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Exclusive: Cochrane summary

Psychological therapies for borderline personality disorder

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This review looked at the effectiveness of psychological therapies in treating borderline personality disorder

Citation: Neville  C (2014) Psychological therapies for borderline personality disorder. Nursing Times; 110:4, 25.

Author: Christine Neville is deputy director, Ipswich Hospital Clinical School, University of Queensland.

Review question

What are the effects of psychological therapies for people with borderline personality disorder?

Nursing implications

Engaging therapeutically with people who have BPD can be challenging as often its characteristics prevent them from maintaining interpersonal relationships. Rapid mood swings, intense feelings of emptiness and abandonment, and problems interpreting others’ intentions can lead to self-harm. These make it difficult for people with BPD to engage with any form of treatment or, if they do, to adhere to it.

Study characteristics

Several psychological therapies have been developed to help health professionals engage more successfully with people with BPD and help them manage their disorder. The review (Stoffers et al, 2012) evaluated the available evidence on the effectiveness of these interventions. Including 28 randomised controlled trials with a total of 1,804 adult participants with BPD, it reviewed the use of psychological therapies; these were defined as comprehensive if they included individual psychotherapy lasting at least three months as a substantial part of the treatment programme, or as non-comprehensive if they did not.

Comprehensive psychological therapies tested against a control condition included:

  • Dialectical behaviour therapy (DBT);
  • Dialectical behavioural therapy adapted for BPD plus post-traumatic stress disorder (DBT-PTSD);
  • Mentalisation-based treatment in a partial hospitalisation (MBT-PH) or outpatient (MBT-out) setting;
  • Transference-focused therapy (TFP);
  • Cognitive behavioural therapy (CBT);
  • Deconstructive dynamic psycho-therapy (DDP);
  • Interpersonal psychotherapy (IPT) or IPT modified for BPD (IPT-BPD), both with fluoxetine.

Direct comparisons of comprehensive psychological therapies included:

  • DBT versus client-centred therapy (CCT);
  • Schema-focused therapy (SFT) versus TFP;
  • SFT versus SFT plus telephone availability of therapist - in case of crisis;
  • Cognitive therapy (CT) versus CCT, and CT versus IPT.

Non-comprehensive psychological therapies evaluated against a control group comprised:

  • DBT-group skills training only;
  • Emotion-regulation group training;
  • SFT group;
  • Systems training for emotional predictability and problem solving for BPD (STEPPS) or STEPPS plus individual therapy;
  • Manual-assisted cognitive treatment (MACT);
  • Psychoeducation.

The only direct comparison of a non-comprehensive psychological therapy against another was MACT versus MACT plus therapeutic assessment. Inpatient treatment was examined in one study where DBT-PTSD was compared with a waiting-list control. No trials were identified for cognitive analytical therapy.

The outcomes included: overall BPD severity; severity of specific BPD symptoms (based on criteria from The Diagnostic and Statistical Manual of Mental Disorders, fourth edition); psychopathology associated with, but not specific to, BPD; attrition; and adverse effects. The quality of evidence was rated moderate-low depending on sample size (range: 16-180). Data was combined in a meta-analysis, where appropriate.

Summary of key evidence

As there was limited data for individual interventions, meta-analytic pooling was only possible for DBT compared with treatment as usual (TAU) for four outcomes. There was evidence of DBT being beneficial over TAU for anger, parasuicidality and mental health, but no evidence that it is more successful for treatment adherence.

The evidence suggests the following therapies benefit BPD core pathology and associated psychopathology: DBT; DBT-PTSD; MBT-PH; MBT-out; TFP and IPT-BPD. IPT was only effective at treating associated depression. CBT and DDP did not have significant effects on BPD core pathology or associated psychopathology. DBT was more effective in treating core and associated psychopathology than CCT, and SFT was more effective than TFP with respect to BPD severity and treatment retention.

Best-practice recommendations

The review suggests comprehensive and non-comprehensive psychological therapies for BPD have some beneficial effects, but the evidence base is weak and there are concerns about individual study quality. Disorder-specific psychological therapies for people with BPD is supported but no particular therapy is recommended. Nurses may wish to explore different disorder-specific techniques but must be aware that data for individual interventions is lacking.

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Readers' comments (1)

  • All research such as this assists in building confidence in choosing how to help. However, the quality of the underlying studies must be questioned and not just accepted, and the limited availability of studies on other therapies (e.g. person-centred, gestalt, mindfulness) skews the perspective of meta-analysis towards the establishment-medical paradigm.

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