Changes in Neurocognitive Functioning After 6 Months of Mentalization-Based Treatment for Borderline Personality Disorder

Pretreatment cognitive performance is associated with differential self-harm outcomes in 6 v. 12-months of dialectical behavior therapy for borderline personality disorder

BACKGROUND

Recent findings suggest that brief dialectical behavior therapy (DBT) for borderline personality disorder is effective for reducing self-harm, but it remains unknown which patients are likely to improve in brief v. 12 months of DBT. Research is needed to identify patient characteristics that moderate outcomes. Here, we characterized changes in cognition across brief DBT (DBT-6) v. a standard 12-month course (DBT-12) and examined whether cognition predicted self-harm outcomes in each arm.

METHODS

In this secondary analysis of 240 participants in the FASTER study (NCT02387736), cognitive measures were administered at pre-treatment, after 6 months, and at 12 months. Self-harm was assessed from pre-treatment to 2-year follow-up. Multilevel models characterized changes in cognition across treatment. Generalized estimating equations examined whether pre-treatment cognitive performance predicted self-harm outcomes in each arm.

RESULTS

Cognitive performance improved in both arms after 6 months of treatment, with no between-arm differences at 12-months. Pre-treatment inhibitory control was associated with different self-harm outcomes in DBT-6 v. DBT-12. For participants with average inhibitory control, self-harm outcomes were significantly better when assigned to DBT-12, relative to DBT-6, at 9-18 months after initiating treatment. In contrast, participants with poor inhibitory control showed better self-harm outcomes when assigned to brief DBT-6 v. DBT-12, at 12-24 months after initiating treatment.

CONCLUSIONS

This work represents an initial step toward an improved understanding of patient profiles that are best suited to briefer v. standard 12 months of DBT, but observed effects should be replicated in a waitlist-controlled study to confirm that they were treatment-specific.

Mentalization-oriented psychodynamic group therapy for patients with personality disorders: a naturalistic prospective cohort study

OBJECTIVES

Patients with personality disorders (PDs) are often treated with non-manualized psychodynamic group therapy (PDT) lasting for several years. Non-manualized PDT often combines a variety of therapeutic approaches from different PDT traditions, including mentalization-based therapy. Currently, little is known about the effect of this long-term, costly treatment. This study investigated the extent to which patients with different PDs benefit from mentalization-oriented PDT as it is implemented in clinical practice in terms of symptom severity, interpersonal problems, and general functioning.

METHODS

The design was a naturalistic, prospective cohort study. Seventy-five consecutive PD patients were assessed before treatment with the Symptom Checklist-90 Revised (SCL-90-R) as the primary outcome measure and the Inventory of Interpersonal Problems (IIP) and Global Assessment of Functioning (GAF) as secondary outcome measures. The sample was repeatedly assessed every 12 months for up to 36 months. Paired t-tests were applied to examine the effectiveness of the intervention.

RESULTS

Among completers (n = 42; 56%), improvement was observed on the SCL-90-R: Global Severity Index (mean change = -0.45 [95% CI = -0.72, -0.19]; Cohen's d = -0.55), Positive Symptom Distress Index (-0.40 [-0.63, -0.17]; -0.56); Positive Symptoms Total (-10.70 [-17.31, -4.09]; -0.52). Secondary outcomes also improved: IIP-total (mean change = -0.50 [95%CI = -0.74, -0.25]; Cohen's d = -0.66); GAF-Functioning (8.79 [6.32, 11.27]; 1.15); and GAF-Symptoms (10.67 [8.09, 13.25]; 1.34).

CONCLUSIONS

Completers improved on symptom severity, interpersonal problems, and general functioning, with within-group effect sizes ranging from medium to large. Approximately half the sample dropped out, suggesting that mentalization-oriented PDT spanning several years may be unrealistic for many patients with PD. Significant outcomesThere are no clear guidelines for psychological interventions targeting personality disorders (PDs), and currently eclectic and non-manualized psychodynamic approaches lasting for up to 3 years are prevailing in some clinical practices.Although this treatment approach may have an effect on compliant patients, the high drop-out rate indicates that it may not be suitable for a large proportion of PD patients since it requires long-term commitment. Furthermore, it is difficult to identify the content of the non-manualized psychodynamic therapy and what helps the patients.More specific clinical guidelines emphasizing the application of evidence-based treatments or at least manualized treatments are warranted for the treatment of emotionally unstable PDs and other PDs. LimitationsThe naturalistic study design, without any control group, limits conclusions about mechanisms of action of the intervention.Since the intervention was not manualized, it is unknown exactly which treatment was actually administered, which reduces external validity.The outcomes are based on completer data of a relatively small sample size with high drop-out rate.

The Relationship Between Cognitive Abilities and Trait Clinical Features in Patients With Borderline Personality Disorder

Very few studies have focused on the relationship between cognitive functions and clinical features in borderline personality disorder (BPD). Subjects with BPD and healthy controls were administered the Repeatable Battery for the Assessment of Neuropsychological Status, Trail Making Test A and B, and the Wisconsin Card Sorting Test. The Brief Symptom Inventory (BSI-53) was used to assess the severity of current symptoms. Attachment style was assessed with the Experiences in Close Relationship Questionnaire, identity integration with the Personality Structure Questionnaire, and other domains of personality dysfunction with the RUDE Scale for Personality Dysfunction. Patients with BPD performed significantly worse than healthy controls in all cognitive domains. Cognitive functions, particularly delayed memory and visuospatial abilities, displayed meaningful associations with trait-like clinical features, above the effect of global cognition and state psychopathology. These findings highlight the need to evaluate effects of cognitive rehabilitation on trait features among individuals with BPD.

Mentalization-based treatment and its evidence-base status: A systematic literature review

PURPOSE

This study reviewed the evidence-base status of mentalization-based treatment (MBT), its quality, strengths, and limitations. The aim was to pave the way for further MBT research.

METHOD

An electronic database and reference lists search identified MBT outcome papers, and these were systematically reviewed. The quality of the studies and the risk of bias were determined using two validated checklist tools.

RESULTS

Twenty-three studies were included in the review. This included nine randomized controlled trials, seven uncontrolled pre- and post-effectiveness studies, three retrospective cohort studies, two uncontrolled randomized trials, and two case studies. The methodological quality of almost half of the papers was assessed as fair (43%), followed by good (34%), poor (17%), and excellent (4%) ratings. Nevertheless, the review identified risk of confounding bias across the majority of studies (60%) and fidelity to treatment was poorly reported in almost half of the studies (47%). Most of the studies focused on borderline personality disorder (BPD), showing positive clinical outcomes for this population but the evidence-base for other presentations was still developing. The treatment of adolescents who self-harm and at-risk mothers in substance abuse treatment showed particularly promising results, as these are client groups that have previously shown limited positive response to psychological interventions.

CONCLUSIONS

Mentalization-based treatment is a potentially effective method across a wide range of clinical presentations but further research should focus on increasing the quality and the quantity of the MBT evidence outside the treatment of BPD.

PRACTITIONER POINTS

MBT can be a particularly effective intervention for the treatment of adults with a diagnosis of BPD and of adolescents who self-harm and mothers enrolled in substance abuse treatments. MBT can be an effective intervention for depression and eating disorders but the evidence is currently limited. Professionals supporting mothers of children at risk may benefit from receiving training in the principles of MBT.

Mentalization-Based Treatment for Personality Disorders: Efficacy, Effectiveness, and New Developments

PURPOSE OF THE REVIEW

This review aims to outline the most recent evidence on the efficacy and effectiveness of mentalization-based treatment (MBT) for personality disorders (PD) from 2015 to 2018 and to describe new treatment developments.

RECENT FINDINGS

Since 2015, 14 new-primarily effectiveness-MBT trials have been published. The main body of studies investigated adult populations (n = 11), patients with a borderline personality disorder (BPD) diagnosis (n = 8), and compared MBT with another psychotherapeutic treatment (n = 6). The majority of studies suggest that MBT has the potential to improve the clinical outcomes for adolescents and adults with a PD diagnosis, particularly BPD, and also with comorbid diagnoses and there are indications for changes in mentalizing being a specific mechanism of change promoted by MBT. Despite promising findings, there is an urgent need for methodological sound and sufficiently powered studies to investigate both the efficacy and effectiveness of MBT, especially beyond BPD.