42 CASPONSOREDT BY CMEE LLC • GPSYCHIATRIC TIMESO • APRIL 2012RY Treatment Approaches for Borderline Personality Disorder by Frank E. Yeomans, MD, PhD, Kenneth N. Levy, PhD, and psychotherapy, and dynamic deconstructive dard CBT treatment has shown efficacy in a ran- Kevin B. Meehan, PhD psychotherapy).2-6 domized controlled trial (RCT), although these Although cognitive-behavioral therapies modified approaches share many core features of (CBTs) and psychodynamic therapies represent a CBT approach, including teaching patients how orderline personality disorder (BPD) is different viewpoints, both models share certain to recognize, manage, or modify painful mental the only disorder to date for which the basic tenets in the treatment of patients with states. American Psychiatric Association’s BPD.7 In this article, we review the treatments CBT-based treatments address deficits in skills (APA) treatment guidelines specify with a strong evidence base and discuss some the needed to tolerate intense affects and distortions Bpsychotherapy as the treatment of choice.1 Over therapies that offer promise but do not yet have a in thinking and, in the case of schema-focused the past decades, many evidence-based therapies rigorous evidence base. therapy, provide a reparative emotional experi- have been developed to address BPD: psycho- ence. These therapies seek to identify dysfunc- therapies based on cognitive-behavioral models Cognitive-behavioral therapies tional beliefs in patients with BPD; these beliefs (dialectical behavior therapy and schema-focused Dialectical behavior therapy and schema-focused include seeing themselves as a combination of therapy) and on psychodynamic models (men therapy are two evidence-based therapies found- undesirable, needy, helpless, bad, unlovable, and talization-based therapy, transference-focused ed on modified CBT principles. To date, no stan- deserving of punishment, and seeing others as
CREDITS: 1.5 ESTIMATED TIME TO COMPLETE participation in the activity. RELEASE DATE: April 20, 2012 The activity in its entirety should take approximately 90 Physician assistants, nurse practitioners, and nurses may EXPIRATION DATE: April 20, 2013 minutes to complete. participate in this educational activity and earn a certifi- FACULTY LEARNING OBJECTIVES cate of completion, as AAPA, AANP, and ANCC accept Frank E. Yeomans, MD, PhD, is Clinical Associate Professor After completing this activity, participants should be able to: AMA PRA Category 1 Credits™ through their reciprocity of Psychiatry and Director of Training, Personality Disorders • Understand the various evidence-based therapies used to agreements. Institute, Weill Medical College of Cornell University, New treat borderline personality disorder DISCLAIMER York; and Lecturer, Columbia University Center for Psycho- • Better understand the safety and efficacy profiles of the The opinions and recommendations expressed by faculty analytic Training and Research, New York. Kenneth N. different therapeutic options and other experts whose input is included in this activity Levy, PhD, is Associate Professor, Department of Psycholo- • Recognize the most suitable therapy for individual are their own and do not necessarily reflect the views of gy, The Pennsylvania State University, University Park. Kevin patients the sponsors or supporter. Discussions concerning drugs, B. Meehan, PhD, is Assistant Professor of Psychology, Long COMPLIANCE STATEMENT dosages, and procedures may reflect the clinical experi- Island University, Brooklyn Campus. 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APRIL 2012 PSYCHIATRIC TIMES 43 CATEGORY1 neglectful, untrustworthy, rejecting, or harmful. tempt as those who received CBTE when ana- and gradual exposure to anxiety-provoking situ- Addressing these beliefs and skills deficits func- lyzed with the treatment year and follow-up pe- ations. The therapy also challenges negative tions to decrease helplessness and increase a riod combined, the difference disappeared when thoughts and beliefs about oneself through cogni- sense of self-efficacy and mastery. only the follow-up period was examined. tive techniques and behavioral experiments while Dialectical behavior therapy. This model The seriousness of suicide attempts differed using the therapy relationship to improve the ca- views emotional dysregulation as at the core of between the two groups in the ITT analysis; pacity to attach to others. BPD, which is seen as developing from the com- however, there were no differences in emergency Giesen-Bloo and colleagues16 compared sche- bination of a genetic tendency to intense emo- department use, hospitalization, parasuicidal at- ma-focused therapy with transference-focused tional reactions and an early environment that tempts, medication use, global functioning, so psychotherapy provided over 3 years. They found does not validate the individual’s emotional expe- cial adjustment, and anger. With regard to dose- that patients benefited from both treatments, rience. The term “dialectic” refers to the combin- controlled effects, completer analyses found no but significantly larger effects favoring schema- ing of and alternating between the therapist’s differences.12 At follow-up 1 year after the com- focused therapy emerged by year 3 in reduced acceptance of the patient as is (the context of pletion of the study, there were also no differ- self-reported BPD symptoms (MSTS = 9.81; emotional validation) and active encouragement ences between the dialectical behavior therapy P < .001), improved self-reported quality of life toward behavioral change. Dialectical behavior and CTBE groups on any of the variables. (MSTS = 6.09; P = .001), and less distress on a therapy provides 1 hour of individual therapy and McMain and colleagues13 compared dialecti- single factor measure of personality functioning 1.5 hours of skills training groups per week. cal behavior therapy with general psychiatric (MSTS = 26.73; P < .001). Furthermore, the The focus is on a therapeutic alliance in which management as articulated in the APA Treatment transference-focused psychotherapy group had a skills (motivation and capability enhancement on Guidelines. On the basis of the APA Guideline’s significantly higher dropout rate over the 3 years the part of both patient and therapist) are taught focus on the centrality of psychosocial treat- of treatment (P = .01). However, completer anal- and reinforced, and undesirable behaviors are de- ments, in this study individual psychodynamic yses did not show any statistically significant ad- creased through contingency management. Skills psychotherapy (based on Gunderson’s14 model of vantage for schema-focused therapy. A second training provides psychoeducation in 4 areas: dis- treatment) was combined with pharmacotherapy RCT compared schema-focused therapy with tress tolerance, emotional regulation, interper- and case management. Results with general psy- telephone consultation with schema-focused sonal effectiveness, and mindfulness. The patient chiatric management plus individual psychody- therapy without telephone consultation and did uses the learned skills to resolve problems with namic psychotherapy were equal to those with not find any group differences.17 Although there emotional dysregulation, impulsivity, and inter- dialectical behavior therapy. Although outcomes are a number of limitations in the Giesen-Bloo personal instability. The dialectic approach in- for patients who received dialectical behavior study, schema-focused therapy nonetheless may volves balancing behavioral change with valida- therapy were comparable to outcomes for pa- be an effective treatment for BPD. tion and acceptance of the patient’s experience. tients in previous studies, there were no between- Other cognitive and behavioral approaches. Therapists meet weekly in a consultation group condition differences in rates of change for sui- Although not as well studied, there are other to receive support in maintaining a validating and cidality, self-injury, psychiatric service use, BPD modified cognitive and behavioral approaches dialectic stance toward their patients. symptoms, depression, anger, and social func- that have begun to show efficacy as treatments for A landmark study by Linehan and colleagues8 tioning. These findings held up after 1-year BPD. For example, Systems Training for Emo- garnered a great deal of attention because it pro- follow-up. tional Predictability and Problem Solving vided the only data of its kind at the time. Com- Schema-focused therapy. This twice-weekly (STEPPS) is a manualized adjunctive group pared with patients who received treatment as individual therapy is an integrative approach that treatment for patients with BPD that integrates usual, patients treated with dialectical behav- “draws on insights and techniques from the cog- cognitive-behavioral and group systems interven- ior therapy dropped out of treatment less often nitive-behavioral, attachment, psychodynamic, tions.18 STEPPS conceptualizes BPD as an “emo- (z = 3.59; P < .001) and had significant reduc- and emotion-focused traditions.”3,15 The schemas tional intensity disorder” for which specialized tions in the number and severity of suicide at- in question are internal representations of self in skills are needed to monitor and manage intense tempts (z = 2.69; P < .01, 1-tailed test) and in the relation to others but do not include a sense of the affects. duration of inpatient stays (z = 1.70; P < .05). dynamic unconscious. Rather, patients are helped BPD is understood in a systemic context in Subsequent studies also found dialectical behav- to identify their schemas without a focus on un- which others may be reinforcing pathological ior therapy efficacious for BPD.9-11 derstanding the motivations that keep them out- behavior. In an RCT of 124 patients with BPD, Despite these encouraging outcomes, there side of awareness. The 4 core mechanisms used patients treated in STEPPS had greater reduc- was a significant limitation to studies of dialecti- in schema-focused therapy are (1) limited repar- tions in BPD symptoms (F1, 89 = 11.0; P = .001), cal behavior therapy—samples sizes were small enting, (2) experiential imagery and dialogue impulsivity (F1, 89 = 6.9; P = .01), emotionality and comparisons were made against control work, (3) cognitive restructuring and education, (F1, 89 = 7.6; P = .007), and global functioning groups in which the patients received less treat- and (4) behavioral pattern breaking. (F1, 84 = 12.1; P < .001) than patients who received ment in a less credible therapy than the patients Limited reparenting has been described as at treatment as usual.19 However, STEPPS was not who received dialectical behavior therapy. In the heart of schema-focused therapy. It is based found to be different from treatment as usual on addition, studies of drug-dependent and opioid- on the assumption that BPD patients’ core emo- key symptoms such as suicidal and self-injurious dependent women with BPD had mixed results. tional needs were not met by their parents or that behaviors or hospitalizations. Nonetheless, these To test dialectical behavior therapy against a the parents overtly traumatized the patient and findings suggest that this promising approach more stringent control, Linehan and colleagues9 that the therapist should provide the experience should be evaluated further, using a more strin- compared 100 patients treated with dialectical of having basic emotional needs met by offering gent comparison group. behavior therapy with patients treated by thera- himself or herself as a parental figure. Thus, lim- Of note: all the evidence-based treatments rep- pists who were nominated by heads of commu- ited reparenting welcomes and encourages de- resent modifications of standard CBT and in fact nity agencies as experts in working with “difficult pendency on the therapist and ranges from pro- tend to be integrative. Linehan and Young were clients.” Patients treated in the latter group were viding warmth, nurturance, and occasional hugs both explicit about developing their modified and designated as having received “community treat- to self-disclosure, firmness, and limit setting. integrative treatments because of their experience ment by experts” (CTBE). Among recipients of The goal is the internalization of the therapist that standard CBT was not effective for BPD. dialectical behavior therapy, there was signifi- as a healthy parent through these re-parenting ex- Data suggest that they were correct in this infer- cantly less dropout than among recipients of periences, emotion-focused work, cognitive re- ence. In the Borderline Personality Disorder CTBE (19.2% v 46.9%, respectively; hazard structuring, and breaking behavioral patterns. Study of Cognitive Therapy (BOSCOT) trial, ratio, 3.2; P < .001). There were few other differ- Schema-focused therapy uses experiential tech- there were no differences between CBT and treat- ences in the intent-to-treat (ITT) analyses. Al- niques, such as imagery, role-playing, and letter ment as usual on any of the primary outcome though patients who received dialectical behavior writing, and behavioral techniques, such as relax- therapy were half as likely to make a suicide at- ation, assertiveness training, anger management, (Please see Borderline Personality Disorder, page 44) 44 PSYCHIATRIC TIMES APRIL 2012 CATEGORY1 Borderline Personality Disorder volves the capacity to think about mental states in fect sizes were reported in mentalization-based Continued from page 43 terms of wishes, desires, and intentions—mental- therapy than in structured clinical management ization. This involves inviting patients to become for reduced suicidal and self-harm behavior and curious about their thoughts, beliefs, and espe- number and length of inpatient hospitalizations measures and on most secondary outcome mea- cially manifest affects about themselves and oth- (χ2(1) = 4.3; P < .04), as well as statistically sig- sures.20 Distress and dysfunction remained high ers; a capacity that is challenged by the activation nificant improvement in depressive symptoms even after 2 years of treatment, which suggests of the attachment system in affectively charged (χ2(3) = 394.37; P < .001) and better social (χ2(3) that standard CBT is contraindicated for patients interpersonal situations. = 327.00; P < .001) and interpersonal functioning who suffer from BPD. Mentalization-based therapy sees the core (χ2(3) = 203.35; P < .001). problem in BPD as a deficit in the capacity to The data from these studies show that mental- Psychodynamic therapies mentalize or reflect on internal experiences and ization-based therapy is effective. To build an Psychodynamic therapies have also been modi- mental states. Therapy focuses on improving the empirically grounded framework for this psycho- fied for treatment of patients with BPD. Three patient’s capacity to think about intentions and therapy, the next step in the hierarchy of treat- manualized psychodynamic treatments have motivations by increasing conscious awareness ment evidence would be to compare mentaliza- shown efficacy for BPD: mentalization-based of previously inchoate affective states, thus pro- tion-based therapy with a well-established, therapy, transference-focused psychotherapy, and moting satisfying interpersonal relationships; well-delivered alternative treatment (such as dia- dynamic deconstructive therapy. In addition, 2 heightened tolerance of distress; and reduction in lectical behavior therapy, transference-focused nonmanualized psychodynamic treatments have impulsive, destructive behaviors. psychotherapy, or schema-focused therapy). shown efficacy. Individual psychodynamic psy- Mentalization-based therapy can be conduct- Transference-focused psychotherapy. In addi- chotherapy, based on Gunderson’s14 model in ed either in a day hospital setting that includes tion to helping improve mentalizing, transfer- combination with general psychiatric manage- expressive individual therapy, group therapy, and ence-focused psychotherapy focuses on conflicts ment, was efficacious in a comparison with dia- a community meeting or in individual outpatient among different internal states and helps the pa- lectical behavior therapy.13 Supportive dynamic therapy. The therapist explores what is going on tient resolve conflicts and establish an inner bal- psychotherapy was efficacious in a trial with in the patient’s mind that leads to his affective ance.5 The therapy is based on the concept of a transference-focused psychotherapy and dialecti- experience, as well as what the patient imagines fundamental split within the patient’s mind that cal behavior therapy.21 is going on in the therapist’s mind. The objectives sequesters affect states into separate all-negative These modified approaches share many core of mentalization-based therapy are described as and all-positive segments. psychodynamic principles, including a concern not “aiming to achieve structural or personality The extreme affect states are connected to im- with helping each individual find a balance change or alter cognitions and schemas; its aim is ages of self and other. Trigger events activate among the forces that affect his or her feelings, to enhance embryonic capacities of mentalization these internal images that are projected onto the thoughts, and behaviors. These forces include the so that the individual is more able to solve prob- current situation. Any affect that the patient expe- biological urges (eg, love, hate, anxiety), inter- lems and to manage emotional states particularly riences is thought to have a connection to the pa- nalized constraints against these urges (moral with interpersonal relationships.”23(p200) tient’s experience of a relationship, including the values), and the values and constraints of the in- Bateman and Fonagy24 compared the effec- relationship with the therapist. Therapy is based dividual’s social context (“external reality”). tiveness of 18 months of a psychoanalytically on the ideas that the raw affect can be transformed Psychodynamic therapies help patients find a oriented day hospital program with routine gen- into words and can be explored to see whether the balance that allows them adequate satisfaction of eral psychiatric care for patients with BPD. Men- extreme feeling in the moment corresponds to the their urges while maintaining adequate control to talization-based therapy statistically significantly reality of the relationship or whether it represents successfully adapt to the world. These therapies improved depressive symptoms (F1, 33 = 13.1; P < an exaggerated, partial, or distorted experience. help the patient understand unconscious irratio- .001), social functioning (F1, 33 = 8.7; P < .006), In this twice-weekly therapy, symptomatic nal patterns of thinking that may underlie behav- and interpersonal functioning (F1, 34 = 63.7; P < change in transference-focused psychotherapy is ioral symptoms. Treatments are based on the idea .001). In addition, there were significant decreas- believed to be accomplished first through limit- that once the patient becomes aware of these un- es in suicidal and parasuicidal behavior (χ2(3) = setting (eg, the treatment frame) and then more conscious thoughts and feelings, he will be able 33.5; P < .001) and number of days in inpatient deeply through the development of integrated to master aspects of himself that had previously treatment (t36 = 13.23; P < .001). representations of self and others, leading to a full exerted unconscious control on his behavior. Follow-up results after 18 months indicate that and coherent sense of self. The analysis of the The goal of treatments based on psychody- patients who completed mentalization-based relationship with the therapist (the transference) namic models is to help people integrate all as- therapy not only maintained their substantial is the primary vehicle for this work. The goal is pects of their internal experience (eg, shameful or gains but also showed continued steady and sta- not just changing symptoms but changing the per- “unacceptable” thoughts, feelings, and motiva- tistically significant improvement on most mea- sonality organization—the split mental structure— tions) to experience themselves and others in a sures.25 The 8-year follow-up showed mainte- that is the basis of the specific symptoms of the more coherent, balanced way. In mentalization- nance of treatment gains26: 87% of patients disorder. based therapy, this is accomplished by helping treated no longer met criteria for BPD, compared In transference-focused psychotherapy, as af- the patient see alternative perspectives and appre- to only 13% of those treated in routine general fects are experienced in sessions, the engaged, ciate the mental states of others. psychiatric care. Decreased suicidality, psychiat- interactive, and emotionally attentive stance of In transference-focused psychotherapy the ric service use, medication use, and improved the therapist is typically experienced by patients therapist helps the patient integrate these dispa- vocational functioning were also maintained; as emotionally holding (containing) because the rate psychological states using the transference however, social functioning remained impaired. therapist conveys that he can tolerate the patient’s relationship as a vehicle for understanding rela- Findings showing the long-term maintenance of negative affective states without denying them or tional patterns that emerge outside of the patient’s treatment gains for BPD patients are important. reacting in a retaliatory way. The process of clar- awareness. For example, the therapist may note However, these long-term follow-up data are ification helps the patient mentalize internal subtle signs of anger under the guise of friendli- based on comparison with a treatment-as-usual states. Then confrontation (identifying elements ness, or vice versa—this alerts the therapist to the cohort; more research is needed to fully evaluate of the patient’s verbal and nonverbal communica- patient’s discomfort and the need to understand the long-term efficacy of this therapy. tions that are in contradiction with each other) the reasons behind the discomfort. More stringent control was provided in a later and interpretation of aspects of the patient’s expe- Mentalization-based therapy. This therapy in- RCT.27 The effectiveness of 18 months of out rience that are split increase the ability to inte- tegrates attachment theory, philosophy (theory patient mentalization-based therapy was com- grate the different parts, a process that improves of mind), ego psychology, and select aspects of pared with structured clinical management for affect tolerance and impulse control. Kleinian theory.22 It posits that the mechanism of patients with BPD. The findings show that while Efficacy was shown in 2 RCTs that compared change in all effective treatments for BPD in- patients benefited from both treatments, larger ef- outcomes for patients who received transference- APRIL 2012 PSYCHIATRIC TIMES 45 CATEGORY1 focused psychotherapy (TFP) with outcomes for In both groups, there were significant im- the general psychiatric management model 28-30 active controls. In the first study, transference- provements in depression (t50 = 3.151; P = .003) would need to be replicated in further RCTs. focused psychotherapy was compared with dia- and anxiety (state anxiety, t51 = 2.388; P = .02; However, this study is suggestive of the value of 35 lectical-behavior therapy (DBT) and a psychody- trait anxiety, t51 = 3.116; P = .02). General psy- Gunderson and Links’ approach to treating pa- namic supportive psychotherapy (SPT).21 Study chopathology also improved in the transference- tients with BPD. data show that all 3 groups had significant im- focused psychotherapy group (t51 = 2.265; P = Dynamic deconstructive psychotherapy has provement in both global functioning (TFP, P = .03), all without significant group differences shown efficacy for comorbid BPD and substance .001; DBT, P = .004; SPT, P = .001) and social (P > .05). Self-harming behavior decreased but use disorders, which is a common but severe and functioning (TFP, P =.03; DBT, P = .001; SPT, did not change significantly in either group. The refractory subgroup.6 P = .001), and significant decreases in depression strengths of this study include the reporting of In a 12-month RCT with 30-month follow-up, (TFP, P = .001; DBT, P = .003; SPT, P = .001) both ITT and completer analyses as well as using dynamic deconstructive psychotherapy was com- and anxiety (TFP, P = .004; DBT, P = .001; SPT, well-trained therapists committed to treating pared with optimized community care—a high- P = .001). Significant improvements were seen in BPD patients in both treatment cells. One limita- intensity community treatment. Dynamic decon- suicidality with transference-focused psycho- tion in this study is that those in the transference- structive psychotherapy resulted in significant therapy and dialectical behavior therapy (TFP, focused psychotherapy group received signifi- improvements in suicide attempts and self-harm P = .01; DBT, P = .01) but not with supportive cantly more psychotherapy sessions than those (S = 18; P = .008), heavy drinking (S = 22; P = psychotherapy. Transference-focused psycho- treated by experienced community psychothera- .008 [P values not reported for within group dif- therapy and supportive psychotherapy pro- pists (2:1 for completers; 3:1 for ITT). ferences]), drug use, and multiple measures of vided significant improvements in anger (TFP, One other general issue regarding transfer- psychopathology, including depression (F1,10 = P = .001; SPT, P = .05), but dialectical behavior ence-focused psychotherapy is that it appears to 13.43; P = .004 [P values not reported for with- therapy did not. Only transference-focused psy- require more intensive training than some of the in group differences]), dissociation, BPD symp- chotherapy demonstrated significant improve- other treatments discussed. For example, typi- toms (F1,10 = 13.43; P = .004), and perceived so- ments in verbal assault (P = .001), direct assault cally nurses in the British National Health Ser- cial support (S = 26; P = .021).36 Therapists’ ad- (P = .05), and irritability (P = .01).28 vice are the mentalization-based therapists (it is herence to dynamic deconstructive psychotherapy Levy and colleagues29 examined changes in at- unclear how easy or difficult it is to train thera- techniques was highly correlated with outcome, tachment organization and reflective function as pists to adherence in dialectical behavior ther which suggests that the putative mechanisms of putative mechanisms of change. After 12 months apy). However, it is important to note that the the treatment were responsible for the improve- of treatment, there was a significant increase in aims of mentalization-based therapy are admit- ments. Findings were maintained at an 18-month the number of patients classified as secure with tedly more modest than those of transference- follow-up. These findings are promising but are respect to attachment state of mind for transfer- focused psychotherapy in that it is not “aiming to hampered by a small sample size. ence-focused psychotherapy (χ2(1) = 4.17; P < achieve structural or personality change or alter As for supportive psychotherapies, 3 RCTs .04) but not for the other two treatments. Signifi- cognitions and schemas.”23(p200) examined modified dynamic supportive psycho- cant changes in narrative coherence (F3,54 = 6.28; Other psychodynamic approaches. A number therapies: one compared it with transference-
P < .05) and reflective function (F3,54 = 15.05; P < of other psychodynamic approaches may be focused psychotherapy and dialectical behavior .05) were found as a function of treatment. There found to be effective BPD treatments with addi- therapy, another compared it with dialectical be- were increases in both constructs during the course tional research. For example, an interpersonal- havior therapy, and the third compared it with of treatment with transference-focused psycho- self psychological approach was compared with mentalization-based therapy. In each case, sup- therapy but not with dialectical behavior therapy treatment as usual: 30% of the patients with BPD portive psychotherapy compared well with other and supportive psychotherapy. These findings are who were treated with interpersonal-self psy- treatments. It is important, however, to stress that notable because they suggest not only that trans- chology twice weekly for 1 year no longer met these supportive psychotherapies were not typi- ference-focused psychotherapy works in a theo- criteria for BPD at the end of the treatment year, cal as carried out in the community. Instead, they retically predicted way, but also that the benefits whereas all of the treatment-as-usual patients still were all modified to be specific with BPD. In ad- of this treatment go beyond symptom reduction met criteria for the diagnosis.31,32 Improvements dition, in each study, the therapists who provided to address broader issues of the patient’s sense of were maintained at the 5-year follow-up; 40% of supportive psychotherapy were experienced in self and relatedness to others. the patients no longer met criteria for BPD, spent treating BPD, and they were being supervised. In Although there were no differences in out- less time in the hospital (although no decrease in some cases. the supportive psychotherapies also come between dialectical behavior therapy and number of hospitalizations), and had an increase included booster sessions. Nonetheless, these transference-focused psychotherapy, the study in time employed.33 modified and supervised intensive supportive was not formally powered to test equivalence and A recently completed second study of similar psychotherapies have done remarkably well and therefore findings cannot technically be inter- design replicated these findings, although the in- deserve further consideration and study. preted as such. However, transference-focused ferences that can be drawn from these studies psychotherapy was found to be uniquely related are limited by the lack of a randomized control Conclusions to changes in attachment and mentalizing capac- group.34 Clearly, the findings from these studies While many different treatments have shown ef- ity during the course of treatment. suggest the promise of the approach and call for ficacy in comparison with “treatment as usual” or Doering and colleagues30 compared 1 year of the more stringent testing in an RCT. to a more stringent comparison group of “experts transference-focused psychotherapy with treat- General psychiatric management is an evi- in the community,” comparisons between well- ment by experienced community psychother dence-based practice approach that incorporates delivered bonafide treatments generally find few apists. While patients improved with both individual psychodynamic psychotherapy for pa- reliable differences. Thus, there is no evidence to treatments, patients randomly assigned to trans- tients with BPD.1,14,35 General psychiatric man- suggest that any of these empirically supported ference-focused psychotherapy showed signifi- agement was recently evaluated by McMain and treatments is the “treatment of choice” for BPD. cantly better outcomes as evidenced by lower colleagues13 in an RCT with dialectical behavior It is highly unlikely that any given treatment dropout rates (38.5% vs 67.3%; χ2(1); P = .003); therapy, and the treatments were found to per- would ever be identified as “one size fits all” significantly greater reductions in the number of form equally well. There were no between-con- treatment for BPD, given the heterogeneity of the attempted suicides (χ2(1) = 13.09; P = .001), dition differences in rates of change across 1 year disorder. Rather, future research and clinical re- number of inpatient admissions (F1, 99 = 8.814; of treatment for suicidality, self-injury, psychi finement of therapies for BPD should focus on P = .004), and BPD symptoms (χ2(1) = 3.961; atric service use, BPD symptoms, depression, the mechanisms within each treatment that are P = .047); and significantly greater improve- anger, and social functioning. most associated with improvement, and on pa- ments in personality organization (F1, 69 = 4.765; This study was not intended to be powered as tient and therapy variables that could help guide
P = .03) and psychosocial functioning (F1, 69 = an equivalence study. Furthermore, individual 6.420; P = .02). psychodynamic psychotherapy’s efficacy within (Please see Borderline Personality Disorder, page 46) 46 PSYCHIATRIC TIMES APRIL 2012 CATEGORY1 [published correction appears in Arch Gen Psychiatry. 1994;51:422]. derline personality disorder. In: Clarkin JF, Fonagy P, Gabbard GO, eds. Borderline Personality Disorder Arch Gen Psychiatry. 1993;50:971-974. Psychodynamic Psychotherapy for Personality Disorders: A Clinical Continued from page 45 11. Verheul R, Van Den Bosch LM, Koeter MW, et al. Dialectical behav- Handbook. Arlington, VA: American Psychiatric Publishing; 2010. iour therapy for women with borderline personality disorder: 12- 24. Bateman A, Fonagy P. Effectiveness of partial hospitalization in the month, randomised clinical trial in The Netherlands. Br J Psychiatry. treatment of borderline personality disorder: a randomized controlled the patient to the specific treatment that would be 2003;182:135-140. trial. Am J Psychiatry. 1999;156:1563-1569. most helpful at that point in his trajectory of ill- 12. Lynch TR. Dialectical behavior therapy: recent research and devel- 25. Bateman A, Fonagy P. Treatment of borderline personality disorder opments. Presented at: National Institute of Mental Health Interna- with psychoanalytically oriented partial hospitalization: an 18-month ness. Only then will we be able to better deter- tional Think Tank for the More Effective Treatment of Borderline Per- follow-up. Am J Psychiatry. 2001;158:36-42. mine “what treatment, by whom, is most effec- sonality Disorder; July 9-11 2004. 26. Bateman A, Fonagy P. 8-year follow-up of patients treated for bor- 13. McMain SF, Links PS, Gnam WH, et al. 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1. Which of the following is founded on modified cognitive- B. Mentalization-based therapy 8. Which of the following therapies has shown promise in behavioral therapy principles? C. Supportive dynamic psychotherapy treating comorbid BPD and substance use disorders? A. Transference-focused psychotherapy A. Dynamic deconstructive psychotherapy B. Mentalization-based therapy 5. The dialectic approach involves balancing behavioral B. General psychiatric management C. Schema-focused therapy change with validation and acceptance of the individual’s C. The interpersonal-self psychological approach experience. D. None of the above 2. Which of the following is an effective treatment for A. True borderline personality disorder (BPD) as evidenced by B. False 9. Which of the following is true of mentalization-based randomized clinical trials? therapy? A. Dialectical behavior therapy 6. Which of the following statements is true about A. It can be provided only as a day hospital treatment. B. Mentalization-based therapy transference-focused therapy? B. It showed continued patient improvement in study C. Transference-focused psychotherapy A. It emphasizes “reparenting” to compensate for traumatic follow-up data. D. All of the above experiences in the patient’s history. C. Its goal is to achieve structural or personality change. B. It addresses deficits in skills. 3. Which of the following therapies provides skills training in C. The goal of treatment is to achieve a coherent sense 10. Future research on BPD treatments should focus on which distress tolerance, emotional regulation, interpersonal of self. of the following? effectiveness, and mindfulness? A. Mechanisms within each treatment that are most A. Mentalization-based therapy 7. All efficacious treatments for BPD include which of the associated with improvement B. Dialectical behavior therapy following qualities? B. Patient variables that could help guide treatment choice C. Schema-focused therapy A. A clear treatment frame C. Therapy variables that would most benefit patients B. A clear conceptual framework D. All of the above 4. Limited reparenting, experiential imagery and dialogue work, C. A peer consultation/supervision group cognitive restructuring and education, and behavioral pattern D. All of the above
breaking are the cornerstones of which therapy? (Please see XXXXXXXXXA12001041, page 46) A. Schema-focused therapy