Evaluation of inpatient dialectical-behavioral therapy for borderline personality disorder--a prospective study

A systematic review and meta-analysis on the efficacy of dialectical behavior therapy variants for the treatment of post-traumatic stress disorder

Background: While there are well-established treatments for post-traumatic stress disorder (PTSD), these interventions appear to be less effective for individuals with comorbid borderline personality disorder (BPD) symptoms. Dialectical Behavior Therapy (DBT) for PTSD and DBT Prolonged Exposure (PE) are both effective interventions for treating these patients, but a comprehensive analysis evaluating the efficacy of these two interventions is lacking.Objective: To determine the effect sizes of PTSD-specific DBT treatments.Methods: We conducted a systematic review and pre-registered meta-analysis of the DBT literature for treating PTSD (osf.io/62rfq). Eligible trials and treatment evaluations published before September 2023 were searched in SCOPUS, PubMed, and the Cochrane Library databases. Thirteen articles were identified, and data were extracted for primary (PTSD symptoms) and secondary outcomes (BPD, depression, dissociation, non-suicidal self-injury [NSSI]). Treatment effects were calculated for randomised controlled trials, controlled clinical trials, and pre-post evaluations.Results: Overall, the studies involved 663 participants. Compared with control groups, PTSD-specific DBT treatments showed moderate effects in reducing PTSD symptom severity g = -0.69 (95% CI -1.03 to -0.34, p < .001) and depression g = -0.62 (95% CI -1.13 to -0.12, p = .016). Moreover, the pre-post changes showed an overall effect size for dissociative symptoms of g = -0.72 (95% CI -1.05 to -0.40, p < .001), for BPD-associated symptoms of g = -0.82 (95% CI -1.06 to -0.59, p < .001), and for NSSI frequency (g = -0.70, 95% CI -1.12 to -0.28, p = .001).Conclusions: Based on the results of our meta-analysis, DBT-PTSD and DBT PE were effective in reducing PTSD symptom severity and comorbid depressive symptoms. Further research on stage-based treatments should focus on systematically assessing NSSI, BPD symptoms, and suicidality.

Effects of intermittent theta burst stimulation add-on to dialectical behavioral therapy in borderline personality disorder: results of a randomized, sham-controlled pilot trial

Dialectical behavioral therapy (DBT) and repetitive transcranial magnetic stimulation (rTMS) are both effective in borderline personality disorder (BPD). We hypothesized that intermittent theta burst stimulation (iTBS), a modified rTMS protocol that provides unilateral stimulation to the left dorsolateral prefrontal cortex, would enhance the effects of DBT and reduce BPD-specific symptoms more than sham stimulation. We performed a single-blind, randomized, sham-controlled pilot study to evaluate iTBS as an add-on to 8-week DBT for BPD in routine inpatient treatment. A total of 53 BPD patients were randomly assigned to either iTBS (n = 25) or sham stimulation (n = 28) in weeks 4-8 of DBT; 40 patients were eligible for inclusion in the analyses according to pre-specified criteria (≥ 16 of 20 iTBS sessions). The primary endpoint was change on the 23-item Borderline Symptom List; secondary endpoints were changes in depressive symptoms and general level of functioning. A mixed model repeated measures analysis with a 2 × 2 factorial between-subjects design showed no significant effect of add-on iTBS treatment, but a distinct trend was observed in favor of iTBS (Cohen's d = 0.23 for group difference). We found a main effect of DBT with and without iTBS over time, indicating efficacy of 8 weeks' DBT (d = 0.89-1.12). iTBS may be beneficial as an add-on to DBT in the long term and warrants further evaluation in larger studies. Trial registration Registered at drks.de (no. DRKS00020413) on January 13, 2020.

Twenty years of research on borderline personality disorder: a scientometric analysis of hotspots, bursts, and research trends

Borderline personality disorder (BPD), a complex and severe psychiatric disorder, has become a topic of considerable interest to current researchers due to its high incidence and severity of consequences. There is a lack of a bibliometric analysis to visualize the history and developmental trends of researches in BPD. We retrieved 7919 relevant publications on the Web of Science platform and analyzed them using software CiteSpace (6.2.R4). The results showed that there has been an overall upward trend in research interest in BPD over the past two decades. Current research trends in BPD include neuroimaging, biological mechanisms, and cognitive, behavioral, and pathological studies. Recent trends have been identified as "prevention and early intervention", "non-pharmacological treatment" and "pathogenesis". The results are like a reference program that will help determine future research directions and priorities.

Theta burst stimulation add on to dialectical behavioral therapy in borderline-personality-disorder: methods and design of a randomized, single-blind, placebo-controlled pilot trial

Specialized psychotherapeutic treatments like dialectical behavioral therapy (DBT) are recommended as first treatment for borderline personality disorder (BPD). In recent years, studies have emerged that focus on repetitive transcranial magnetic stimulation (rTMS) in BPD. Both have independently demonstrated efficacy in the treatment of BPD. Intermitted theta burst stimulation (iTBS), a modified design of rTMS, is thought to increase the excitability of neurons and could be a supplement to psychotherapy in addition to being a standalone treatment. However, no studies to date have investigated the combination of DBT and rTMS/iTBS. This study protocol describes the methods and design of a randomized, single-blinded, sham-controlled clinical pilot study in which BPD patients will be randomly assigned to either iTBS or sham during four consecutive weeks (20 sessions in total) in addition to standardized DBT treatment. The stimulation will focus on the unilateral stimulation of the left dorsolateral prefrontal cortex (DLPFC), which plays an important role in the control of impulsivity and risk-taking. Primary outcome is the difference in borderline symptomatology, while secondary target criteria are depressive symptoms, general functional level, impulsivity and self-compassion. Statistical analysis of therapy response will be conducted by Mixed Model Repeated Measurement using a 2 × 2-factorial between-subjects design with the between-subject factor stimulation (TMS vs. Sham) and the within-subject factor time (T0 vs. T1). Furthermore, structural magnetic resonance imaging (MRI) will be conducted and analyzed. The study will provide evidence and insight on whether iTBS has an enhancing effect as add-on to DBT in BPD.Trial registration: drks.de (DRKS00020413) registered 13/01/2020.

Effective management of patients with borderline personality disorder in a busy acute inpatient ward using dialectical behaviour therapy principles

OBJECTIVE

The study aimed to highlight principles of Dialectical Behaviour Therapy (DBT) that can provide a framework in the management of patients with borderline personality disorder (BPD) and outline some guiding principles in the effective management of these patients on a busy acute inpatient ward.

CONCLUSIONS

The inpatient environment is often a place where invalidating experiences can occur. These include feeling ignored, misunderstood and where private experiences are trivialised or denied. Patients with BPD are extremely sensitive to these experiences and are likely to decompensate if strategies are not in place to facilitate a more validating experience during admission. The proposed guidelines are feasible to implement and support a cohesive treatment team and collaborative patient-centred care which is likely to improve patient outcomes.

[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.

Adapting dialectical behavior therapy in Mandarin-speaking Chinese patients with borderline personality disorder: An open pilot trial in Taiwan

INTRODUCTION

Dialectical behavior therapy (DBT) is the most commonly used treatment for patients suffering from borderline personality disorder (BPD). However, data on its applications in Asian countries remain lacking. This pilot study aims to evaluate the feasibility and effectiveness of applying Mandarin-translated DBT among suicidal Chinese patients with BPD in Taiwan.

METHODS

An open-label trial design was implemented for the 1-year standard DBT model. Patients from a psychiatric outpatient department in a general hospital in Taiwan with a history of ≥2 episodes of suicidal behavior within the previous year and who scored >40 on the Borderline Symptom List were invited to participate in this trial. Outcomes of suicidal behaviors, severity of BPD and depression symptoms, suicidal ideation, hopelessness, and quality of life were assessed at the beginning of the treatment and every 3 months until 12 months.

RESULTS

Eighteen patients participated, three of whom (16.7%) dropped out. Significant improvements were found in the frequency and severity of suicidal behaviors and ideations, depressive symptoms, and BPD symptoms beginning as early as the third month after initiating DBT.

DISCUSSION

This pilot study found that DBT may be an effective and feasible intervention for Mandarin-speaking individuals with a recent history of suicidal behaviors with BPD. Future randomized controlled trials with comparison groups are needed to further determine the efficacy of DBT on this population.

Characteristics of inpatients in dialectical behaviour therapy modified for a resource-limited setting

Background

Aim

Setting

Methods

Results

Conclusions

Efficacy and sustainability of dialectical behaviour therapy for inpatient adolescents: a follow-up study

Background

Dialectical behaviour therapy (DBT) is an evidence-based treatment for adolescents targeting suicidal and non-suicidal self-injurious behaviours. Research supports DBT's efficacy in inpatient settings, but implementation and sustainability are understudied.

Aims

This study is a follow-up of a previous study by Tebbett-Mock et al and examines the efficacy and sustainability of an adolescent DBT inpatient unit within a psychiatric hospital in the Northeast. We hypothesised that adolescents who received DBT in our follow-up group (DBT Group 2) would not have statistical difference (ie, greater or fewer) of the following compared with the first group of patients who received DBT on the unit the year prior (DBT Group 1) and would have significantly fewer of the following compared with the treatment as usual (TAU) group: (1) constant observation hours for suicidal ideation, self-injury and aggression; (2) incidents of suicide attempts, self-injury and aggression; (3) restraints; (4) seclusions; (5) days hospitalised; (6) times readmitted to the unit within 30 days of discharge.

Methods

We conducted a retrospective chart review for adolescents receiving inpatient DBT (DBT Group 1, n=425; DBT Group 2, n=393) and a historical control group (TAU, n=376). The χ² tests and one-way analysis of variance were conducted as preliminary analyses to examine group differences on diagnosis, gender and age. Kruskal-Wallis H tests were conducted to examine group differences on outcomes. Mann-Whitney U tests were used as post hoc analyses.

Results

Patients in DBT Group 2 were comparable to DBT Group 1 for the number of constant observation hours for self-injury (U=83 432.50, p=0.901), restraints (U=82 109, p=0.171) and days hospitalised (U=83 438.5, p=0.956). Patients in DBT Group 2 had a significantly greater number of incidents of suicide attempts compared with DBT Group 1 (U=82 662.5, p=0.037) and of self-injury compared with patients in DBT Group 1 (U=71724.5, p<0.001) and TAU (U=65649.0, p<0.001).

Conclusions

Results provide support for adolescent inpatient DBT compared with TAU and highlight staff turnover and lack of training as potential barriers to sustainability and efficacy.

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.

Interventions to reduce self-harm on in-patient wards: systematic review

BACKGROUND

Incidents of self-harm are common on psychiatric wards. There are a wide variety of therapeutic, social and environmental interventions that have shown some promise in reducing self-harm in in-patient settings, but there is no consensus on the most appropriate means of reducing and managing self-harm during in-patient admissions.

AIMS

To review interventions used to reduce self-harm and suicide attempts on adolescent and adult psychiatric in-patient wards.

METHOD

A systematic literature search was conducted between 14 March 2019 and 25 January 2021 using PsycINFO and Medline (PROSPERO ID: CRD42019129046). A total of 23 papers were identified for full review.

RESULTS

Interventions fell into two categories, therapeutic interventions given to individual patients and organisational interventions aimed at improving patient-staff communication and the overall ward milieu. Dialectical behaviour therapy was the most frequently implemented and effective therapeutic intervention, with seven of eight studies showing some benefit. Three of the six ward-based interventions reduced self-harm. Two studies that used a combined therapeutic and ward-based approach significantly reduced self-harm on the wards. The quality of the studies was highly variable, and some interventions were poorly described. There was no indication of harmful impact of any of the approaches reported in this review.

CONCLUSIONS

A number of approaches show some promise in reducing self-harm, but the evidence is not strong enough to recommend any particular approach. Current evidence remains weak overall but provides a foundation for a more robust programme of research aimed at providing a more substantial evidence base for this neglected problem on wards.

Self-esteem instability and affective instability in everyday life after remission from borderline personality disorder

BACKGROUND

Borderline personality disorder (BPD) is defined by a pervasive pattern of instability. According to prior findings and clinical theories, self-esteem instability and affective instability are key features of BPD. Previous e-diary studies showed that instability in self-esteem is heightened and that it is highly intertwined with affective instability in BPD in comparison to healthy controls (HC). The present study sought to extend these findings by adding symptomatologically remitted BPD patients (BPD-REM), i.e. former patients with BPD who met four or fewer BPD criteria within the past year, as a comparison group.

METHODS

To examine differences regarding self-esteem instability and affective instability, we used e-diaries for repeatedly collecting data on self-esteem, valence, and tense arousal 12 times a day for four consecutive days while participants underwent their daily life activities. Determining three different state-of-the-art instability indices and applying multilevel analyses, we compared 35 BPD-REM participants with previously reported 60 acute BPD patients (BPD-ACU) and 60 HC.

RESULTS

Our results revealed that self-esteem instability was significantly lower in the BPD-REM compared to the BPD-ACU group, irrespective of the instability index. In contrast, there were no significant differences regarding affective instability between the BPD-REM participants and those in the BPD-ACU group. The comparison between the BPD-REM with the HC indicated both a significantly higher instability in self-esteem as well as significantly heightened affective instability in the BPD-REM participants. Moreover, even though the associations were not significant, we found tentative support for the assumption that affective changes that are accompanied by changes in self-esteem are experienced as more burdensome and negatively impact the quality of life of remitted BPD participants.

CONCLUSIONS

This study builds on growing evidence for the importance of self-esteem instability in BPD. Whereas affective instability has been reported in various psychiatric disorders and might indeed constitute a transdiagnostic marker of affective dysregulation, our results indicate that self-esteem instability might be a specific symptom that construes the unique pathology in BPD.

Changes in Emotions Over the Course of Dialectical Behavior Therapy and the Moderating Role of Depression, Anxiety, and Posttraumatic Stress Disorder

Evidence-based borderline personality disorder (BPD) treatments such as dialectical behavior therapy (DBT) emphasize the acquisition and use of strategies to down regulate negative emotion. However, little research examines whether specific emotions change during DBT. Further, it is unclear if BPD-relevant comorbidities that involve heightened emotion-namely, depression, anxiety disorders, and posttraumatic stress disorder (PTSD)-moderate these outcomes. This study investigated which specific emotions (hostility/anger, fear, shame/guilt, and sadness) decrease during DBT, and whether comorbid depression, anxiety disorders, and PTSD moderate these outcomes. Individuals with BPD (N = 101) completed 6 months of standard DBT and provided measurements of specific emotions at every session and at pre-, mid-, and posttreatment. Generalized estimating equations revealed moderate effect-sized reductions in anger at major assessment time points. Anxiety disorders and PTSD moderated the effect of time on fear, shame, and guilt. PTSD also moderated the effect of time on sadness. For all moderating effects, individuals with the comorbidity exhibited greater reductions than those without. These findings corroborate that DBT reduces several specific emotions, and comorbid PTSD and anxiety disorders may facilitate this effect for fear, shame/guilt, and sadness (clinical trial registration number = NCT03123198).

How to Assess Recovery in Borderline Personality Disorder: Psychosocial Functioning and Satisfaction With Life in a Sample of Former DBT Study Patients

Longitudinal studies provide substantial evidence for a high rate of symptomatic remission in borderline personality disorder (BPD), while social and vocational functioning seems to remain consistently impaired. Less data is available on recovery and the associated objective and personal indicators. We examined 58 patients 12-18 years after their diagnosis of BPD and compared two different recovery criteria: observer-based global assessment of functioning and self-rated satisfaction with life (SWL). Symptomatic remission was observed in 81% of the participants (according to DSM-IV), but only 44% of them achieved a GAF level > 60, and only 49% reported SWL within the range of one standard deviation of the normal population. In line with previous research, our data show that DSM symptom remission alone is an insufficient indicator for recovery from BPD. Replacing the GAF with patient-reported satisfaction with life considers empowerment in BPD and offers an efficient alternative criterion for recovery.

Theoretical Model of Mindful Coping Power: Optimizing a Cognitive Behavioral Program for High-Risk Children and Their Parents by Integrating Mindfulness

This paper describes a theoretical model of Mindful Coping Power, a preventive intervention targeting high-risk children and their parents. Mindful Coping Power integrated mindfulness into Coping Power, an evidence-based cognitive behavioral intervention. Reactive aggression is emotionally driven, impulsive, and often referred to as being "hot-blooded." It has been resistant to change, given the high level of emotional arousal and impulsive angry outbursts. Our premise is that mindfulness impacts the mechanisms of reactive aggression-attentional, cognitive, behavioral, and emotional dysregulation. Also in the model are parents who exhibit emotionally charged interactions with their child. Mindful parenting focuses on parents' own emotional self-regulation and being fully present with their child. Our model sets the stage for incorporating mindfulness into existing interventions, thereby optimizing programs and maximizing effects.

Severity of borderline personality disorder symptoms as a moderator of the association between the use of dialectical behaviour therapy skills and treatment outcomes

A core aspect of Dialectical Behaviour Therapy (DBT) is the acquisition and use of DBT skills to replace maladaptive behaviours. However, it is unclear whether DBT skill use is associated with differential reductions in psychological distress across individuals with varying severities of borderline personality disorder (BPD) symptoms. In the current study, moderated mediation analyses were conducted to examine the relationships among DBT skill use and attitudes towards skill use, pre-treatment BPD symptom severity and changes in psychological distress over the course of a 12-week DBT-informed program in a sample of outpatients with mixed psychopathology (N = 102), including a minority with BPD (N = 16). It was predicted that (i) self-reported use of the four types of DBT skills (mindfulness, emotion regulation, distress tolerance and interpersonal effectiveness) and (ii) patient attitudes towards these skills (confidence and perceived effectiveness) would be associated with greater improvements in psychological distress in individuals with higher levels of BPD symptoms compared to individuals with lower levels of BPD symptoms. Results supported this hypothesis, indicating that self-reported DBT skill use and attitudes towards DBT skills are associated with differential patterns of reductions in psychological distress.

Efficacy of Dialectical Behavior Therapy Versus Treatment as Usual for Acute-Care Inpatient Adolescents

OBJECTIVE

Dialectical behavior therapy (DBT) is an evidence-based treatment that targets suicidal behavior and nonsuicidal self-injury (NSSI) and has been adapted for adolescents. Given the seriousness of these behaviors, many adolescents are psychiatrically hospitalized, but minimal research has been conducted on specific interventions during hospitalization. The goal of this study was to evaluate DBT versus treatment as usual (TAU) for adolescents on an acute-care psychiatric inpatient unit.

METHOD

We conducted a retrospective chart review for adolescents receiving inpatient DBT (n = 425) and for a historical control group treated on the same unit before DBT (ie, TAU, n = 376). Both χ² and t tests were conducted as preliminary analyses to examine differences between groups on diagnosis, sex, and age. Mann-Whitney U tests were conducted to examine differences between groups on outcome variables. The potential benefit of cost savings was analyzed.

RESULTS

Patients who received DBT had significantly fewer constant observation (CO) hours for self-injury; incidents of suicide attempts and self-injury; restraints; and days hospitalized compared to patients who received TAU. Statistically significant differences were not found between DBT and TAU groups for number of CO hours for aggression, incidents of aggression toward patients or staff, seclusions, or readmissions. A cost analysis determined that $251,609 less was spent on staff time for CO hours with DBT compared to TAU.

CONCLUSION

Results provide support for the implementation of DBT in an acute-care adolescent psychiatric inpatient unit for adolescents. Clinical implications, study limitations, and future research directions are discussed.

Effectiveness of a 5-Week Inpatient Dialectical Behavior Therapy for Borderline Personality Disorder

OBJECTIVE

The goal of this study was to evaluate whether symptoms are reduced and emotion regulation improves when patients with borderline personality disorder (BPD) receive a 5-week course of inpatient dialectical behavioral therapy (DBT) and if changes in emotion regulation are associated with changes in symptoms.

METHODS

Forty-four patients with BPD receiving a 5-week course of DBT in a German psychiatry clinic participated. The short version of the "Borderline Symptom List" (BSL-23) was the patient-reported outcome. To measure emotion regulation, the "Self-Report Measure for the Assessment of Emotion Regulation Skills" (SEK-27) was administered. Wilcoxon tests were performed to evaluate whether pre-post changes in the BSL-23 and SEK-27 reached statistical significance. Effect sizes (d) were calculated and correlations between the pre-post differences for both measures were computed to test associations between changes in emotion regulation and changes in symptoms. Completer (n=33) and intention-to-treat (n=43) analyses were performed.

RESULTS

Symptoms (BSL-23) were reduced and emotion regulation (SEK-27) improved during the 5-week inpatient DBT treatment (completer and intention-to-treat analysis: P<0.001). Effect sizes reached d=0.47 for the BSL-23 and d=0.84 for the SEK-27 in the completer analysis, and d=0.38 for the BSL-23 and d=0.68 for the SEK-27 in the intention-to-treat analysis. Improvements in emotion regulation (SEK-27) were correlated with reductions in symptoms (BSL-23) in both the completer (r=0.54; P=0.001) and the intention-to-treat (r=0.59; P<0.001) analyses.

CONCLUSIONS

These findings indicate that a 5-week course of inpatient DBT can effectively reduce symptoms in patients with BPD and that the more patients' emotion regulation improves, the more the patients benefit from the therapy.

A qualitative analysis of suicidal psychiatric inpatients views and expectations of psychological therapy to counter suicidal thoughts, acts and deaths

BACKGROUND

Suicide is a global problem and suicidal behavior is common in acute psychiatric wards. Inpatient suicides regularly occur with 10.4/100,000 such deaths recorded in the UK in 2016. Inpatient suicides are potentially the most avoidable of all suicides as inpatients have 24-h staff contact. Current inpatient treatment prioritizes maintenance of physical safety by observation, medication and general supportive measures, however efficacious and effective specific treatments are lacking. Psychological treatments have a growing evidence base for suicide prevention yet provision of inpatient therapy is uncommon. The present qualitative study aimed to understand the patient acceptability issues by investigating suicidal inpatients views and expectations of a novel suicide-focussed cognitive behavioural psychological therapy which was nested alongside a pilot clinical trial of the intervention.

METHODS

Thematic analysis of semi-structured individual qualitative interviews with twenty suicidal psychiatric inpatients to investigate their views and expectations about ward-based suicide-focused psychological treatment.

RESULTS

Two main themes were identified. The first, 'A therapy that works', revealed inpatients' views of the necessary components for effective ward-based suicide-focused psychological therapy. The second, 'Concerns about in-patient suicide-focused therapy', depicted their fears about engaging in this treatment. Results suggested that suicide-focused psychological therapy was cautiously welcomed by inpatients' whose narratives expressed their needs, priorities and concerns. Further data analysis enabled formation of a user-informed model of suicide-focussed psychological therapy which offers guidance for researchers and clinicians.

CONCLUSIONS

We conclude that hospitalization of suicidal individuals offers a critical opportunity to intervene with effective treatment to preserve life and that suicide-focussed psychological therapy is likely to be well received by suicidal inpatients warranting further testing with a sufficiently powered definitive trial. It is important that provision of ward-based psychological therapy for suicidal inpatients addresses the considerable context-specific challenges inherent in this setting.

TRIAL REGISTRATION NUMBER

ISRCTN 17890126 , Registry: UK Clinical Trials Gateway, Date of registration: 22/04/15, Date of enrolment of first participant to the trial: 20/05/14 (retrospectively registered).

A naturalistic longitudinal study of extended inpatient treatment for adults with borderline personality disorder: An examination of treatment response, remission and deterioration

BACKGROUND

Experts express reluctance to hospitalize patients with borderline personality disorder (BPD) for more than a few days, arguing that extended inpatient care leads to deterioration and adverse events. To date, there is no empirical support for these assertions.

AIMS

The current study examined the assumption of iatrogenic effects among BPD adults.

METHODS

Clinically significant and reliable change in symptoms, functional capacities, and adverse events were quantified for both inpatients with BPD (n = 245) and a well-matched inpatient reference (n = 220) sample. Latent growth curve (LGC) models were used to evaluate moderators of the trajectory of PHQ-9 depression scores over the course of hospitalization.

RESULTS

Large effect size improvements were observed in depression, anxiety, suicidal ideation and functional disability among patients with BPD (Cohen's d ≥ 1.0) and those in the reference sample (Cohen's d ≥ .80). Clinical deterioration and adverse events were rare (occurring in no more than 1.1% of BPD and reference patients on any outcome) with no difference across patient cohorts. BPD diagnosis failed to influence the trajectory of continuous depression severity. Rather, trait emotion dysregulation was associated with initial depression severity.

CONCLUSIONS

Twenty-five years ago it was assumed that adults with BPD could not benefit from psychiatric treatment. Today there are a number of effective evidence-based outpatient treatments for BPD, but beliefs about extended inpatient treatment have changed little. Current results indicate that extended inpatient treatment can result in significant and clinically meaningful symptomatic and functional improvement in BPD patients without iatrogenic effects.

DNA methylation of APBA3 and MCF2 in borderline personality disorder: Potential biomarkers for response to psychotherapy

Borderline personality disorder (BPD) is a severe and complex mental disease associated with high suicidal tendencies and hospitalization rates. Accumulating evidence suggests that epigenetic mechanisms are implicated in the etiology of BPD. A recent epigenome-wide study identified several novel genes which are epigenetically dysregulated in BPD. Those genes include APBA3 and MCF2. Psychotherapy such as Dialectical Behavior Therapy (DBT), an established treatment for BPD, provides an excellent setting to investigate environmental influences on epigenetic mechanisms in order to identify biomarkers for disease status and therapy success. However, the effects of DBT on epigenetic regulation has only been researched in one previous study analyzing BDNF. In the present study, we aimed to investigate the role of DNA methylation of APBA3 and MCF2 as possible biomarkers for treatment outcome in BPD, whilst validating the previous findings of differential DNA methylation in a cohort of 44 BPD patients and 44 well-matched healthy control individuals. Unexpectedly, we did not detect significant DNA methylation differences between patients and control individuals. However, we found a high correlation between the methylation status of APBA3 and MCF2 and therapy outcome: before DBT treatment, both genes were significantly higher methylated in patients responding to therapy compared to patients that did not respond. Our study is the first to report results pointing to possible predictive epigenetic biomarkers of DBT outcome in BPD patients. Following replication in independent cohorts, our finding could facilitate the development of more personalized therapy concepts for BPD patients by including epigenetic information.

Repeated self-injury: perspectives from general psychiatry

Patients who repeatedly injure themselves present particular management problems for general psychiatric teams. This article, the first of a series of four, examines the characteristics of those that present to adult mental health services, and the possible underlying background and trigger factors that lead to these anxiety-raising events. Suggestions are made on preventive and assessment procedures, staff reactions and management strategies aimed at helping patients deal with the overwhelming feelings that underlie self-injury.

Assessing the marks of change: how psychotherapy alters the brain structure in women with borderline personality disorder

BACKGROUND

There is increasing evidence that psychotherapy can alter the function of the brain of patients with borderline personality disorder (BPD). However, it is not known whether psychotherapy can also modify the brain structure of patients with BPD.

METHODS

We used structural MRI data of female patients with BPD before and after participation in 12 weeks of residential dialectical behavioural therapy (DBT) and compared them to data from female patients with BPD who received treatment as usual (TAU). We applied voxel-based morphometry to study voxel-wise changes in grey matter volume over time.

RESULTS

We included 31 patients in the DBT group and 17 in the TAU group. Patients receiving DBT showed an increase of grey matter volume in the anterior cingulate cortex, inferior frontal gyrus and superior temporal gyrus together with an alteration of grey matter volume in the angular gyrus and supramarginal gyrus compared with patients receiving TAU. Furthermore, therapy response correlated with increase of grey matter volume in the angular gyrus.

LIMITATIONS

Only women were investigated, and groups differed in size, medication (controlled for) and intensity of the treatment condition.

CONCLUSION

We found that DBT increased grey matter volume of brain regions that are critically implicated in emotion regulation and higher-order functions, such as mentalizing. The role of the angular gyrus for treatment response may reside in its cross-modal integrative function. These findings enhance our understanding of psychotherapy mechanisms of change and may foster the development of neurobiologically informed therapeutic interventions.

A standardized crisis management model for self-harming and suicidal individuals with three or more diagnostic criteria of borderline personality disorder: The Brief Admission Skåne randomized controlled trial protocol (BASRCT)

BACKGROUND

Brief Admission is a crisis and risk management strategy in which self-harming and suicidal individuals with three or more diagnostic criteria of borderline personality disorder self-admit to hospital at times of increasing risk when other efforts to stay safe are failing. Standardized in the current randomized controlled trial, the intensity of Brief Admission Skåne is implemented in durations of three days, with a maximum frequency of three times a month. Brief Admission is integrated into existing treatment plans in advance of crises to prevent reliance on general psychiatric admissions for risk management, as these may be lengthy, unstructured, and of uncertain therapeutic value.

METHODS/DESIGN

The overall objective of the Brief Admission Skåne randomized controlled trial is to determine if Brief Admission can replace general psychiatric admission for self-harming and suicidal individuals with complex mental illness at times of escalating risk. Other objectives of the study are to evaluate whether Brief Admission increases daily functioning and enhances coping, reduces psychiatric symptoms including frequency and severity of self-harm and suicidal behaviours. A final objective is to determine if Brief Admission is an effective crisis management model for this population. Participants are randomized at an individual level to either Brief Admission Skåne plus Treatment as Usual or Treatment As Usual. Based on a priori power analyses, N = 124 participants will be recruited to the study. Data collection is in progress, and will continue until June 2018. All participant data are single-blinded and will be handled with intention-to-treat analysis.

DISCUSSION

Based on the combined clinical experience of our international research group, the Brief Admission Skåne randomized controlled trial upon which the current protocol is based represents the first initiative to standardize, implement and evaluate Brief Admission amongst self-harming and suicidal individuals, including those with borderline traits. Objectively measuring protocol fidelity and developing English-language Brief Admission study protocols and training materials are implementation and dissemination targets developed in order to facilitate adherent international export of Brief Admission Skåne.

TRIAL REGISTRATION

NCT02985047 . Registered November 25, 2016. Retrospectively registered.

A Meta-analysis on the Association Between Emotional Awareness and Borderline Personality Pathology

Theories on borderline personality pathology (BPP) suggest that characteristic emotional dysregulation is due to low levels of emotional awareness or alexithymia. This study is the first meta-analysis to systematically review and analyze the evidence. A systematic search of the literature was performed using PsycInfo, Web of Science/MEDLINE, and Scopus. The term "borderline personality disorder" was searched for in conjunction with "emotional awareness," "emotional self-awareness," "emotion recognition," "alexithymia," "emotional processing," "emotional granularity," "emotional intelligence," or "emotion regulation." All references in the included studies were reviewed for additional relevant articles. Thirty-nine studies were then evaluated in a random effects meta-analysis to assess the association between BPP and emotional awareness. An overall moderate positive association between BPP and emotional awareness was significant (r = 0.359; 95% CI [0.283, 0.431]; Z = 8.678; p < 0.001) along with high heterogeneity (Q(38) = 456.7; p < .001; I² = 91.7%). Studies comparing borderline personality disorder to healthy controls yielded a strong association (r = 0.518; 95% CI [0.411, 0.611]). No significant difference was found between studies using instruments for emotional awareness and those using alexithymia instruments. The strongest associations with regard to aspects of alexithymia were found for difficulties in identifying and describing emotions rather than externally oriented thinking. The results corroborate a moderate relationship between low emotional awareness and BPP. However, the mono-method self-report used in almost all studies is found problematic and precludes drawing definite conclusions. Since leading psychotherapeutic treatments strongly focus on increasing emotional awareness, future research should address this issue and further examine to what extent low levels of emotional awareness, particularly alexithymia, can be treated.

Neural correlates of distraction in borderline personality disorder before and after dialectical behavior therapy

Neural underpinnings of emotion dysregulation in borderline personality disorder (BPD) are characterized by limbic hyperactivity and disturbed prefrontal activity. It is unknown whether neural correlates of emotion regulation change after a psychotherapy which has the goal to improve emotion dysregulation in BPD, such as dialectical behavioral therapy (DBT). We investigated distraction as a main emotion regulation strategy before and after DBT in female patients with BPD. Thirty-one BPD patients were instructed to either passively view or memorize letters before being confronted with negative or neutral pictures in a distraction task during functional magnetic resonance imaging. This paradigm was applied before and after a 12-week residential DBT-based treatment program. We compared the DBT group to 15 BPD control patients, who continued their usual, non-DBT-based treatment or did not have any treatment, and 22 healthy participants. Behaviorally, BPD groups and healthy participants did not differ significantly with respect to alterations over time. On the neural level, BPD patients who received DBT-based treatment showed an activity decrease in the right inferior parietal lobe/supramarginal gyrus during distraction from negative rather than neutral stimuli when compared to both control groups. This decrease was correlated with improvement in self-reported borderline symptom severity. DBT responders exhibited decreased right perigenual anterior cingulate activity when viewing negative (rather than neutral) pictures. In conclusion, our findings reveal changes in neural activity associated with distraction during emotion processing after DBT in patients with BPD. These changes point to lower emotional susceptibility during distraction after BPD symptom improvement.

Tolerability and suitability of brief group mindfulness-oriented interventions in psychiatric inpatients: a pilot study

OBJECTIVE

Mindfulness-oriented therapies have a positive impact on patients' overall well-being and alleviate many psychiatric conditions. However, little is known about their use in people with severe mental illness. We aimed to identify which clinical and sociodemographic factors are associated with suitability/tolerability of a brief group mindfulness-oriented therapy.

METHODS

This retrospective study examines pre-/post-data from 40 psychiatric inpatients who underwent one session of a 10-min mindfulness-oriented group intervention between January and March 2014. The main outcome was 'suitability for and tolerating the brief mindfulness-oriented group intervention'. We assessed potential correlates of the main outcome, including female gender, shorter hospitalisation, the absence of psychosis and good pre-morbid functioning.

RESULTS

The intervention was well tolerated (92.5%) and 50% of patients met both of our relatively stringent suitability and tolerability criteria. Sociodemographic and clinical variables were not associated with suitability/tolerability. Tai chi was the most suitable/tolerable compared to body scan and mindful eating (76.5% vs. 35.7% vs. 22.2%, Fisher's exact p = 0.01, Bonferroni p < 0.05).

CONCLUSIONS

Brief group mindfulness therapy interventions are very well tolerated and often suitable for acutely hospitalised psychiatric inpatients, including those with acute psychosis. Mindfulness-oriented intervention with an active component (e.g., tai chi, mindful walking) may potentially be best suited for this population.

Dialectical Behavior Therapy for Suicidal Adolescent Inpatients

Dialectical behavior therapy (DBT) is an empirically supported treatment for chronically parasuicidal adult women with borderline personality disorder. It has recently been modified for use with other psychiatric disorders and populations. In this article, the authors briefly review the theoretical and research basis for the use of DBT with parasuicidal adolescent inpatients, and a case study is presented. The case study includes a DBT case formulation, and its application to the inpatient management of a chronically parasuicidal adolescent is described. This adolescent had significant difficulties engaging in treatment and required use of DBT commitment strategies, which are reviewed. The authors also describe (a) the use of a stage theory of treatment, (b) the application of Linehan's biosocial theory, (c) use of behavioral analysis of parasuicidal behavior, and (d) dialectical treatment of this patient. Finally, 1-year follow-up data on this patient are presented.

Assertive Anger Mediates Effects of Dialectical Behaviour-informed Skills Training for Borderline Personality Disorder: A Randomized Controlled Trial

Dialectical behaviour therapy (DBT)-informed skills training for borderline personality disorder (BPD) aims at the development of specific emotion regulation skills in patients, particularly with regard to the regulation of problematic anger. While the effects of dialectical behaviour skills training have been shown, their processes of change are rarely examined. Neacsiu, Rizvi and Linehan (2010) found that patient's self-reported use of emotion regulation skills was a mediator of therapeutic change in these treatments; however, they found no effect for problematic anger. From an integrative perspective on anger (Pascual-Leone & Greenberg, 2007; Pascual-Leone & Paivio, 2013), there are several forms of anger, varying in their degree of therapeutic productivity. The present add-on randomized controlled trial included n = 41 patients with BPD (n = 21 DBT-informed skills training versus n = 20 treatment as usual). The first study examined the outcome of the DBT-informed skills training encompassing basic components of training in mindfulness, distress tolerance, interpersonal effectiveness and emotion regulation. Results showed that symptom reduction was significantly greater in the DBT-informed skills training, compared with the treatment as usual. The second study used process assessment, for which all patient completers underwent a 50-min-long psychological interview both early and late in treatment, which was rated using the Classification of Affective Meaning States. DBT-informed skills training produced increased levels of primary 'assertive' anger, as compared with the treatment as usual, whereas no effect was found for 'rejecting' secondary anger. Most importantly, we showed that changes in assertive anger mediated the reported symptom reduction, in particular in patient's social roles. We discuss these results in the context of underlying mechanisms of change in DBT skills group treatments, in particular towards developing more productive forms of anger in this patient population. Copyright © 2015 John Wiley & Sons, Ltd.

KEY PRACTITIONER MESSAGE

A 20-session dialectical behaviour therapy (DBT)-informed skills training is a promising adjunct intervention for patients with borderline personality disorder, in particular for reducing problems related to social role. Increases in assertive anger mediate the effects of DBT-informed skills training, whereas rejecting anger remains unchanged over the course of treatment. Short-term objectives for intervention might involve the specific increase of assertive anger in BPD, by using DBT-informed skills training; long-term objectives for intervention might involve a specific decrease of rejecting anger in BPD.

Effectiveness of group dialectical behavior therapy (based on core distress tolerance and emotion regulation components) one expulsive anger and impulsive behaviors

INTRODUCTION

The purpose of this study is to measure Effectiveness of group dialectical behavior therapy (based on core distress tolerance and emotion regulation components) on Expulsive Anger and Impulsive Behaviors.

MATERIALS & METHODS

Research method is a semi experimental socio-statistic approach consisting of experimental group (dialectical behavior therapy) and control group. Participants were patients referred to Amir Kabir Hospital in Arak who suffered from Expulsive Anger and Impulsive Behaviors. Based on stratified random sampling, 16 patients (women) were placed in each group. Research tools included the structured diagnosis interview according to DSM-IV-TR (2000), Barrat impulsivity scale(1994) Distress Tolerance Scale (2005) Difficulties of Emotion Regulation Scale (2004) and dialectical behavior therapy were done for two months,8 group-sessions).

FINDINGS

Dialectical behavior therapy was effective on Expulsive Anger and Impulsive Behaviors.

DISCUSSION & CONCLUSION

Distress tolerance and emotion regulation components were effective on Expulsive Anger and Impulsive Behaviors.

Non-suicidal self-injury during an exposure-based treatment in patients with posttraumatic stress disorder and borderline features

Patients with posttraumatic stress disorder (PTSD) and features of borderline personality disorder (BPD) often show non-suicidal self-injury (NSSI). However, patients with on-going NSSI are mostly excluded from PTSD treatments and NSSI during PTSD treatment has rarely been investigated. The aim of the present study was to evaluate the course of NSSI during an exposure-based PTSD treatment. This study focused on a subset (n = 34) of data from a randomised controlled trial that tested the efficacy of a residential PTSD programme (DBT-PTSD) in comparison to a treatment-as-usual wait-list. In this subset we compared a) NSSI during treatment between participants who had or had not engaged in NSSI pre-treatment and b) NSSI between treatment weeks that included exposure interventions vs. those that did not. We further compared the outcome between participants with vs. without NSSI at pre-treatment. At pre-treatment, 62% participants reported on-going NSSI. During treatment, the percentage of participants carrying out NSSI decreased to 38% (p = 0.003). The rates of NSSI were similar in treatment weeks with exposure compared to weeks without. Similar results were observed for the frequency of NSSI. At the end of treatment, participants showed comparable improvement in PTSD symptoms regardless of whether or not they had exhibited NSSI beforehand.

Three-week inpatient Cognitive Evolutionary Therapy (CET) for patients with personality disorders: evidence of effectiveness in symptoms reduction and improved treatment adherence

OBJECTIVES

The aim of this study was to evaluate the efficacy of Cognitive Evolutionary Therapy (CET) in an intensive short residential treatment of a wide range of severe personality disorders (PDs) that resulted in a reduction of social functioning and significant personal distress.

DESIGN

Each patient was assessed at admission, discharge, and 3 months later in order to determine if there was a reduction in symptoms and an improved adherence to former outpatient programs and to check if patients were undergoing new treatment after discharge.

METHOD

Fifty-one patients participated in this study. The 20-hr weekly program consisted of two individual sessions and various group modules. Outcome measures included: self-reported measures of depression, anxiety, general symptoms, number and duration of inpatient admissions after the programme, and continuation in an outpatient treatment programme.

RESULTS

The results show an overall improvement in general psychopathology after the release and in follow-up sessions, a decrease in the number of further hospital admissions, and an increased level of attendance of outpatient therapy.

CONCLUSIONS

This study shows that intensive short residential treatment is an effective treatment for patients with a wide range of PDs.

A Proof of Concept for Using Brief Dialectical Behavior Therapy as a Treatment for Problem Gambling

Fourteen ‘treatment resistant’ problem gamblers received 9 weeks of Dialectical Behavior Therapy (DBT) at specialist problem gambling services delivered in Melbourne, Australia. This study is the first to investigate the effectiveness of a brief DBT treatment for problem gambling, with a focus on measuring change in the four DBT process skills (mindfulness, distress tolerance, emotion dysregulation, and negative relationships). Although there were no statistically significant improvements in measures of gambling behaviour, 83% of participants were abstinent or reduced their gambling expenditure pre- to post-treatment. Participants also reported statistically and clinically significant improvements in psychological distress, mindfulness, and distress tolerance. Moreover, there were no increases in alcohol or substance use. These results are discussed in the context of focusing on a single DBT process skill, and the benefits of using group-based approaches.

Altered sleep in Borderline Personality Disorder in relation to the core dimensions of psychopathology

The aim of the study was to review the literature regarding sleep disturbances in Borderline Personality Disorder (BPD) and to relate the reported sleep alterations to the underlying core dimensions of BPD pathology. We present a qualitative and theoretical review regarding the empirical studies that investigated objective and subjective sleep quality in BPD and in different psychiatric conditions showing high co-morbidity with this disorder. We show that disturbed sleep including sleep fragmentation, alterations in Slow Wave Sleep and REM sleep, and dysphoric dreaming are prevalent symptoms in BPD. We provide a framework relating the specific sleep alterations to the core dimensions of BPD pathology in order to clarify the inconsistencies of the different findings. The specific sleep disturbances in BPD seem to be related to different dimensions of psychopathological functioning and may have detrimental consequences on waking affect and cognition. Investigating disturbed sleep in BPD in relation to waking symptoms and underlying neural functioning would shed more light on the nature of this complex disorder. Moreover, a stronger emphasis on sleep disturbances would enrich the treatment protocols of BPD.

A randomized, controlled, pilot study of dialectical behavior therapy skills in a psychoeducational group for individuals with bipolar disorder

BACKGROUND

Bipolar disorder (BD) is a chronic and disabling psychiatric disorder characterized by recurrent episodes of mania/hypomania and depression. Dialectical behavior therapy (DBT) techniques have been shown to effectively treat borderline personality disorder, a condition also marked by prominent affective disturbances. The utility of DBT techniques in treating BD has been largely unexplored. The purpose of this research was to conduct a pilot study of a DBT-based psychoeducational group (BDG) in treating euthymic, depressed, or hypomanic Bipolar I or II patients.

METHODS

In this experiment, 26 adults with bipolar I or II were randomized to intervention or wait-list control groups and completed the Beck depression inventory II, mindfulness-based self-efficacy scale, and affective control scale at baseline and 12 weeks. The BDG intervention consisted of 12 weekly 90-min sessions which taught DBT skills, mindfulness techniques, and general BD psychoeducation.

RESULTS

Using RM-ANOVA, subjects in BDG demonstrated a trend toward reduced depressive symptoms, and significant improvement in several MSES subscales indicating greater mindful awareness, and less fear toward and more control of emotional states (ACS). These findings were supported with a larger sample of patients who completed the BDG. Furthermore, group attendees had reduced emergency room visits and mental health related admissions in the six months following BDG.

LIMITATIONS

The small sample size in RCT affects power to detect between group differences. How well improvements after the12-week BDG were maintained is unknown.

CONCLUSIONS

There is preliminary evidence that DBT skills reduce depressive symptoms, improve affective control, and improve mindfulness self-efficacy in BD. Its application warrants further evaluation in larger studies.

Utilization of evidenced based dialectical behavioral therapy in assertive community treatment: examining feasibility and challenges

Assertive Community Treatment (ACT) programs have been treating individuals with chronic and severe mental illness since the 1970s. While ACT programs were developed to address the treatment needs of severely mentally ill persons traditionally suffering from chronic mental illnesses, ACT programs are seeing a growing number of persons with co-morbid personality disorders. The efficacy of traditional ACT programs in treating individuals with co-occurring personality disorders is uncertain, in particular individuals with co-morbid Borderline Personality Disorder (BPD). Dialectical Behavior Therapy (DBT) has been proposed as an effective approach to treating clients with BPD in this setting. The purpose of this paper is to examine the value of DBT for individuals with BPD in ACT programs. The writers discuss the prevalence of Borderline Personality Disorders in ACT populations, briefly review the literature on DBT in ACT, address the feasibility of implementing DBT in an ACT model, examine potential barriers to this implementation, and highlight potential areas for future research.

Psychological therapies for people with borderline personality disorder

BACKGROUND

Psychotherapy is regarded as the first-line treatment for people with borderline personality disorder. In recent years, several disorder-specific interventions have been developed. This is an update of a review published in the Cochrane Database of Systematic Reviews in 2006.

OBJECTIVES

To assess the effects of psychological interventions for borderline personality disorder (BPD).

SEARCH METHODS

We searched the following databases: CENTRAL 2010(3), MEDLINE (1950 to October 2010), EMBASE (1980 to 2010, week 39), ASSIA (1987 to November 2010), BIOSIS (1985 to October 2010), CINAHL (1982 to October 2010), Dissertation Abstracts International (31 January 2011), National Criminal Justice Reference Service Abstracts (15 October 2010), PsycINFO (1872 to October Week 1 2010), Science Citation Index (1970 to 10 October 2010), Social Science Citation Index (1970 to 10 October 2010), Sociological Abstracts (1963 to October 2010), ZETOC (15 October 2010) and the metaRegister of Controlled Trials (15 October 2010). In addition, we searched Dissertation Abstracts International in January 2011 and ICTRP in August 2011.

SELECTION CRITERIA

Randomised studies with samples of patients with BPD comparing a specific psychotherapeutic intervention against a control intervention without any specific mode of action or against a comparative specific psychotherapeutic intervention. Outcomes included overall BPD severity, BPD symptoms (DSM-IV criteria), psychopathology associated with but not specific to BPD, attrition and adverse effects.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed the risk of bias in the studies and extracted data.

MAIN RESULTS

Twenty-eight studies involving a total of 1804 participants with BPD were included. Interventions were classified as comprehensive psychotherapies if they included individual psychotherapy as a substantial part of the treatment programme, or as non-comprehensive if they did not.Among comprehensive psychotherapies, dialectical behaviour therapy (DBT), mentalisation-based treatment in a partial hospitalisation setting (MBT-PH), outpatient MBT (MBT-out), transference-focused therapy (TFP), cognitive behavioural therapy (CBT), dynamic deconstructive psychotherapy (DDP), interpersonal psychotherapy (IPT) and interpersonal therapy for BPD (IPT-BPD) were tested against a control condition. Direct comparisons of comprehensive psychotherapies included DBT versus client-centered therapy (CCT); schema-focused therapy (SFT) versus TFP; SFT versus SFT plus telephone availability of therapist in case of crisis (SFT+TA); cognitive therapy (CT) versus CCT, and CT versus IPT.Non-comprehensive psychotherapeutic interventions comprised DBT-group skills training only (DBT-ST), emotion regulation group therapy (ERG), schema-focused group therapy (SFT-G), systems training for emotional predictability and problem solving for borderline personality disorder (STEPPS), STEPPS plus individual therapy (STEPPS+IT), manual-assisted cognitive treatment (MACT) and psychoeducation (PE). The only direct comparison of an non-comprehensive psychotherapeutic intervention against another was MACT versus MACT plus therapeutic assessment (MACT+). Inpatient treatment was examined in one study where DBT for PTSD (DBT-PTSD) was compared with a waiting list control. No trials were identified for cognitive analytical therapy (CAT).Data were sparse for individual interventions, and allowed for meta-analytic pooling only for DBT compared with treatment as usual (TAU) for four outcomes. There were moderate to large statistically significant effects indicating a beneficial effect of DBT over TAU for anger (n = 46, two RCTs; standardised mean difference (SMD) -0.83, 95% confidence interval (CI) -1.43 to -0.22; I(2) = 0%), parasuicidality (n = 110, three RCTs; SMD -0.54, 95% CI -0.92 to -0.16; I(2) = 0%) and mental health (n = 74, two RCTs; SMD 0.65, 95% CI 0.07 to 1.24 I(2) = 30%). There was no indication of statistical superiority of DBT over TAU in terms of keeping participants in treatment (n = 252, five RCTs; risk ratio 1.25, 95% CI 0.54 to 2.92).All remaining findings were based on single study estimates of effect. Statistically significant between-group differences for comparisons of psychotherapies against controls were observed for BPD core pathology and associated psychopathology for the following interventions: DBT, DBT-PTSD, MBT-PH, MBT-out, TFP and IPT-BPD. IPT was only indicated as being effective in the treatment of associated depression. No statistically significant effects were found for CBT and DDP interventions on either outcome, with the effect sizes moderate for DDP and small for CBT. For comparisons between different comprehensive psychotherapies, statistically significant superiority was demonstrated for DBT over CCT (core and associated pathology) and SFT over TFP (BPD severity and treatment retention). There were also encouraging results for each of the non-comprehensive psychotherapeutic interventions investigated in terms of both core and associated pathology.No data were available for adverse effects of any psychotherapy.

AUTHORS' CONCLUSIONS

There are indications of beneficial effects for both comprehensive psychotherapies as well as non-comprehensive psychotherapeutic interventions for BPD core pathology and associated general psychopathology. DBT has been studied most intensely, followed by MBT, TFP, SFT and STEPPS. However, none of the treatments has a very robust evidence base, and there are some concerns regarding the quality of individual studies. Overall, the findings support a substantial role for psychotherapy in the treatment of people with BPD but clearly indicate a need for replicatory studies.