A randomized controlled trial of a Dutch version of systems training for emotional predictability and problem solving for borderline personality disorder

A randomized 3-month, parallel-group, controlled trial of CALMA m-health app as an adjunct to therapy to reduce suicidal and non-suicidal self-injurious behaviors in adolescents: study protocol

Background

Suicidal and non-suicidal self-injurious behaviors are among the leading causes of death and injury in adolescents and youth worldwide. Mobile app development could help people at risk and provide resources to deliver evidence-based interventions. There is no specific application for adolescents and young people available in Spanish. Our group developed CALMA, the first interactive mobile application with the user in Spanish, which provides tools based on Dialectical Behavioral Therapy to manage a crisis of suicidal or non-suicidal self-directed violence with the aim of preventing suicide in adolescents and youth.

Methods

To test the effectiveness, safety and level of engagement of the CALMA app in people aged 10 to 19 who are treated in mental health services of two public hospitals, we will conduct a parallel-group, two-arm randomized controlled trial. Participants will be assessed face-to-face and via video call at four timepoints: day-0 (baseline), day-30, day-60, and day-90. A total of 29 participants per group will be included. Change in the frequency of suicidal and non-suicidal self-injurious behaviors will be compared between groups, as well as the level of emotional dysregulation, level of app engagement and time of psychiatric admission during the follow-up period.

Discussion

This study is particularly relevant to young people given their widespread use of mobile technology, while there are currently no available smartphone app-based self-guided psychological strategies in Spanish that attempt to reduce suicidal behavior in adolescents who are assisted in the public health sector from low and middle-income countries in Latin America.

Clinical trial registration

https://clinicaltrials.gov/, NCT05453370.

Dropout from psychological treatment for borderline personality disorder: a multilevel survival meta-analysis

BACKGROUND

Dropout from psychotherapy for borderline personality disorder (BPD) is a notorious problem. We investigated whether treatment, treatment format, treatment setting, substance use exclusion criteria, proportion males, mean age, country, and other variables influenced dropout.

METHODS

From Pubmed, Embase, Cochrane, Psycinfo and other sources, 111 studies (159 treatment arms, N = 9100) of psychotherapy for non-forensic adult patients with BPD were included. Dropout per quarter during one year of treatment was analyzed on participant level with multilevel survival analysis, to deal with multiple predictors, nonconstant dropout chance over time, and censored data. Multiple imputation was used to estimate quarter of drop-out if unreported. Sensitivity analyses were done by excluding DBT-arms with deviating push-out rules.

RESULTS

Dropout was highest in the first quarter of treatment. Schema therapy had the lowest dropout overall, and mentalization-based treatment in the first two quarters. Community treatment by experts had the highest dropout. Moreover, individual therapy had lowest dropout, group therapy highest, with combined formats in-between. Other variables such as age or substance-use exclusion criteria were not associated with dropout.

CONCLUSION

The findings do not support claims that all treatments are equal, and indicate that efforts to reduce dropout should focus on early stages of treatment and on group treatment.

Systems Training for Emotional Predictability and Problem Solving for borderline personality disorder: A systematic review

Systems Training for Emotional Predictability and Problem Solving (STEPPS) is a group treatment program for patients with borderline personality disorder (BPD). The program was intended to be highly accessible, both for patients and therapists. During STEPPS, patients are taught emotion regulation and behavior management skills. This systematic review synthesizes the current empirical status of STEPPS, focusing on research designs, quality of studies, target groups, protocols, and outcome. We selected 20 studies, with three randomized controlled trials. Patients with BPD, subthreshold BPD, and patients with BPD and comorbid antisocial personality disorder were investigated. One study was conducted in adolescents. There were no studies in older adults. Results demonstrated STEPPS to be associated with reduced BPD symptoms, improved quality of life, decreased depressive symptoms, and decreased negative affectivity. Mixed results were found for impulsivity and suicidal behaviors. STEPPS has both been studied as an add-on therapy to patients' ongoing treatment, and, with the addition of individual STEPPS sessions, as a stand-alone treatment. High attrition rates were found in patients attending STEPPS, complicating the generalizability of the results. Although the evidence for STEPPS is promising, further research is needed before firm conclusions can be drawn. Recommendations for future research are discussed.

Effectiveness of outpatient and community treatments for people with a diagnosis of 'personality disorder': systematic review and meta-analysis

BACKGROUND

Quality of care and access to effective interventions have been widely criticised as limited for people diagnosed with 'personality disorder' or who have comparable needs (described in some recent papers as "Complex Emotional Needs" (CEN). It is important to identify effective interventions and the optimal context and mode of delivery for people with CEN. We aimed to investigate the effectiveness of psychosocial interventions delivered in community and outpatient settings in treating symptoms associated with 'personality disorder', and the moderating effects of treatment-related variables.

METHODS

We systematically searched MEDLINE, EMBASE, PsycINFO, CINAHL, HMIC, ASSIA for articles published in English, from inception to November 23, 2020. We included randomized controlled trials examining interventions provided in community or outpatient settings for CEN. The primary outcome was 'personality disorder' symptoms, while secondary outcomes included anxiety symptoms, depressive symptoms, and global psychiatric symptoms. Random-effects meta-analysis was conducted for each outcome, and meta-regression analysis was performed to assess the moderating effects of treatment characteristics. The quality of the studies and the degree of publication bias was assessed.

RESULTS

We included 54 trials (n = 3716 participants) in the meta-analysis. We found a large effect size (g = 0.78, 95% CI: 0.56 to 1.01, p < 0.0001) favoring interventions for 'borderline personality disorder' (BPD) symptoms over Treatment as Usual or Waitlist (TAU/WL), and the efficacy was maintained at follow-up (g = 1.01, 95% CI: 0.37 to 1.65, p = 0.002). Interventions effectively reduced anxiety symptoms (g = 0.58, 95% CI: 0.21 to 0.95, p = 0.002), depressive symptoms (g = 0.57, 95% CI: 0.32 to 0.83, p < 0.0001), and global psychiatric symptoms (g = 0.50, 95% CI: 0.35 to 0.66, p < 0.0001) compared to TAU/WL. The intervention types were equally effective in treating all symptom categories assessed. Treatment duration and treatment intensity did not moderate the effectiveness of the interventions for any outcome.

CONCLUSIONS

People with a 'personality disorder' diagnosis benefited from psychological and psychosocial interventions delivered in community or outpatient settings, with all therapeutic approaches showing similar effectiveness. Mental health services should provide people with CEN with specialised treatments in accordance with the availability and the patients' preferences.

Current state of the evidence on community treatments for people with complex emotional needs: a scoping review

BACKGROUND

Improving the quality of care in community settings for people with 'Complex Emotional Needs' (CEN-our preferred working term for services for people with a "personality disorder" diagnosis or comparable needs) is recognised internationally as a priority. Plans to improve care should be rooted as far as possible in evidence. We aimed to take stock of the current state of such evidence, and identify significant gaps through a scoping review of published investigations of outcomes of community-based psychosocial interventions designed for CEN.

METHODS

We conducted a scoping review with systematic searches. We searched six bibliographic databases, including forward and backward citation searching, and reference searching of relevant systematic reviews. We included studies using quantitative methods to test for effects on any clinical, social, and functioning outcomes from community-based interventions for people with CEN. The final search was conducted in November 2020.

RESULTS

We included 226 papers in all (210 studies). Little relevant literature was published before 2000. Since then, publications per year and sample sizes have gradually increased, but most studies are relatively small, including many pilot or uncontrolled studies. Most studies focus on symptom and self-harm outcomes of various forms of specialist psychotherapy: most result in outcomes better than from inactive controls and similar to other specialist psychotherapies. We found large evidence gaps. Adaptation and testing of therapies for significant groups (e.g. people with comorbid psychosis, bipolar disorder, post-traumatic stress disorder, or substance misuse; older and younger groups; parents) have for the most part only reached a feasibility testing stage. We found little evidence regarding interventions to improve social aspects of people's lives, peer support, or ways of designing effective services.

CONCLUSIONS

Compared with other longer term mental health problems that significantly impair functioning, the evidence base on how to provide high quality care for people with CEN is very limited. There is good evidence that people with CEN can be helped when specialist therapies are available and when they are able to engage with them. However, a much more methodologically robust and substantial literature addressing a much wider range of research questions is urgently needed to optimise treatment and support across this group.

Psychotherapies for borderline personality disorder: a focused systematic review and meta-analysis

BACKGROUND

A recently updated Cochrane review supports the efficacy of psychotherapy for borderline personality disorder (BPD).

AIMS

To evaluate the effects of standalone and add-on psychotherapeutic treatments more concisely.

METHOD

We applied the same methods as the 2020 Cochrane review, but focused on adult samples and comparisons of active treatments and unspecific control conditions. Standalone treatments (i.e. necessarily including individual psychotherapy as either the sole or one of several treatment components) and add-on interventions (i.e. complementing any ongoing individual BPD treatment) were analysed separately. Primary outcomes were BPD severity, self-harm, suicide-related outcomes and psychosocial functioning. Secondary outcomes were remaining BPD diagnostic criteria, depression and attrition.

RESULTS

Thirty-one randomised controlled trials totalling 1870 participants were identified. Among standalone treatments, statistically significant effects of low overall certainty were observed for dialectical behaviour therapy (self-harm: standardised mean difference (SMD) -0.54, P = 0.006; psychosocial functioning: SMD -0.51, P = 0.01) and mentalisation-based treatment (self-harm: risk ratio 0.51, P < 0.0007; suicide-related outcomes: risk ratio 0.10, P < 0.0001). For adjunctive interventions, moderate-quality evidence of beneficial effects was observed for DBT skills training (BPD severity: SMD -0.66, P = 0.002; psychosocial functioning: SMD -0.45, P = 0.002), and statistically significant low-certainty evidence was observed for the emotion regulation group (BPD severity: mean difference -8.49, P < 0.00001), manual-assisted cognitive therapy (self-harm: mean difference -3.03, P = 0.03; suicide-related outcomes: SMD -0.96, P = 0.005) and the systems training for emotional predictability and problem-solving (BPD severity: SMD -0.48, P = 0.002).

CONCLUSIONS

There is reasonable evidence to conclude that psychotherapeutic interventions are helpful for individuals with BPD. Replication studies are needed to enhance the certainty of findings.

Factor structure of borderline personality disorder and response to Systems Training for Emotional Predictability and Problem Solving

Differential response to the Systems Training for Emotional Predictability and Problem Solving (STEPPS) program was compared in subgroups identified through latent class analysis (LCA). STEPPS is an evidence-based group treatment program for patients with borderline personality disorder (BPD). A reanalysis of data was conducted using data from a 20-week randomized controlled trial and 1-year follow-up. Subjects (n = 164) with DSM-IV BPD were assessed for comorbid Axis I and II disorders and selected clinical variables. Severity was assessed using the Zanarini Rating Scale for BPD (ZAN-BPD) and the Borderline Evaluation of Severity Over Time (BEST). Three- and four-class models were identified with the four-class model having the better fit. The latter included a high severity (HS) class (26%), an affective instability/substance abuse (AISA) class (16%), an empty/dissociation/identity disturbance (EDID) class (27%), and a low severity (LS) class (30%). High impulsiveness predicted membership in the HS class. Improvement was determined using a linear mixed-effects model. Those most likely to benefit were those in the HS group characterized by high symptom severity, Axis I and II comorbidity, problem relationships, abandonment fears, and intense anger. This work should help further efforts to match patients with treatments based on sociodemographic, diagnostic, and other illness characteristics.

Guided internet-based cognitive behavioral therapy for insomnia in patients with borderline personality disorder: Study protocol for a randomized controlled trial

Borderline personality disorder (BPD) is a highly disabling psychiatric disorder with emotion dysregulation at its core, resulting in affective instability, impulsivity and sometimes self-harming or suicidal behavior. Sleep is increasingly recognized to play a crucial role in emotion regulation. BPD patients often suffer from (severe) insomnia, potentially aggravating symptoms and preventing recovery from BPD. Yet, the effects of insomnia treatments have not been investigated in context of BPD. Guided internet-based cognitive behavioral therapy for insomnia (iCBT-I; i-Sleep) has been proven effective in improving both insomnia and affective symptoms. In this randomized controlled trial among 96 patients with a DSM-5 diagnosis of BPD (or other personality disorder with ≥4 BPD traits) and insomnia symptoms, we will test the effectiveness of iCBT-I before regular BPD treatment starts, during the waitlist period, on BPD symptoms. Patients in the control group monitor their sleep through a sleep diary during the waitlist period and also receive standard BPD treatment after that. Using linear mixed models we will test the hypothesis that the iCBT-I group improves more than the control group on BPD symptoms (primary outcome), insomnia severity, additional subjective and objective sleep variables, emotion regulation, comorbid anxiety and depression complaints, and quality of life. These effects are thought to arise from a direct effect of improved sleep on emotion regulation and a synergistic effect on the consolidation and internalization of the BPD treatment effect. To our knowledge, this is the first trial assessing effectiveness of CBT-I in patients with BPD (traits). The accessibility of the studied intervention greatly facilitates clinical implication in case of positive results.

CALMA, a Mobile Health Application, as an Accessory to Therapy for Reduction of Suicidal and Non-Suicidal Self-Injured Behaviors: A Pilot Cluster Randomized Controlled Trial

The present study was aim to evaluate the acceptability and preliminary effectiveness of a mobile-health application, CALMA, based on dialectical behavioral therapy skills. CALMA was proposed as an adjunct to therapy for the reduction of non-suicidal and suicidal self-injury behaviors. A parallel design was used to compare the intervention group (DBT + CALMA) and the comparison group (DBT). Patients were randomized based on their groups following a randomized cluster design. After treatment, patients completed a follow-up assessment four weeks later. Each cluster was represented by a different DBT Skills Training Group offered weekly at FORO Foundation for Mental Health. Six DBT Skills Training groups were randomized to the intervention or comparison group. Twenty-one individuals met inclusion criteria and eighteen were included in the analysis. Acceptability was measured with the User Experience Questionnaire short version (UEQ-s) and preliminary efficacy with the Self-injurious thoughts and behaviors interview (SITBI). CALMA shows good acceptability to be used as an adjunct to therapy specific to the reduction of suicidal and non-suicidal self-directed violence. Evidence for preliminary efficacy included a high probability of decreased in more behaviors evaluated with the SITBI pre- and post-intervention for the group that received CALMA as compared to the comparison group. Our study provides initial evidence for the effectiveness and acceptability of CALMA. Future studies scaling up this intervention in a larger number of participants are necessary. CALMA may be especially useful in low and middle-income Latin American countries to improve access to evidence-based interventions openly available in Spanish and free to download.HighlightsCALMA is a DBT-based app aimed to reduce non-suicidal and suicidal self-directed violence.The app showed good acceptability by usersA high probability of decrease in suicidal ideation, suicidal plan, suicidal gesture, thoughts about NSSI and NSSI pre- and post-intervention was observed.

Effectiveness of Nonsuicidal Self-Injury Interventions among Incarcerated Women in Correctional Facilities and Secure Settings: An Integrative Review

Nonsuicidal self-injury (NSSI) is prevalent among incarcerated women in correctional facilities. This poses a challenge in selecting appropriate intervention. This integrative review aimed to identify effective interventions for managing NSSI among incarcerated women. Whittemore and Knafl's framework for integrative reviews was used, and eight databases were searched with 11 papers meeting the inclusion criteria. Six interventions for NSSI for incarcerated women were identified as promising in reducing the rate of NSSI. Data did not support the effectiveness of gender-specific interventions for incarcerated women. There is a need for further research to identify appropriate interventions to target NSSI among incarcerated women.

Investigating Effectiveness and Predicting Outcome and Dropout From Systems Training for Emotional Predictability and Problem Solving for Emotional Intensity Difficulties (STEPPS EI) in UK Primary Care

Systems Training for Emotional Predictability and Problem Solving (STEPPS) for borderline personality disorder (BPD) has been adapted for a primary care setting into a 13-week group treatment for emotional intensity difficulties (STEPPS EI). This is the first study to examine the effectiveness and potential outcome and dropout predictors of STEPPS EI in a primary care setting. Severity of BPD, depression, and anxiety symptoms were measured pre- and postintervention for 148 participants. Treatment completers showed improvements in depression, anxiety, and BPD symptoms with medium to large effect sizes. A predictor of symptom improvement was higher baseline severity for each of the symptom measures. Attending a psychoeducational group prior to STEPPS EI was associated with lower odds of dropout. The findings support the use of STEPPS EI in a primary care setting, with the potential to alleviate the burden from other local services.

STEPPS for Borderline Personality Disorder: A Pragmatic Trial and Naturalistic Comparison With Noncompleters

Systems Training for Emotional Predictability and Problem Solving (STEPPS) is a group psychotherapy approach that is effective for patients with borderline personality disorder (BPD) in a public health care setting. The sample in this study comprised 118 outpatients with BPD who were asked to participate in a Spanish-adapted version of STEPPS for 18 months, a psychotherapy program that could be added to their usual psychiatric intervention. They were divided into an experimental group who participated in STEPPS, and a control group, who received treatment as usual. Several variables were collected and the Borderline Evaluation of Severity Over Time (BEST) scale was administered at pretest, Months 3 and 6, posttest (Month 18), and 2-year follow-up (Month 42), after which a post hoc data analysis was carried out. The STEPPS program improved the as-usual treatment provided previously, and the results were cost-effective. A higher educational level and good patient collaboration predicted better outcome.

Resilience as a predictor of quality of life in participants with borderline personality disorder before and after treatment

BACKGROUND

Studies have suggested that psychotherapy improves the Quality of Life (QoL) of participants with Borderline Personality Disorder (BPD). However, there are no studies on the differential efficacy of treatments on the QoL of participants with BPD. Moreover, the relationship between QoL and resilience has rarely been studied in participants with BPD.

OBJECTIVES

a) to examine whether people with BPD have worse QoL than the non-clinical population; b) to examine whether there are statistically significant differences between Dialectical Behavioural Therapy (DBT), Systems Training for Emotional Predictability and Problem Solving (STEPPS), or Cognitive Behavioural Therapy-Treatment at Usual (CBT-TAU) in the improvement of QoL; c) to examine whether participants show clinically significant improvements in QoL after treatment; d) to analyse whether resilience is associated with QoL before and after the BPD treatment; e) to analyse whether resilience is a predictor of QoL at pre-treatment and posttreatment.

METHOD

The sample comprised 403 participants (n = 202 participants diagnosed with BPD and n = 201 non-clinical). Participants filled out the Quality of Life Index, Resilience Scale, and Beck Depression Inventory. The clinical participants received one of these possible treatments, DBT, STEPPS, or CBT-TAU. MANOVA and regression analyses were performed.

RESULTS

a) participants diagnosed with BPD had statistically significant lower resilience than the non-clinical population; b) all three forms of psychotherapy statistically improved QoL, but there were no statistically significant differences between DBT, STEPPS, and CBT-TAU in the improvement of QoL; c) participants did not show clinically significant improvements in QoL after treatment; d) resilience was associated with QoL before and after treatment; and e) resilience was a predictor of QoL before and after treatment.

CONCLUSION

It is necessary to assess QoL and Resilience in studies on psychotherapy with BPD patients.

Effect of Psychotherapy for Borderline Personality Disorder on Quality of Life: A Systematic Review and Meta-Analysis

Whereas several meta-analyses have shown that psychotherapy is effective for reducing borderline personality disorder (BPD) pathology, the overall impact of psychotherapy for BPD on quality of life (QoL) remains as yet unclear. Because impaired QoL is associated with poor long-term outcomes after therapy for BPD, this seems a timely and relevant issue. The authors conducted a systematic review and meta-analysis of randomized controlled trials of psychotherapies for adults diagnosed with BPD that reported results of QoL at posttreatment. Fourteen trials were included (1,370 individuals with BPD). Psychotherapies for BPD relative to control conditions showed significant effect sizes for QoL (Cohen's d = 0.31; 95% CI [0.18, 0.44]), and for BPD pathology (d = 0.43; 95% CI [0.23, 0.64]). The effect on QoL was not significantly moderated by the effect on BPD pathology. Psychotherapies for BPD have a positive effect on QoL of patients with BPD. However, more studies are needed to examine the impact of psychotherapy on QoL and long-term outcome, including recovery.

Exploring the Effectiveness of Dialectical Behavior Therapy Versus Systems Training for Emotional Predictability and Problem Solving in a Sample of Patients With Borderline Personality Disorder

Dialectical behavior therapy (DBT) and systems training for emotional predictability and problem solving (STEPPS) are two treatment protocols for people with borderline personality disorder (BPD) that have received important empirical support. However, their possible differential effectiveness has not yet been studied. The objective of this study is to explore the effectiveness of these two treatment programs. A nonrandomized clinical trial was carried out in which both treatments were applied for six months. The sample consisted of 72 patients diagnosed with BPD. The results indicate that both groups experienced a statistically significant reduction in BPD symptom, emotional regulation, impulsiveness, dissociative experiences, suicidal risk, depression, or anger. However, the DBT condition obtained statistically significant differences in BPD behavioral symptoms and fear of suicide. DBT and STEPPS treatment are effective treatments for participants with BPD, and DBT was more effective for the behavioral symptoms of BPD.

A Feasibility Study of the Addition of STEPPS in Outpatients With Bipolar Disorder and Comorbid Borderline Personality Features: Promises and Pitfalls

Background: Pharmacotherapy is a cornerstone in bipolar disorder (BD) treatment whereas borderline personality disorder (BPD) is treated primarily with psychotherapy. Given the overlap in symptomatology, patients with BD may benefit from psychotherapy designed for BPD. Aims: This paper reports the findings of a non-controlled open feasibility study of STEPPS training in patients with BD and borderline personality features (BPF). Methods: Outpatients with BD were screened for BPD, and if positive interviewed with SCID-II. Patients with at least three BPF, always including impulsivity and anger burst, were included in the intervention study. Severity of BD and BPD and quality of life were assessed. Descriptive statistics were performed. Results: Of 111 patients with BD 49.5% also screened positive on BPD according to PDQ-4+, and 52.3% of these had BPD according to SCID-II. Very few participants entered the intervention study, and only nine patients completed STEPPS. Descriptive statistics showed improvement on all outcome variables post treatment, but no longer at 6-month follow up. We reflect on the potential reasons for the failed inclusion. Conclusion: Features of BPD were highly prevalent in patients with BD. Still, recruiting patients for a psychological treatment originally designed for BPD proved to be difficult. Feedback of participants suggests that the association of STEPPS with "borderline" had an aversive effect, which may have caused limited inclusion for screening and subsequent drop-out for the treatment. Therefore, STEPPS should be adapted for BD to be an acceptable treatment option. Clinical Trial Registration: www.ClinicalTrials.gov/3856, identifier: NTR4016.

Brief psychological interventions for borderline personality disorder. A systematic review and meta-analysis of randomised controlled trials

BACKGROUND

People with Borderline Personality Disorder (BPD) have limited access to long term psychological therapies. Briefer interventions have been developed but trial evidence to support their use has not been reviewed.

AIMS

To examine whether psychological interventions for adults with BPD of six months duration or less improve symptoms, mood, self-harm, suicidal behaviour, and service use.

METHODS

The protocol was prospectively registered (PROSPERO CRD42017063777). Database searches were conducted up to April 2020. Inclusion, data extraction and risk of bias were assessed in duplicate. We identified 27 randomised controlled trials. We conducted random-effects meta-analyses sub-grouping data into delivery method, additional support, and comparison type.

RESULTS

High levels of bias were found for attrition and reporting. Heterogeneity was high in some pooled data. Borderline symptom reductions were greatest for interventions including additional support (SMD. -1.23, 95% C.I. -2.13, -0.33). Planned generic support may be as effective as specialist interventions for borderline symptoms (SMD = -0.11, 95% C.I. -0.51, 0.29) and social functioning (SMD = -0.16., 95% C.I. -0.65, 0.33). Follow-up was limited and direct comparison with post-intervention results was unreliable.

CONCLUSIONS

Short-term interventions may be effective. Access to additional support has an impact on outcomes. It is unclear if symptomatic change is sustained.

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

BACKGROUND

A routinely collected big data set was analyzed to determine the effectiveness of naturalistic inpatient treatment and to identify predictors of treatment outcome and discontinuation.

METHODS

The sample included 878 patients with borderline personality disorder who received non-manualized dialectic behavioral therapy in a psychosomatic clinic. Effect sizes (Hedge's g) were calculated to determine effectiveness. A bootstrap-enhanced regularized regression with 91 potential predictors was used to identify stable predictors of residualized symptom- and functional change and treatment discontinuation. Results were validated in a holdout sample and repeated cross validation.

RESULTS

Effect sizes were small to medium (g = 0.28-0.51). Positive symptom-related outcome was predicted by low affect regulation skills and no previous outpatient psychotherapy. Lower age, absence of work disability, high emotional and physical role limitations and low bodily pain were associated with greater improvement in functional outcome. Higher education and comorbid recurrent depressive disorder were the main predictors of treatment completion. The predictive quality of the models varied, with the best being found for symptom-related outcome (R2 = 18%).

CONCLUSION

While the exploratory process of variable selection replicates previous findings, the validation results suggest that tailoring treatment to the individual patient might not be based solely on sociodemographic, clinical and psychological baseline data.

Psychological therapies for people with borderline personality disorder

BACKGROUND

Over the decades, a variety of psychological interventions for borderline personality disorder (BPD) have been developed. This review updates and replaces an earlier review (Stoffers-Winterling 2012).

OBJECTIVES

To assess the beneficial and harmful effects of psychological therapies for people with BPD.

SEARCH METHODS

In March 2019, we searched CENTRAL, MEDLINE, Embase, 14 other databases and four trials registers. We contacted researchers working in the field to ask for additional data from published and unpublished trials, and handsearched relevant journals. We did not restrict the search by year of publication, language or type of publication.

SELECTION CRITERIA

Randomised controlled trials comparing different psychotherapeutic interventions with treatment-as-usual (TAU; which included various kinds of psychotherapy), waiting list, no treatment or active treatments in samples of all ages, in any setting, with a formal diagnosis of BPD. The primary outcomes were BPD symptom severity, self-harm, suicide-related outcomes, and psychosocial functioning. There were 11 secondary outcomes, including individual BPD symptoms, as well as attrition and adverse effects.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected trials, extracted data, assessed risk of bias using Cochrane's 'Risk of bias' tool and assessed the certainty of the evidence using the GRADE approach. We performed data analysis using Review Manager 5 and quantified the statistical reliability of the data using Trial Sequential Analysis.

MAIN RESULTS

We included 75 randomised controlled trials (4507 participants), predominantly involving females with mean ages ranging from 14.8 to 45.7 years. More than 16 different kinds of psychotherapy were included, mostly dialectical behaviour therapy (DBT) and mentalisation-based treatment (MBT). The comparator interventions included treatment-as-usual (TAU), waiting list, and other active treatments. Treatment duration ranged from one to 36 months. Psychotherapy versus TAU Psychotherapy reduced BPD symptom severity, compared to TAU; standardised mean difference (SMD) -0.52, 95% confidence interval (CI) -0.70 to -0.33; 22 trials, 1244 participants; moderate-quality evidence. This corresponds to a mean difference (MD) of -3.6 (95% CI -4.4 to -2.08) on the Zanarini Rating Scale for BPD (range 0 to 36), a clinically relevant reduction in BPD symptom severity (minimal clinical relevant difference (MIREDIF) on this scale is -3.0 points). Psychotherapy may be more effective at reducing self-harm compared to TAU (SMD -0.32, 95% CI -0.49 to -0.14; 13 trials, 616 participants; low-quality evidence), corresponding to a MD of -0.82 (95% CI -1.25 to 0.35) on the Deliberate Self-Harm Inventory Scale (range 0 to 34). The MIREDIF of -1.25 points was not reached. Suicide-related outcomes improved compared to TAU (SMD -0.34, 95% CI -0.57 to -0.11; 13 trials, 666 participants; low-quality evidence), corresponding to a MD of -0.11 (95% CI -0.19 to -0.034) on the Suicidal Attempt Self Injury Interview. The MIREDIF of -0.17 points was not reached. Compared to TAU, psychotherapy may result in an improvement in psychosocial functioning (SMD -0.45, 95% CI -0.68 to -0.22; 22 trials, 1314 participants; low-quality evidence), corresponding to a MD of -2.8 (95% CI -4.25 to -1.38), on the Global Assessment of Functioning Scale (range 0 to 100). The MIREDIF of -4.0 points was not reached. Our additional Trial Sequential Analysis on all primary outcomes reaching significance found that the required information size was reached in all cases. A subgroup analysis comparing the different types of psychotherapy compared to TAU showed no clear evidence of a difference for BPD severity and psychosocial functioning. Psychotherapy may reduce depressive symptoms compared to TAU but the evidence is very uncertain (SMD -0.39, 95% CI -0.61 to -0.17; 22 trials, 1568 participants; very low-quality evidence), corresponding to a MD of -2.45 points on the Hamilton Depression Scale (range 0 to 50). The MIREDIF of -3.0 points was not reached. BPD-specific psychotherapy did not reduce attrition compared with TAU. Adverse effects were unclear due to too few data. Psychotherapy versus waiting list or no treatment Greater improvements in BPD symptom severity (SMD -0.49, 95% CI -0.93 to -0.05; 3 trials, 161 participants), psychosocial functioning (SMD -0.56, 95% CI -1.01 to -0.11; 5 trials, 219 participants), and depression (SMD -1.28, 95% CI -2.21 to -0.34, 6 trials, 239 participants) were observed in participants receiving psychotherapy versus waiting list or no treatment (all low-quality evidence). No evidence of a difference was found for self-harm and suicide-related outcomes. Individual treatment approaches DBT and MBT have the highest numbers of primary trials, with DBT as subject of one-third of all included trials, followed by MBT with seven RCTs. Compared to TAU, DBT was more effective at reducing BPD severity (SMD -0.60, 95% CI -1.05 to -0.14; 3 trials, 149 participants), self-harm (SMD -0.28, 95% CI -0.48 to -0.07; 7 trials, 376 participants) and improving psychosocial functioning (SMD -0.36, 95% CI -0.69 to -0.03; 6 trials, 225 participants). MBT appears to be more effective than TAU at reducing self-harm (RR 0.62, 95% CI 0.49 to 0.80; 3 trials, 252 participants), suicidality (RR 0.10, 95% CI 0.04, 0.30, 3 trials, 218 participants) and depression (SMD -0.58, 95% CI -1.22 to 0.05, 4 trials, 333 participants). All findings are based on low-quality evidence. For secondary outcomes see review text.

AUTHORS' CONCLUSIONS

Our assessments showed beneficial effects on all primary outcomes in favour of BPD-tailored psychotherapy compared with TAU. However, only the outcome of BPD severity reached the MIREDIF-defined cut-off for a clinically meaningful improvement. Subgroup analyses found no evidence of a difference in effect estimates between the different types of therapies (compared to TAU) . The pooled analysis of psychotherapy versus waiting list or no treatment found significant improvement on BPD severity, psychosocial functioning and depression at end of treatment, but these findings were based on low-quality evidence, and the true magnitude of these effects is uncertain. No clear evidence of difference was found for self-harm and suicide-related outcomes. However, compared to TAU, we observed effects in favour of DBT for BPD severity, self-harm and psychosocial functioning and, for MBT, on self-harm and suicidality at end of treatment, but these were all based on low-quality evidence. Therefore, we are unsure whether these effects would alter with the addition of more data.

Borderline Personality Disorder in Patients With Medical Illness: A Review of Assessment, Prevalence, and Treatment Options

OBJECTIVE

Borderline personality disorder (BPD) occurs in 0.7% to 3.5% of the general population. Patients with BPD experience excessive comorbidity of psychiatric and somatic diseases and are known to be high users of health care services. Because of a range of challenges related to adverse health behaviors and their interpersonal style, patients with BPD are often regarded as "difficult" to interact with and treat optimally.

METHODS

This narrative review focuses on epidemiological studies on BPD and its comorbidity with a specific focus on somatic illness. Empirically validated treatments are summarized, and implementation of specific treatment models is discussed.

RESULTS

The prevalence of BPD among psychiatric inpatients (9%-14%) and outpatients (12%-18%) is high; medical service use is very frequent, annual societal costs vary between &OV0556;11,000 and &OV0556;28,000. BPD is associated with cardiovascular diseases and stroke, metabolic disease including diabetes and obesity, gastrointestinal disease, arthritis and chronic pain, venereal diseases, and HIV infection as well as sleep disorders. Psychotherapy is the treatment of choice for BPD. Several manualized treatments for BPD have been empirically validated, including dialectical behavior therapy, transference-focused psychotherapy, mentalization-based therapy, and schema-focused therapy.

CONCLUSIONS

Health care could be substantially improved if all medical specialties would be familiar with BPD, its pathology, medical and psychiatric comorbidities, complications, and treatment. In mental health care, several empirically validated treatments that are applicable in a wide range of clinical settings are available.

Short-term versus long-term mentalization-based therapy for outpatients with subthreshold or diagnosed borderline personality disorder: a protocol for a randomized clinical trial

Background

Psychotherapy for borderline personality disorder is often lengthy and resource-intensive. However, the current length of outpatient treatments is arbitrary and based on trials that never tested if the treatment intensity could be reduced. As a result, there is insufficient evidence to inform the decision between short-term and long-term psychotherapy for borderline personality disorder. Mentalization-based therapy is one treatment option for borderline personality disorder and consists traditionally of an 18-month treatment program.

Methods/design

This trial is an investigator-initiated single-center randomized clinical superiority trial of short-term (20 weeks) compared to long-term (14 months) mentalization-based therapy for outpatients with subthreshold or diagnosed borderline personality disorder. Participants will be recruited from the Outpatient Clinic for Personality Disorders at Stolpegaard Psychotherapy Centre, Mental Health Services, Capital Region of Denmark. Participants will be included if they meet a minimum of four DSM-V criteria for borderline personality disorder. Participants will be assessed before randomization, and at 8, 16, and 24 months after randomization. The primary outcome is severity of borderline symptomatology assessed with the Zanarini Rating Scale for borderline personality disorder. Secondary outcomes include self-harm incidents, functional impairment (Work and Social Adjustment Scale, Global Assessment of Functioning) and quality of life (Short-Form Health Survey 36). Severity of psychiatric symptoms (Symptom Checklist 90-R) will be included as an exploratory outcome. Measures of personality functioning, attachment, borderline symptoms, group alliance, and mentalization skills will be included to explore potential predictors and mechanisms of change.

Discussion

This trial will provide evidence of the beneficial and harmful effects of short-term compared to long-term mentalization-based therapy for outpatients with subthreshold or diagnosed borderline personality disorder.

Trial registration

ClinicalTrials.gov, NCT03677037. Registered on September 19, 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3306-7) contains supplementary material, which is available to authorized users.

Does response to the STEPPS program differ by sex, age, or race in offenders with borderline personality disorder?

Systems Training for Emotional Predictability and Problem Solving (STEPPS) is an evidence-based group treatment program for ambulatory patients with borderline personality disorder (BPD). The program was introduced to the Iowa correctional system in 2005, and groups have been ongoing ever since. In this analysis, we examine whether response to the STEPPS program differs based on sex, age (<40/≥40 years), or race/ethnicity (minority/non-minority) using data collected in Iowa prisons and in community corrections. Subjects were recruited and assessed by correctional staff. Offenders with BPD were offered the opportunity to participate in the STEPPS program. The presence of BPD was assessed using a module from the Structured Interview for DSM-IV Personality. Efficacy assessments included the Borderline Evaluation of Severity Over Time Scale, the Beck Depression Inventory, and the Positive and Negative Affectivity Scale. The Client Satisfaction Questionnaire-8 assessed program satisfaction. Data on 77 offenders were analyzed. All participated in the STEPPS program and 53% completed all 20 weeks. The analysis showed that there were no significant differences in response to STEPPS in terms of sex, age, or race/ethnicity on any of the three efficacy measures. Women expressed greater satisfaction than men, but there were no differences with regard to age or race/ethnicity. The implications of the findings are discussed.

STEPPS treatment programme for borderline personality disorder: Which scale items improve? An item-level analysis

We examined which items on the Borderline Evaluation of Severity Over Time and the Zanarini Rating Scale for Borderline Personality Disorder improved during participation in Systems Training for Emotional Predictability and Problem Solving (STEPPS). Data on 193 subjects from two independent sources were included: (1) a randomized controlled trial at an academic medical centre and (2) uncontrolled data from Iowa's correctional system. STEPPS effect size was estimated by contrasting effect size for those in the randomized controlled trial assigned to STEPPS + treatment as usual to effect size for those assigned to treatment as usual alone. Items from the Borderline Evaluation of Severity Over Time scale showing the greatest improvement assessed affective instability, 'taking steps to avoid/prevent problems', 'choosing to use a positive activity', identity disturbance and abandonment fears. The Zanarini Rating Scale for Borderline Personality Disorder items showing the greatest improvement assessed mood instability, chronic feelings of emptiness and identity disturbance. STEPPS effect size was significant for the Borderline Evaluation of Severity Over Time items rating paranoia and 'taking steps to avoid/prevent problems' and the Zanarini Rating Scale for Borderline Personality Disorder items assessing paranoia, impulsivity, chronic emptiness and unstable relationships. This, and future work, could eventually help in matching patients to particular treatment programmes that target their preponderant symptoms. © 2018 John Wiley & Sons, Ltd.

Psychoeducation with problem-solving (PEPS) therapy for adults with personality disorder: a pragmatic randomised controlled trial to determine the clinical effectiveness and cost-effectiveness of a manualised intervention to improve social functioning

BACKGROUND

If effective, less intensive treatments for people with personality disorder have the potential to serve more people.

OBJECTIVES

To compare the clinical effectiveness and cost-effectiveness of psychoeducation with problem-solving (PEPS) therapy plus usual treatment against usual treatment alone in improving social problem-solving with adults with personality disorder.

DESIGN

Multisite two-arm, parallel-group, pragmatic randomised controlled superiority trial.

SETTING

Community mental health services in three NHS trusts in England and Wales.

PARTICIPANTS

Community-dwelling adults with any personality disorder recruited from community mental health services.

INTERVENTIONS

Up to four individual sessions of psychoeducation, a collaborative dialogue about personality disorder, followed by 12 group sessions of problem-solving therapy to help participants learn a process for solving interpersonal problems.

MAIN OUTCOME MEASURES

The primary outcome was measured by the Social Functioning Questionnaire (SFQ). Secondary outcomes were service use (general practitioner records), mood (measured via the Hospital Anxiety and Depression Scale) and client-specified three main problems rated by severity. We studied the mechanism of change using the Social Problem-Solving Inventory. Costs were identified using the Client Service Receipt Inventory and quality of life was identified by the European Quality of Life-5 Dimensions questionnaire. Research assistants blinded to treatment allocation collected follow-up information.

RESULTS

There were 739 people referred for the trial and 444 were eligible. More adverse events in the PEPS arm led to a halt to recruitment after 306 people were randomised (90% of planned sample size); 154 participants received PEPS and 152 received usual treatment. The mean age was 38 years and 67% were women. Follow-up at 72 weeks after randomisation was completed for 62% of participants in the usual-treatment arm and 73% in the PEPS arm. Intention-to-treat analyses compared individuals as randomised, regardless of treatment received or availability of 72-week follow-up SFQ data. Median attendance at psychoeducation sessions was approximately 90% and for problem-solving sessions was approximately 50%. PEPS therapy plus usual treatment was no more effective than usual treatment alone for the primary outcome [adjusted difference in means for SFQ -0.73 points, 95% confidence interval (CI) -1.83 to 0.38 points; p = 0.19], any of the secondary outcomes or social problem-solving. Over the follow-up, PEPS costs were, on average, £182 less than for usual treatment. It also resulted in 0.0148 more quality-adjusted life-years. Neither difference was statistically significant. At the National Institute for Health and Care Excellence thresholds, the intervention had a 64% likelihood of being the more cost-effective option. More adverse events, mainly incidents of self-harm, occurred in the PEPS arm, but the difference was not significant (adjusted incidence rate ratio 1.24, 95% CI 0.93 to 1.64).

LIMITATIONS

There was possible bias in adverse event recording because of dependence on self-disclosure or reporting by the clinical team. Non-completion of problem-solving sessions and non-standardisation of usual treatment were limitations.

CONCLUSIONS

We found no evidence to support the use of PEPS therapy alongside standard care for improving social functioning of adults with personality disorder living in the community.

FUTURE WORK

We aim to investigate adverse events by accessing centrally held NHS data on deaths and hospitalisation for all PEPS trial participants.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN70660936.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 52. See the NIHR Journals Library website for further project information.

Systems Training for Emotional Predictability and Problem Solving Program and Emotion Dysregulation: A Pilot Study

The aim of this study was to assess the observed changes on emotion dysregulation obtained through the Systems Training for Emotional Predictability and Problem Solving (STEPPS) program. The sample is composed of 24 subjects with a personality disorder with borderline features. All participants filled out the Difficulties in Emotion Regulation Scale (DERS). There was a significant decrease in the DERS total score at the end of the treatment and at 6-month follow-up. Friedman test showed a significant decrease in suicide attempts and hospitalizations over time. The analysis of the DERS subscales showed that "goals" and "impulse" were the two dimensions on which the treatment acted and the changes were stable over time. STEPPS is associated with an improvement in emotion regulation and a reduction in the number of hospitalizations and suicide attempts. The treatment seems to act on the behavioral dimensions of emotion dysregulation like the ability to control impulsive behaviors and to achieve goals.

What Works in the Treatment of Borderline Personality Disorder

PURPOSE OF THE REVIEW

This review summarizes advances in treatments for adults with borderline personality disorder (BPD) in the last 5 years.

RECENT FINDINGS

Evidence-based advances in the treatment of BPD include a delineation of generalist models of care in contrast to specialist treatments, identification of essential effective elements of dialectical behavioral therapy (DBT), and the adaptation of DBT treatment to manage post-traumatic stress disorder (PTSD) and BPD. Studies on pharmacological interventions remain limited and have not provided evidence that any specific medications can provide stand-alone treatment.

SUMMARY

The research on treatment in BPD is leading to a distillation of intensive packages of treatment to be more broadly and practically implemented in most treatment environments through generalist care models and pared down forms of intensive treatments (e.g., informed case management plus DBT skills training groups). Evidence-based integrations of DBT and exposure therapy for PTSD provide support for changing practices to simultaneously treat PTSD and BPD.

A randomized trial of brief dialectical behaviour therapy skills training in suicidal patients suffering from borderline disorder

OBJECTIVE

Evidence-based therapies for borderline personality disorder (BPD) are lengthy and scarce. Data on brief interventions are limited, and their role in the treatment of BPD is unclear. Our aim was therefore to evaluate the clinical effectiveness of brief dialectical behaviour therapy (DBT) skills training as an adjunctive intervention for high suicide risk in patients with BPD.

METHOD

Eighty-four out-patients were randomized to 20 weeks of DBT skills (n = 42) or a waitlist (WL; n = 42). The primary outcome was frequency of suicidal or non-suicidal self-injurious (NSSI) episodes. Assessments were conducted at baseline 10, 20 and 32 weeks.

RESULTS

DBT participants showed greater reductions than the WL participants on suicidal and NSSI behaviours between baseline and 32 weeks (P < 0.0001). DBT participants showed greater improvements than controls on measures of anger, distress tolerance and emotion regulation at 32 weeks.

CONCLUSIONS

This abbreviated intervention is a viable option that may be a useful adjunctive intervention for the treatment of high-risk behaviour associated with the acute phase of BPD.

Small Group Process and Outcome Research Highlights: A 25-Year Perspective

We summarize major research findings from the past 25 years within the larger evolution of group psychotherapy. Small group process findings are highlighted from a group-as-a-whole, interpersonal relation, subgroup, individual member characteristics, and leader perspective. Special emphasis is given to cohesion and the significant correlation between cohesion and outcome. We note that group therapy is an empirically well-supported treatment for a large number of psychiatric disorders and describe evidence supporting the outcome of various theoretical orientations. Key studies showing outcome equivalence for group and individual therapy are reviewed, followed by a high-level summary of group therapy's efficacy research for depression, bipolar, social phobia, panic disorder, obsessive compulsive, bulimia nervosa, binge-eating, substance-related, trauma-related, HIV/AIDS, breast cancer, chronic pain, schizophrenia, and borderline personality. We conclude with the promise of recent advances for moving the field forward over the next 25 years.

Integrated sociotherapy – IS from rehabilitation to recovery integrating sociotherapy and cognitivism in a TC for borderline personality disorders

Purpose

The purpose of this paper is to explain that an integration of cognitivism with sociotherapy is possible and appropriate to help severe BPD cases. What follows is both an outline and a rationale of this integration.

Design/methodology/approach

Recovery programs for serious BPD represent a challenge because they require complex answers in three problematic areas: interdependent relationships, emotional intensity and identity, virtually at the same time. This prompted Raymond Gledhill Community the opportunity to integrate recovery programs with treatments that have yielded proven results for each cluster. Schema therapy and Systems Training for Emotional Predictability and Problem Solving have been integrated with sociotherapy.

Findings

This integration has led to considerable results including: increased motivation among the resident community, the adoption of a shared language, improved communication levels in the community, greater mutual support, increased trust in, and empathy toward, fellow residents, and more self-awareness – even among the facilitators.

Originality/value

It is the belief that the integration of cognitive tools with sociotherapy can indeed target recovery for people with BPD in a much more efficacious and cost effective manner.

What Influences Treatment Satisfaction in Patients with Personality Disorders? A Naturalistic Investigation in a Hospitalization Setting

Treatment satisfaction of different mental disorders is still poorly understood, but of high clinical interest. Inpatients of a general psychiatric care hospital were asked to fill out questionnaires on satisfaction and clinical variables at admission and discharge. On the basis of an exploratory approach, differences in treatment satisfaction among diagnostic groups were examined by means of one-way analysis of variance. Potential associated clinical and socio-demographic variables were studied using multi/univariate tests. Patients with personality disorders (n=18) showed a significantly lower treatment satisfaction (ZUF-8, Zurich Satisfaction Questionnaire) and a slightly lower improvement of symptoms (CGI, Clinical Global Impression) and global functioning (GAF, Global Assessment of Functioning scale) than that of other diagnostic groups (n=95). Satisfaction in patients with personality disorders correlated much stronger with the symptom improvement and slightly with the functioning level than in patients without personality disorders. Interestingly, in patients with personality disorders psychopharmacological treatment in general (present versus not present) was independent from satisfaction. This exploratory investigation suggests that a lower satisfaction of patients with personality disorders in a general psychiatric hospital is mainly based on a reduced improvement of the symptoms and of the global functioning level.

Do people with borderline personality disorder complicated by antisocial personality disorder benefit from the STEPPS treatment program?

Systems Training for Emotional Predictability and Problem Solving (STEPPS) is a group treatment for persons with borderline personality disorder (BPD). We describe results from two data sets on outcome in persons who participated in STEPPS with BPD alone or BPD plus antisocial personality disorder (ASPD). In Study 1, we examined the effect of comorbid ASPD on outcome in 65 persons with BPD who participated in a randomized controlled trial at an academic medical centre. In Study 2, we examined the effect of comorbid ASPD on outcome in 64 offenders with BPD who participated in STEPPS in correctional settings. All subjects were assessed for the presence of BPD and ASPD. In Study 1, subjects with ASPD experienced greater improvement in BPD symptoms, impulsiveness and global symptoms. In Study 2, offenders with ASPD experienced greater improvement in positive and negative behaviours and positive affectivity. We conclude that persons with BPD plus ASPD benefit from STEPPS in community and correctional settings. The findings suggest that persons with BPD plus ASPD show greater improvement in some domains than persons with BPD only. People with ASPD should not be automatically excluded from participation in the program. Copyright © 2015 John Wiley & Sons, Ltd.

Curriculum ad Psychoeducational Groups: Opportunities and Challenges

Curriculum and psychoeducational groups have become increasingly popular because of their strong evidence base and presumed ease of implementation. The curriculum provides a valuable guide to social workers leading groups as they decide on topics for discussion. Typically, the literature emphasizes the content--the material being presented--over the process: the ways in which members interact with one another and with the leader. The authors of this article contend that when the social worker adheres too rigidly to the content, members' ability to make meaning of and internalize the information being presented is compromised. They advocate for an approach to group facilitation that emphasizes flexible presentation of curriculum topics. The benefits of group participation are maximized when collaborative learning, which involves members' interactions with one another and the leader, is encouraged. The article includes a summary of the theoretical foundation and evidence base of psychoeducational and curriculum groups and presents strategies to promote collaborative learning using case examples.

Change in interpersonal functioning during psychological interventions for borderline personality disorder—a systematic review of measures and efficacy

OBJECTIVE

To provide a systematic review of measures of interpersonal functioning used in treatments for people diagnosed with borderline personality disorder (BPD) and to report the effectiveness of treatments on these measures of interpersonal functioning.

METHOD

Literature was reviewed using the online databases and reference lists of previous systematic reviews. Selected studies were randomized controlled trials (RCTs) that examined psychotherapeutic interventions for people with BPD and contained quantitative outcomes on various aspects of interpersonal functioning and reported their results in peer-reviewed journals. Reliability and validity of the results were evaluated.

RESULTS

Nineteen RCTs met our inclusion criteria. We found 16 different (sub)scales that measured some aspect of interpersonal functioning. Only four instruments were used by more than one research team. There is some evidence that psychotherapeutic interventions have beneficial effects on some aspects of interpersonal functioning in people diagnosed with BPD, both after individual and group therapy. Generalizability of these findings is limited.

CONCLUSION

There is preliminary evidence that psychotherapeutic interventions have beneficial effects on various aspects of interpersonal reactivity that characterize people diagnosed with BPD. However, none of these effects have a robust evidence base. There are serious concerns about the lack of agreed-upon concepts and instruments.

Are recommendations for psychological treatment of borderline personality disorder in current U.K. guidelines justified? Systematic review and subgroup analysis

Current U.K. guidelines on the management of borderline personality disorder include specific recommendations about the duration of therapy and number of sessions per week that patients should be offered. However, very little research has been conducted to examine the impact of these aspects of treatment process on patient outcomes. We therefore undertook a systematic review to examine the impact of treatment duration, number of sessions per week and access group-based therapy on general mental health, depression, social functioning and deliberate self-harm. We identified 25 randomized trials for possible inclusion in the review. However, differences in outcome measures used meant that only 12 studies could be included in the analysis. Statistically significant reductions in self-harm and depression and improvement in social functioning were found for treatments that include more than one session per week and those that included group-based sessions but were not found for those that deliver in individual sessions or one or fewer sessions per week. Longer term outcomes of short-term interventions have not been examined. Further research is needed to examine the impact of shorter term interventions and to compare the effects of group-based versus individual therapies for people with borderline personality disorder.

[Dialectical behavior therapy : a review of studies on skills training groups and applications in psychiatric settings]

Patients suffering from borderline personality disorder (BPD) represent a substantial proportion of hospitalized and outpatient patients in psychiatry. They use up to 40% of mental health resources. Dialectical behavioral therapy (DBT) is one of the best studied treatment for this population. Unfortunately, its deployment in Quebec remains quite limited partly because resources are lacking to provide individual therapy and a response to emergency calls. Although the complete package, as originally studied, is not widely available, several psychiatric departments offer skills training groups for patients with BPD. This article aims to provide a brief overview of the DBT model, review studies on DBT groups and some existing adaptations to the original model. The author will also present the model used in two psychiatric settings, the Centre de Santé et Services Sociaux du Sud de Lanaudière and Pavilion Albert-Prévost, as well as the adaptations in the context of transfers to community health settings.

Reporting of harms in randomized controlled trials of psychological interventions for mental and behavioral disorders: a review of current practice

BACKGROUND

Data suggest that certain psychological interventions can induce harm in a significant number of patients. While the need for adequate reporting of harms in clinical trials has repeatedly been emphasized, it is uncertain whether such information is routinely collected and reported in trials within this research field.

METHOD

We used the two major databases in clinical psychology and medicine (PsycINFO and PubMed) to identify original publications from 2010 reporting randomized controlled trials of psychological interventions for patients with mental and behavioral disorders. Two reviewers searched the full-text reports for information about monitoring of adverse events, side effects, and deterioration.

RESULTS

A total of 132 eligible trials were identified. Only 28 trials (21%) included information that indicated any monitoring of harms on patient level. Four (3%) of these trials provided a description of adverse events as well as the methods used for collecting these data. Five of the trials (4%) reported adverse events but did not give complete information about the method. An additional four reports (3%) briefly stated that no adverse events occurred, whereas 15 trials (11%) only provided information on deterioration or indicated monitoring of deterioration. The probability of including harm-related information was related to the journal impact factor.

CONCLUSION

Important information about harms is not reported systematically within this research field, suggesting that the risk of reporting bias is nontrivial in conclusions about the risk-benefit ratio of psychological treatments. Guidelines on how to define, detect, and report harms related to psychological interventions could facilitate better reporting.

Outcome of mentalization-based and supportive psychotherapy in patients with borderline personality disorder: a randomized trial

OBJECTIVE

This study presents data from a randomized outcome study comparing mentalization-based and supportive psychotherapy for patients with borderline personality disorder (BPD).

METHOD

Eighty-five SCID-II diagnosed borderline patients were randomized to either i) 2 years of intensive (twice weekly) combined (individual and group), mentalization-based psychotherapy (MBT) or ii) 2 years of less-intensive (biweekly) supportive group therapy. Treatment outcome was assessed using a battery of self-report questionnaires, SCID-II interviews and therapist-rated global assessment of functioning (GAF).

RESULTS

Fifty-eight patients completed 2 years of treatment. Significant changes in both treatment groups were identified for several outcome measures, including self-reported measures of general functioning, depression, social functioning and number of diagnostic criteria met for BPD, as outlined by the SCID-II interview. General linear modelling was used to compare treatment outcome in the two groups. Only GAF showed a significantly higher outcome in the MBT group. A trend was found for a higher rate of recovery from BPD in the MBT group. Pre-post effect sizes were high (0.5-2.1) and for the most part highly significant in both groups.

CONCLUSION

The study indicates that both MBT and supportive treatment are highly effective in treating BPD when conducted by a well-trained and experienced psychodynamic staff in a well-organized clinic.

Systems Training for Emotional Predictability and Problem Solving (STEPPS) group treatment for offenders with borderline personality disorder

Systems Training for Emotional Predictability and Problem Solving (STEPPS) is a manual-based group treatment of persons with borderline personality disorder (BPD). We report results from a study of offenders supervised by the Iowa Department of Corrections. Seventy-seven offenders participated in STEPPS groups. The offenders experienced clinically significant improvement in BPD-related symptoms (d = 1.30), mood, and negative affectivity. Suicidal behaviors and disciplinary infractions were reduced. Baseline severity was inversely associated with improvement. The offenders indicated satisfaction with STEPPS. We conclude that STEPPS can be successfully integrated into the care of offenders with BPD in prison and community corrections settings.

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.

Effectiveness of Systems Training for Emotional Predictability and Problem Solving (STEPPS) for borderline personality problems in a 'real-world' sample: moderation by diagnosis or severity?

BACKGROUND

Systems Training for Emotional Predictability and Problem Solving (STEPPS) is a group treatment for borderline personality disorder (BPD). Two prior randomized controlled trials (RCTs) have shown the efficacy of this training. In both RCTs, patients with borderline features who did not meet the DSM-IV criteria for BPD were excluded, which were many. We investigated the effectiveness of STEPPS in a sample representative of routine clinical practice and examined whether DSM-IV diagnosis and/or baseline severity were related to differential effectiveness.

METHODS

Patients whom their practicing clinician diagnosed with BPD were randomized to STEPPS plus adjunctive individual therapy (STEPPS, n = 84) or to treatment as usual (TAU, n = 84).

RESULTS

STEPPS recipients showed more improvement on measures of general and BPD-specific psychopathology as well as quality of life than TAU recipients, both at the end of treatment and at a 6-month follow-up. Presence of DSM-IV-diagnosed BPD was not related to differential treatment effectiveness, but dimensional measures of symptom severity were; STEPPS was superior to TAU particularly in patients with higher baseline severity scores.

CONCLUSIONS

The findings show the effectiveness of STEPPS in a 'real-world' sample, and underscore the importance of dimensional versus categorical measures of personality disturbance.

Psychotherapy for personality disorders

Personality disorders are widely prevalent among those seeking mental health services, resulting in substantial distress and a heavy burden on public assistance and health resources. We conducted a qualitative review of randomized controlled trials (RCTs) of psychosocial interventions for personality disorders. Articles were identified through searches of electronic databases and classified based on the focus of the psychological intervention. Data regarding treatment, participants and outcomes were identified. We identified 33 RCTs that evaluated the efficacy of various psychosocial treatments. Of these studies, 19 focused on treatment of borderline personality disorder, and suggested that there are several efficacious treatments and one well-established treatment for this disorder. In contrast, only five RCTs examined the efficacy of treatments for Cluster C personality disorders, and no RCTs tested the efficacy of treatments for Cluster A personality disorders. Although other personality disorders, especially Cluster A, place heavy demands on public assistance, and in spite of recommendations that psychosocial interventions should be the first line of treatment for these disorders, our review underscored the dearth of treatment research for many of these personality disorders. We highlight some obstacles to such research and suggest directions for future research.

Common factors in empirically supported treatments of borderline personality disorder

In this article, we examine the manuals of empirically supported psychotherapies for borderline personality disorder (BPD) by comparing their common and specific treatment strategies. We compare these treatments using a previously constructed scale of treatment interventions. Individual psychotherapies for BPD have several common strategies: clear treatment framework, attention to affect, focus on treatment relationship, an active therapist, and exploratory and change-oriented interventions. Use of interpretations, supportive interventions, designating treatment targets, attention to patient functioning, multimodal treatment, and support for therapies varied across the psychotherapies. We discuss these findings in the context of clusters of BPD symptoms, reports regarding overlap in treatment interventions used by various psychotherapies, and the effectiveness of specific treatment strategies.