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

Short-Term versus Long-Term Mentalization-Based Therapy for Borderline Personality Disorder: A Randomized Clinical Trial (MBT-RCT)

INTRODUCTION

Borderline personality disorder (BPD) is a severe and prevalent psychiatric disorder. Mentalization-based therapy (MBT) is an evidence-based intervention for BPD, and several countries offer treatment programs for BPD lasting for years, which is resource demanding. No previous trial has compared short-term with long-term MBT.

OBJECTIVE

The aim of the study was to assess the efficacy and safety of short-term versus long-term MBT for outpatients with BPD.

METHODS

Adult outpatients (≥18 years) with subthreshold or diagnosed BPD were randomly assigned (1:1) to short-term MBT (5 months) or long-term MBT (14 months). The primary outcome was BPD symptoms assessed with the Zanarini Rating Scale for Borderline Personality Disorder. Secondary outcomes were functional impairment, quality of life, global functioning, and severe self-harm. All outcomes were primarily assessed at 16 months after randomization. This trial was prospectively registered at ClinicalTrials.gov, NCT03677037.

RESULTS

Between October 4, 2018, and December 3, 2020, we randomly assigned 166 participants to short-term MBT (n = 84) or long-term MBT (n = 82). Regression analyses showed no evidence of a difference when assessing BPD symptoms (MD 0.99; 95% CI: -1.06 to 3.03; p = 0.341), level of functioning (MD 1.44; 95% CI: -1.43 to 4.32; p = 0.321), quality of life (MD -0.91; 95% CI: -4.62 to 2.79; p = 0.626), global functioning (MD -2.25; 95% CI: -6.70 to 2.20; p = 0.318), or severe self-harm (RR 1.37; 95% CI: 0.70-2.84; p = 0.335). More participants in the long-term MBT group had a serious adverse event compared with short-term MBT (RR 1.63; 95% CI: 0.94-3.07; p = 0.088), primarily driven by a difference in psychiatric hospitalizations (RR 2.03; 95% CI: 0.99-5.09; p = 0.056).

CONCLUSION

Long-term MBT did not lead to lower levels of BPD symptoms, nor did it influence any of the secondary outcomes compared with short-term MBT.

The difference between shorter- versus longer-term psychotherapy for adult mental health disorders: a systematic review with meta-analysis

BACKGROUND

The optimal psychotherapy duration for mental health disorders is unclear. Our aim was to assess the beneficial and harmful effects of shorter- versus longer-term psychotherapy for adult mental health disorders.

METHOD

We searched relevant databases and websites for published and unpublished randomised clinical trials assessing different durations of the same psychotherapy type before June 27, 2022. Our methodology was based on Cochrane and an eight-step procedure. Primary outcomes were quality of life, serious adverse events, and symptom severity. Secondary outcomes were suicide or suicide-attempts, self-harm, and level of functioning.

RESULTS

We included 19 trials randomising 3,447 participants. All trials were at high risk of bias. Three single trials met the required information size needed to confirm or reject realistic intervention effects. One single trial showed no evidence of a difference between 6 versus 12 months dialectical behavioral therapy for borderline personality when assessing quality of life, symptom severity, and level of functioning. One single trial showed evidence of a beneficial effect of adding booster sessions to 8 and 12 weeks of internet-based cognitive behavioral therapy for depression and anxiety when assessing symptom severity and level of functioning. One single trial showed no evidence of a difference between 20 weeks versus 3 years of psychodynamic psychotherapy for mood- or anxiety disorders when assessing symptom severity and level of functioning. It was only possible to conduct two pre-planned meta-analyses. Meta-analysis showed no evidence of a difference between shorter- and longer-term cognitive behavioural therapy for anxiety disorders on anxiety symptoms at end of treatment (SMD: 0.08; 95% CI: -0.47 to 0.63; p = 0.77; I2 = 73%; four trials; very low certainty). Meta-analysis showed no evidence of a difference between shorter and longer-term psychodynamic psychotherapy for mood- and anxiety disorders on level of functioning (SMD 0.16; 95% CI -0.08 to 0.40; p = 0.20; I2 = 21%; two trials; very low certainty).

CONCLUSIONS

The evidence for shorter versus longer-term psychotherapy for adult mental health disorders is currently unclear. We only identified 19 randomised clinical trials. More trials at low risk of bias and at low risk of random errors assessing participants at different levels of psychopathological severity are urgently needed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019128535.

Mentalizing the therapist – Therapist experiences with short-term mentalization-based therapy for borderline personality disorder: A qualitative study

Background

Mentalization-Based Therapy (MBT) was originally developed as a structured psychotherapy approach developed to treat borderline personality disorder (BPD) lasting up to 18 months in outpatient settings. However, a short-term (5 months) MBT program has recently been developed. No studies have investigated how MBT therapists experience the shift towards conducting short-term MBT for BPD.

Objective

The objective of this study was to explore therapist experiences with conducting short-term MBT for outpatients with BPD in the Danish mental health services.

Methods

Semi-structured qualitative interviews were conducted with seven therapists about their experiences with short-term MBT after a one-year pilot phase. The interviews were verbatim transcribed and analyzed using thematic analysis.

Results

The following four major themes from the therapists’ experiences with short-term MBT were found in the qualitative analysis: (1) The longer the better, (2) Change processes can be intellectual or experiential, (3) Short-term therapy is hard work, and (4) Termination is more challenging in short-term MBT.

Conclusion

Most therapists were overall reluctant towards changing from long-term to short-term MBT. These therapist experiences could inform implementation of short-term MBT in mental health settings in the future.

Adapting Short-Term Mentalization-Based Therapy to ICD-11 Personality Disorder in Adolescents

Following the introduction of the 11th revision of the International Classification of Diseases (ICD-11), adolescents can now be diagnosed with a personality disorder based on severity ranging from mild to moderate to severe. This dimensional model has potential implications for treatment, as it allows clinicians and researchers to search for effective treatments targeting adolescents at different severity levels rather than offering all patients the same treatment. In this conceptual paper, we propose that the short-term mentalization-based therapy (MBT) program, originally developed to treat adults with borderline personality disorder (BPD), has potential clinical advantages for adolescents with ICD-11 personality disorder at the mild to moderate severity level. The short-term MBT program is a 5-month structured treatment approach including individual therapy, combined psychotherapy with the individual therapist also being one of the group therapists, and closed-group therapy to enhance cohesion and a feeling of security. The purpose of this paper is to make a case for the use of this format, as opposed to the traditional long-term MBT format, for adolescents with BPD. Future research should include large-scale randomized clinical trials powered to assess patient-important outcomes.

Borderline Personality Disorder: Updates in a Postpandemic World

Progress in understanding borderline personality disorder has unfolded in the last decade, landing in a new COVID-19-influenced world. Borderline personality disorder is now firmly established as a valid diagnosis, distinct from its co-occurring mood, anxiety, trauma-related, and behavioral disorders. Further, it is also understood as a reflection of general personality dysfunction, capturing essential features shared among all personality disorders. Neuroimaging research, representing the vast neurobiological advances made in the last decade, illustrates that the disorder shares frontolimbic dysfunction with many psychiatric diagnoses but has a distinct signature of interpersonal and emotional hypersensitivity. This signature is the conceptual basis of the psychotherapies and clinical management approaches proven effective for the disorder. Medications remain adjunctive and are contraindicated by some guidelines internationally. Less invasive brain-based therapeutics show promise. The most significant change in the treatment landscape is a focus on briefer, less intensive formats of generalist management. Shorter variants of therapies, such as dialectical behavior therapy and mentalization-based treatment, are in the process of being shown to be adequately effective. Earlier intervention and greater emphasis on functional improvement are needed to more effectively curb the disabilities and risks of borderline personality disorder for patients and their families. Remote interventions show promise in broadening access to care.

A clinical illustration of short-term mentalization-based therapy for borderline personality disorder

OBJECTIVE

Mentalization-based therapy (MBT) is an evidence-supported, long-term psychotherapy program developed to treat borderline personality disorder (BPD). A short-term, 20-week adaptation to the original MBT format including case formulation, psychoeducation, and group and individual therapy has recently been proposed. The current case material will illustrate how the recent adaptation to the mentalization-based practice can enhance personality functioning using a short-term format.

METHODS

Case material is presented to demonstrate the clinical application of short-term MBT in the treatment of a young woman diagnosed with BPD who has a history of failed treatment attempts and who showed signs of affective dysregulation, unstable relationships, and intense abandonment anxiety.

RESULTS

The case illustration shows how short-term MBT can facilitate improvement in personality functioning, specifically targeting situations in which the patient lost her temper and became overwhelmed by abandonment anxiety. By continuously employing therapeutic shifts toward greater autonomy and agency, and by maintaining a balanced empathetic therapeutic stance, the therapists were able to enhance the patients mentalizing and personality functioning.

CONCLUSIONS

Short-term MBT can be effectively implemented to enhance the mentalizing capacity and personality functioning in outpatients with BPD.

Psychometric evaluation of the German version of the Brief Reflective Functioning Interview

OBJECTIVES

To measure mentalization in a feasible manner, various instruments have been designed in recent years. The Brief Reflective Functioning Interview (BRFI) is a short interview that is based on the Adult Attachment Interview (AAI). The aim of both studies was to examine the psychometric properties of the German version of the BRFI and to compare them to those of the AAI.

METHODS

In Study 1, we examined 60 students using the BRFI and the AAI. In Study 2, the validity of the BRFI was examined using a mixed sample of students and patients (N = 149). Trained coders evaluated the Reflective Functioning Scale (RFS) for the BRFI and the AAI.

RESULTS

We found a significant positive correlation between the RFS total scores of the BRFI and those of the AAI. In addition, both interviews showed excellent internal consistency. We could also show that persons with mental disorders exhibit lower levels of RF score than mentally stable individuals. Women had higher RF scores in the BRFI than men in both samples. Persons whose mentalization capacity was rated below average in either the BRFI or the AAI also reported significantly lower mentalization ability in the self-assessment (p < .01).

CONCLUSIONS

Our results revealed that the RFS scores measured by the BRFI are highly comparable to those measured by the AAI. Our findings support the results of previous studies, suggesting that the BRFI is a reliable, valid and easy-to-administer alternative to the AAI.

PRACTITIONER POINTS

The German version of the Brief Reflective Functioning Interview (BRFI) proved to be a reliable and valid instrument for the assessment of reflective functioning that is shorter in terms of time to complete and the evaluation process than the measurement via the Adult Attachment Interview (AAI). Reflective functioning is negatively associated with psychopathology.

Day hospital versus intensive outpatient mentalization-based treatment: 3-year follow-up of patients treated for borderline personality disorder in a multicentre randomized clinical trial

BACKGROUND

Two types of mentalization-based treatment (MBT), day hospital MBT (MBT-DH) and intensive outpatient MBT (MBT-IOP), have been shown to be effective in treating patients with borderline personality disorder (BPD). This study evaluated trajectories of change in a multi-site trial of MBT-DH and MBT-IOP at 36 months after the start of treatment.

METHODS

All 114 patients (MBT-DH n = 70, MBT-IOP n = 44) from the original multicentre trial were assessed at 24, 30 and 36 months after the start of treatment. The primary outcome was symptom severity measured with the Brief Symptom Inventory. Secondary outcome measures included borderline symptomatology, personality and interpersonal functioning, quality of life and self-harm. Data were analysed using multilevel modelling and the intention-to-treat principle.

RESULTS

Patients in both MBT-DH and MBT-IOP maintained the substantial improvements made during the intensive treatment phase and showed further gains during follow-up. Across both conditions, 83% of patients improved in terms of symptom severity, and 97% improved on borderline symptomatology. No significant differences were found between MBT-DH and MBT-IOP at 36 months after the start of treatment. However, trajectories of change were different. Whereas patients in MBT-DH showed greater improvement during the intensive treatment phase, patients in MBT-IOP showed greater continuing improvement during follow-up.

CONCLUSIONS

Patients in both conditions showed similar large improvements over the course of 36 months, despite large differences in treatment intensity. MBT-DH and MBT-IOP were associated with different trajectories of change. Cost-effectiveness considerations and predictors of differential treatment outcome may further inform optimal treatment selection.

Mentalizing the patient-Patient experiences with short-term mentalization-based therapy for borderline personality disorder: A qualitative study

BACKGROUND

Mentalization-based therapy (MBT) is an evidence-supported psychotherapy approach for borderline personality disorder (BPD) that has been implemented in mental health services worldwide. Originally, MBT was developed as an 18-months program for BPD. However, a short-term (5 months) MBT program has been developed. Research into patient experiences with long-term MBT for BPD is scarce, and no studies have investigated patient experience with short-term MBT for BPD.

OBJECTIVE

The objective of this study was to explore patient experience with short-term MBT for BPD in the Danish mental health services.

METHODS

Semi-structured qualitative interviews were conducted with 12 outpatients diagnosed with BPD, who attended short-term MBT for 5 months. The interviews were verbatim transcribed and analyzed using thematic analysis with double coding.

RESULTS

The analysis resulted in four subordinate themes: (1) Treatment duration - too short or appropriately short?, (2) The group as a "safe space," (3) Bad experiences impacted treatment negatively, and (4) My life has changed for the better.

CONCLUSION

The results suggest that most of the patients were overall satisfied with short-term MBT, which they experienced as having a positive impact on their lives. However, a subgroup of patients wanted more therapy. This study highlighted the strengths and limitations of short-term MBT for BPD as experienced by the patients, and points to barriers in developing service-user informed short-term treatment options for BPD.

Affective theory of the mind and suicide in women with borderline personality disorder and schizophrenia: a comparative study

Background

Theory of mind (ToM) is one of the essential components of social cognition. Affective ToM enables us to interpret other’s feelings and behaviors. Borderline personality disorder (BPD) and schizophrenia are two distinct mental disorders, yet they have a mutual deficit in interpreting emotions, thoughts, and intentions which may lead to a higher incidence of suicidality. Studies that involved social cognition, particularly ToM in schizophrenia, or BPD have controversial results. Therefore, this study aimed at comparing affective ToM functioning in female patients with BPD, schizophrenia, and healthy controls. In addition, identifying the possible impact and any correlation exists between the affective ToM and liability for suicide in those patients. Sixty individuals were recruited from the Institute of Psychiatry, Ain Shams University, Cairo, Egypt, and assigned into 3 groups where group A involved 20 BPD patients, group B involved 20 schizophrenic patients, and group C were healthy persons as a control. Assessment of affective ToM was done using Reading the Mind in the Eyes Test (RMET), and probability of suicide was measured using Suicide Probability Scale (SPS).

Results

Regarding ToM, the three groups were assessed using RMET and the results revealed a significantly higher mean score (hypermentalization) in BPD patients than both schizophrenic patients and controls. While schizophrenic patients had significantly lower mean scores than the control group (hypomentalization). As well, BPD patients had a significantly higher suicide probability total score than Schizophrenic patients and in all subdomains except for the hostility subdomain that was significantly higher in schizophrenic patients. Interestingly, in BPD, the suicide probability total score was positively correlated with RMET.

Conclusions

BPD patients have enhanced affective ToM and hypermentalization that is significantly associated with increased suicide probability in those patients, while in schizophrenia, hypomentalization could not be linked to increased suicide probability. Rehabilitation and proper management of ToM abnormalities might be a crucial tool in suicide prevention in mental illnesses, particularly, BPD.

A service evaluation of short-term mentalisation based treatment for personality disorder

BACKGROUND

People with personality disorder experience long waiting times for access to psychological treatments, resulting from a limited availability of long-term psychotherapies and a paucity of evidence-based brief interventions. Mentalisation-based treatment (MBT) is an efficacious therapeutic modality for personality disorder, but little is known about its viability as a short-term treatment.

AIMS

We aimed to evaluate mental health, client satisfaction and psychological functioning outcomes before and after a 10-week group MBT programme as part of a stepped-care out-patient personality disorder service.

METHOD

We examined routinely collected pre-post treatment outcomes from 176 individuals (73% female) aged 20-63 years, attending a dedicated out-patient personality disorder service, who completed MBT treatment. Participants completed assessments examining mentalising capacity, client satisfaction, emotional reactivity, psychiatric symptom distress and social functioning.

RESULTS

Post-MBT outcomes suggested increased mentalising capacity (mean difference 5.1, 95% CI 3.4-6.8, P < 0.001) and increased client satisfaction with care (mean difference 4.3, 95% CI 3.3-5.2, P < 0.001). Post-MBT emotional reactivity (mean difference -6.3, 95% CI -8.4 to -4.3, P < 0.001), psychiatric symptom distress (mean difference -5.2, 95% CI -6.8 to -3.7, P < 0.001) and impaired social functioning (mean difference -0.7, 95% CI -1.2 to -0.3, P = 0.002) were significantly lower than pre-treatment. Improved mentalising capacity predicted improvements in emotional reactivity (β = -0.56, P < 0.001) and social functioning (β = -0.35, P < 0.001).

CONCLUSIONS

Short-term MBT as a low-intensity treatment for personality disorder was associated with positive pre-post treatment changes in social and psychological functioning. MBT as deployed in this out-patient service expands access to personality disorder treatment.

Detailed statistical analysis plan for the short-term versus long-term mentalisation-based therapy for outpatients with subthreshold or diagnosed borderline personality disorder randomised clinical trial (MBT-RCT)

Background

Psychotherapy for borderline personality disorder is often extensive and resource-intensive. Mentalisation-based therapy is a psychodynamically oriented treatment option for borderline personality disorder, which includes a case formulation, psychoeducation, and group and individual therapy. The evidence on short-term compared with long-term mentalisation-based therapy is currently unknown.

Methods/design

The Short-Term MBT Project (MBT-RCT) is a single-centre, parallel-group, investigator-initiated, randomised clinical superiority trial in which short-term (20 weeks) will be compared with long-term (14 months) mentalisation-based therapy for outpatients with subthreshold or diagnosed borderline personality disorder. Outcome assessors, data managers, the data safety and monitoring committee, statisticians, and decision-makers will be blinded to treatment allocation. Participants will be assessed before randomisation and at 8, 16, and 24 months after randomisation. The primary outcome will be the severity of borderline symptomatology assessed with the Zanarini Rating Scale for Borderline Personality Disorder. Secondary outcomes will be functional impairment (Work and Social Adjustment Scale), quality of life (Short-Form Health Survey 36—mental component), global functioning (Global Assessment of Functioning), and proportion of participants with severe self-harm. In this paper, we present a detailed statistical analysis plan including a comprehensive explanation of the planned statistical analyses, methods to handle missing data, and assessments of the underlying statistical assumptions. Final statistical analyses will be conducted independently by two statisticians following the present plan.

Discussion

We have developed this statistical analysis plan before unblinding of the trial results in line with the Declaration of Helsinki and the International Conference on Harmonization of Good Clinical Practice Guidelines, which should increase the validity of the MBT-RCT trial by mitigation of analysis bias.

Trial registration

ClinicalTrials.gov NCT03677037. Registered on 19 September 2018

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05450-y.

Personality Functioning and Mentalizing in Patients With Subthreshold or Diagnosed Borderline Personality Disorder: Implications for ICD-11

The 11th revision of the International Classification of Diseases for Mortality and Morbidity Statistics (ICD-11) defines personality disorder according to personality functioning, which relates to self- and interpersonal functioning. The aim of the present study was to assess the relationship between mentalizing and personality functioning in patients with subthreshold or diagnosed borderline personality disorder. A total of 116 eligible participants were included. Mentalizing was assessed using the Mentalization Questionnaire (MZQ), personality functioning (self- and interpersonal functioning) was assessed using the Level of Personality Functioning Scale-Brief Form 2.0 (LPFS-BF), and borderline severity was assessed using the Zanarini Rating Scale (ZAN-BPD). Mediation analysis was employed to test if mentalizing accounted for the relationship between borderline severity and self- and interpersonal functioning. We found a significant relationship between borderline severity and both subscales of the LPFS-BF. Mentalizing fully and significantly mediated the relationship between borderline severity and interpersonal functioning. However, mentalizing only partly mediated the relationship between borderline severity and self-functioning. Controlling for the covariates gender and age did not impact the results. Mentalizing is likely to be involved in the ICD-11 model of personality functioning, especially interpersonal functioning. This could emphasize the relevance of therapy aimed at strengthening mentalizing abilities when treating personality pathology in general and people with borderline personality disorder in particular. However, self-functioning may be more nuanced, as aspects other than mentalizing also influence self-functioning. The study is explorative in nature and has methodological limitations that require caution in the interpretation and generalizability.

Delineamentos de Pesquisa em Psicologia Clínica: Classificação e Aplicabilidade

Resumo Sabe-se que para que uma pesquisa produza dados válidos, é importante que tenha sido bem desenhada metodologicamente. Em que pese a ampla literatura disponível sobre metodologia de pesquisa, há poucos estudos, particularmente em psicologia, que discutem suas especificidades quanto ao método. Esta revisão narrativa apresenta os principais tipos de delineamentos utilizados em pesquisas na área da psicologia clínica, assim como reflexões sobre sua utilidade em diferentes contextos. Também exibe um fluxograma para classificação dos delineamentos abordados. Destaca-se que não se defende uma taxonomia dos delineamentos, mas busca-se construir um guia para auxiliar no entendimento dos desenhos disponíveis e na escolha dentre eles, com vistas a facilitar a comunicação entre pesquisadores. Portanto, acredita-se que este trabalho contribui para a construção de estudos precisamente conduzidos metodologicamente, bem como para a identificação e o aprimoramento do emprego dos diversos delineamentos na área da psicologia clínica.

How does level of personality functioning inform clinical management and treatment? Implications for ICD-11 classification of personality disorder severity

PURPOSE OF REVIEW

The International Classification of Diseases, 11th Edition (ICD-11) classifies personality disturbance according to levels of severity. This article reviews the literature on levels of personality functioning in relation to clinical management and treatment, and proposes how these findings apply to the ICD-11 classification of personality disorders.

RECENT FINDINGS

Findings were primarily derived from studies using the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) Level of Personality Functioning Scale (LPFS), Kernberg's Level of Personality Organization, and the general P-factor of personality disorder. Severity of personality dysfunction is related to treatment outcome, risk of dropout, therapeutic alliance, readiness for treatment, risk of harm to self or others, risk of dissociation and psychotic-like breaks, coherence in narrative identity, reflective functioning, and epistemic trust.

SUMMARY

The overall level of personality disorder severity indicates risk of negative outcomes and may be used as decision tool for 'personalized medicine' and required treatment intensity (e.g., strength of alliance and the need for establishing epistemic trust). Beyond the ICD-11 guidelines for determining personality disorder severity, these implications also apply to practitioners using comparable frameworks such as the DSM-5 LPFS and Kernberg's Level of Personality Organization. Future research should focus on the interaction of severity with trait qualifiers in relation to clinical management.