-specific outpatient psychotherapy is still insufficient also in Germany.

OBJECTIVE

This article provides an overview of the available data on the effectiveness of inpatient psychotherapy for BPD.

MATERIAL AND METHODS

A qualitative review on the effectiveness and therapy outcome predictors was conducted based on a literature search in PubMed.

RESULTS

Overall, very few randomized controlled trials are available; in contrast uncontrolled studies are predominant. Most evidence is available for dialectical behavior therapy (DBT) but other approaches, including psychodynamic procedures, have also been studied.

DISCUSSION

The currently available data suggest an efficacy of inpatient psychotherapy for BPD; however, randomized trials with larger samples and sufficient representation including male patients are largely lacking. There is also no substantial direct evidence for the superiority of inpatient compared to outpatient psychotherapy.

Investigating predictors of treatment response in Dialectical Behavior Therapy for borderline personality disorder using LASSO regression

OBJECTIVE

Prior studies of Dialectical Behavior Therapy (DBT) for borderline personality disorder (BPD) have yielded heterogeneous findings on what factors differentiate individuals with or without sufficient treatment response, highlighting the need for further research.

METHOD

We investigated a sample of 105 individuals with BPD receiving a 6-month course of DBT. Participants were categorized as sufficient or insufficient responders using clinical and statistical change indices (based on emotion dysregulation, BPD symptom severity, utilization of DBT skills, and functional impairment). Sociodemographic, clinical severity, and treatment process factors were tested as potential predictors of treatment response using a machine learning approach (LASSO regression).

RESULTS

Two cross-validated LASSO regression models predicted treatment response (AUCs > .75). They suggested that higher homework completion rate, retention in treatment, and greater baseline severity were the most important predictors of DBT treatment response indicated by BPD symptom severity and utilization of DBT skills. Favorable effects of some aspects of therapeutic alliance during initial sessions were also found.

CONCLUSIONS

Future research may benefit from consolidating the criteria of treatment response, identifying clinically relevant variables, and testing the generalizability of findings to enhance knowledge of insufficient treatment response in DBT for BPD.

How childhood maltreatment alters perception and cognition - the predictive processing account of borderline personality disorder

Borderline personality disorder (BPD) is a severe mental disorder, comprised of heterogeneous psychological and neurobiological pathologies. Here, we propose a predictive processing (PP) account of BPD to integrate these seemingly unrelated pathologies. In particular, we argue that the experience of childhood maltreatment, which is highly prevalent in BPD, leaves a developmental legacy with two facets: first, a coarse-grained, alexithymic model of self and others - leading to a rigidity and inflexibility concerning beliefs about self and others. Second, this developmental legacy leads to a loss of confidence or precision afforded beliefs about the consequences of social behavior. This results in an over reliance on sensory evidence and social feedback, with concomitant lability, impulsivity and hypersensitivity. In terms of PP, people with BPD show a distorted belief updating in response to new information with two opposing manifestations: rapid changes in beliefs and a lack of belief updating despite disconfirmatory evidence. This account of distorted information processing has the potential to explain both the instability (of affect, self-image, and interpersonal relationships) and the rigidity (of beliefs about self and others) which is typical of BPD. At the neurobiological level, we propose that enhanced levels of dopamine are associated with the increased integration of negative social feedback, and we also discuss the hypothesis of an impaired inhibitory control of the prefrontal cortex in the processing of negative social information. Our account may provide a new understanding not only of the clinical aspects of BPD, but also a unifying theory of the corresponding neurobiological pathologies. We conclude by outlining some directions for future research on the behavioral, neurobiological, and computational underpinnings of this model, and point to some clinical implications of it.

Inpatient psychotherapy for depression in a large routine clinical care sample: A Bayesian approach to examining clinical outcomes and predictors of change

BACKGROUND

A routinely collected dataset was analyzed (1) to determine the naturalistic effectiveness of inpatient psychotherapy for depression in routine psychotherapeutic care, and (2) to identify potential predictors of change.

METHODS

In a sample of 22,681 inpatients with depression, pre-post and pre-follow-up effect sizes were computed for various outcome variables. To build a probabilistic model of predictors of change, an independent component analysis generated components from demographic and clinical data, and Bayesian EFA extracted factors from the available pre-test, post-test and follow-up questionnaires in a subsample (N = 6377). To select the best-fitted model, the BIC of different path models were compared. A Bayesian path analysis was performed to identify the most important factors to predict changes.

RESULTS

Effect sizes were large for the primary outcome and moderate for various secondary outcomes. Almost all pretreatment factors exerted significant influences on different baseline factors. Several factors were found to be resistant to change during treatment: suicidality, agoraphobia, life dissatisfaction, physical disability and pain. The strongest cross-loadings were observed from suicidality on negative cognitions, from agoraphobia on anxiety, and from physical disability on perceived disability.

LIMITATIONS

No causal conclusions can be drawn directly from our results as we only used cross-lagged panel data without control group.

CONCLUSIONS

The results indicate large effects of inpatient psychotherapy for depression in routine clinical care. The direct influence of pretreatment factors decreased over the course of treatment. However, some factors appeared stable and difficult to treat, which might hinder treatment outcome. Findings of different predictors of change are discussed.

Praxisorientierte Forschung in der Psychotherapie

Zusammenfassung. In den letzten Jahrzehnten hat sich durch randomisiert-kontrollierte Studien (RCTs) eine breite Evidenzbasis von Psychotherapie mit mittleren bis großen Effekten für verschiedene psychische Störungen gebildet. Neben der Bestimmung dieser Wirksamkeit („Efficacy“) ebneten Studien zur Wirksamkeit unter alltäglichen Routinebedingungen („Effectiveness“) historisch den Weg zur Entwicklung eines praxisorientierten Forschungsparadigmas. Im Beitrag wird argumentiert, dass im Rahmen dieses Paradigmas praxisbasierte Studien eine wertvolle Ergänzung zu RCTs darstellen, da sie existierende Probleme in der Psychotherapieforschung adressieren können. In der gegenwärtigen praxisorientierten Forschung liefern dabei neue Ansätze aus der personalisierten Medizin und Methoden aus der ‚Computational Psychiatry‘ wichtige Anhaltspunkte zur Optimierung von Effekten in der Psychotherapie. Im Kontext der Personalisierung werden bspw. klinische multivariable Prädiktionsmodelle entwickelt, welche durch Rückmeldeschleifen an Praktiker_innen kurzfristig ein evidenzbasiertes Outcome-Monitoring ermöglicht und langfristig das Praxis-Forschungsnetzwerk in Deutschland stärkt. Am Ende des Beitrags werden zukünftige Richtungen für die praxisorientierte Forschung im Sinne des ‘Precision Mental Health Care’ -Paradigmas abgeleitet und diskutiert.

Individual participant data systematic reviews with meta-analyses of psychotherapies for borderline personality disorder

INTRODUCTION

The heterogeneity in people with borderline personality disorder (BPD) and the range of specialised psychotherapies means that people with certain BPD characteristics might benefit more or less from different types of psychotherapy. Identifying moderating characteristics of individuals is a key to refine and tailor standard treatments so they match the specificities of the individual participant. The objective of this is to improve the quality of care and the individual outcomes. We will do so by performing three systematic reviews with meta-analyses of individual participant data (IPD). The aim of these reviews is to investigate potential predictors and moderating patient characteristics on treatment outcomes for patients with BPD.

METHODS AND ANALYSIS

We performed comprehensive searches in 22 databases and trial registries up to October 6th 2020. These will be updated with a top-up search up until June 2021. Our primary meta-analytic method will be the one-stage random-effects approach. To identify predictors, we will use the one-stage model that accounts for interaction between covariates and treatment allocation. Heterogeneity in case-mix will be assessed with a membership model based on a multinomial logistic regression where study membership is the outcome. A random-effects meta-analysis is chosen to account for expected levels of heterogeneity.

ETHICS AND DISSEMINATION

The statistical analyses will be conducted on anonymised data that have already been approved by the respective ethical committees that originally assessed the included trials. The three IPD reviews will be published in high-impact factor journals and their results will be presented at international conferences and national seminars.

PROSPERO REGISTRATION NUMBER

CRD42021210688.

Outcomes of brief versions of Dialectical Behaviour Therapy for diagnostically heterogeneous groups in a routine care setting

INTRODUCTION

Brief versions of Dialectical Behaviour Therapy (DBT) may enhance patient outcomes in diverse service settings. This study examined the effectiveness of two DBT-informed treatments for diagnostically heterogeneous groups in routine practice: 5-day group training in DBT skills (DBT-5) and a 12-week DBT program (DBT-12).

METHODS

: Depression, anxiety, stress, borderline symptoms, self-esteem, and general mental wellbeing were measured at pre-and post-treatment in a sample of inpatients and outpatients (N=395). Rates of clinically significant change on these measures were calculated and effect sizes benchmarked against prior DBT outcome studies. Readmission rates were used to measure treatment response maintenance.

RESULTS

: Scores on all measures improved significantly from pre- to post-treatment. DBT-5 and DBT-12 yielded similar effect sizes compared to prior DBT outcome studies. At least 43.5% of patients were classified as recovered or improved regarding borderline symptoms at the end of both DBT-5 and DBT-12. Readmission rates were also low (5%-6.8%).

CONCLUSIONS

Brief DBT-informed treatments may offer a fast reduction in symptoms and quicker return to functioning.