Treating Borderline Personality Disorder

Today, I look at three studies of treatment approaches to Borderline Personality Disorder (BPD) so it’s a longer than usual post. First, Crotty, et al. (2023) published “Psychotherapies for the Treatment of Borderline Personality Disorder: A systematic review” in Journal of Consulting and Clinical Psychology. This is available as open source full text for those who want to read the entire article, but here are the edited details I found most pertinent:

Borderline personality disorder (BPD) is the most common personality disorder, affecting 1.8% of the general population, 10% of psychiatric outpatients, and 15%–25% of psychiatric inpatients. Practice guidelines recommend psychotherapies as first-line treatments. However, psychotherapies commonly used for the treatment of BPD are numerous, and little is known about the comparative effectiveness of each individual psychotherapy versus treatment as usual (TAU) or other psychotherapies. To systematically assess the comparative effectiveness of commonly used psychotherapies versus TAU or versus other psychotherapies for BPD treatment.  We conducted systematic literature searches in MEDLINE, EMBASE, the Cochrane Library, and APA PsycINFO up to July 14, 2022, and searched reference lists of pertinent articles and reviews. Inclusion criteria were (a) patients 13 years or older with a diagnosis of BPD, (b) treatment with commonly used psychotherapies, (c) comparison with TAU or another psychotherapy, (d) assessment of relevant BPD-related health outcomes, and (e) randomized or nonrandomized trials or controlled observational studies. Two investigators independently screened abstracts and full-text articles and graded the certainty of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. We found 25 psychotherapy studies meeting inclusion criteria with data on 2,545 participants. Seventeen studies compared nine psychotherapies with TAU and nine studies compared eight psychotherapies with another psychotherapy for the treatment of BPD. Overall, both TAU and included psychotherapies were effective in treating the severity and symptoms of BPD. Moderate certainty of evidence suggests that systems training for emotional predictability and problem solving is more effective than TAU for the treatment of BPD; low certainty of evidence suggests that dialectical behavior therapy, schema therapy, transference-focused psychotherapy, acceptance and commitment therapy, manual-assisted cognitive therapy, and cognitive behavioral therapy are more effective than TAU for treating BPD. We were unable to draw conclusions from head-to-head comparisons of psychotherapies, which were limited to single studies with very low to low certainty of evidence.  All commonly used psychotherapies improve BPD severity, symptoms, and functioning. Our assessment found no strong evidence suggesting that any one psychotherapy is more beneficial than another.

Individuals with BPD suffer severe and persistent functional impairment, including high rates of comorbid mental disorders, substance use, deliberate self-harm, and suicidal ideation. Women are more frequently diagnosed with BPD than men, but it is unclear whether women simply present for treatment more often or BPD is more common among women than among men. Symptoms of BPD often first appear during adolescence. Although most individuals with BPD experience symptom improvement during adulthood—with about 85% reaching diagnostic remission within 10 years after diagnosis specific symptoms, such as fear of abandonment, impulsivity, intense anger, and an unstable self-image can persist over a lifetime. Individuals with BPD also commonly suffer from other mental disorders, including depression, anxiety, posttraumatic stress disorder, substance use disorders, and eating disorders. They frequently face social stigma, have poor social and occupational outcomes, and have a substantial risk for suicide death. Individuals with BPD are frequent users of general primary care and the societal costs of BPD are substantial; the annual direct health care costs and indirect costs (i.e., lost productivity) are more than 16 times higher among patients with BPD compared with matched controls without BPD.

In clinical practice, patients with BPD are often treated with medication alone or in conjunction with psychotherapy. In a previous systematic review we conducted, which analyzed the comparative effectiveness of pharmacological treatments for BPD, we found that there is insufficient evidence to support the efficacy of pharmacotherapies alone in reducing the severity of BPD. Therefore, considering these findings, psychotherapies should be a more frequently utilized option for treating BPD. Our findings also suggest that generalized psychotherapies may be as effective as intensive specialized BPD treatments that require expert training. 

The strength of evidence for the general effectiveness and comparative effectiveness of commonly used psychotherapies for the treatment of BPD is mostly low to very low. The findings from this systematic review suggest that all commonly used psychotherapies and TAU improve BPD severity, symptoms, and functioning, and there is no strong evidence suggesting that any one commonly used psychotherapy is more beneficial than another. In addition, very little is known about psychotherapy-related harms. To improve the strength of evidence, future research in this area should focus on standardizing intervention components and treatment protocols, improving intervention fidelity, and selecting common outcome measures to measure BPD severity and related symptoms. In addition, to confirm some of the key findings found in this systematic review, future research should focus on determining whether specialized therapies for reducing the severity of BPD including DBT and MBT are any more effective than TAU or treatment with more generalized psychotherapies. Future research should also focus on head-to-head comparisons across those psychotherapies that showed effectiveness over TAU including DBT, STEPPS, schema therapy, transference-focused psychotherapy, ACT, MACT, and CBT.

I started with this one because it illustrates how lousy research on therapy is. The next two attempt to address that in focused ways. Sauer-Zavala et al. (2023) published “BPD compass: A randomized controlled trial of a short-term, personality-based treatment for borderline personality disorder” in Personality Disorders: Theory, Research, and Treatment. Here’s the edited abstract:

Borderline personality disorder (BPD) is a heterogeneous condition that is particularly associated with three broad personality dimensions: neuroticism (i.e., high negative affectivity), agreeableness (i.e., low antagonism), and conscientiousness (i.e., low disinhibition). The purpose of the present study was to explore whether treatment with BPD Compass, a novel personality-based intervention for BPD, results in greater reductions in BPD symptoms, neuroticism, agreeableness, and conscientiousness compared to a waitlist control (WLC) condition. We also aimed to characterize within-treatment effects for participants assigned to the BPD Compass condition and evaluate patients' satisfaction with treatment. Participants (N = 51; Mage = 28.38; 83.3% female; 93.8% White; 54.2% sexual minority) meeting DSM-5 criteria for BPD were enrolled in a randomized controlled trial to evaluate the efficacy of BPD Compass. Patients were randomly assigned to receive 18 sessions of BPD Compass or complete an 18-week waiting period. BPD Compass led to larger reductions in BPD symptoms (assessor-rated [β = −0.47] and self-reported [β = −0.62]) and neuroticism (β = −0.37), but not agreeableness (β = 0.08) or conscientiousness (β = 0.10), compared to the WLC condition. Within the BPD Compass condition, pre- to posttreatment improvements in BPD symptoms, neuroticism, and conscientiousness were significant and large in magnitude (Hedges' gs: −1.38 to −1.08). Patients were highly satisfied with BPD Compass and generally perceived it to be an appropriate length. Thus, BPD Compass may be an accessible and useful complement to more specialty or intensive treatments for BPD. 

BPD Compass is a cognitive behavioral approach that typically involves 18 sessions. It’s not a huge sample and, consistent with the first article, a largely female sample, but it also has a high percentage of sexual minority participants. It’s a nice example of a well-designed study and has encouraging findings. The final study looks at DBT. Spina & Levy (2023) published “The Availability of Dialectical Behavior Therapy in Partial Hospitalization and Residential Services for Borderline Personality Disorder: An exploratory longitudinal study of the National Mental Health Services Survey from 2014 to 2021” in Journal of Consulting and Clinical Psychology. Here are the edited abstract and impact statements:

Treatment guidelines on borderline personality disorder (BPD) recommend day-hospital or residential treatments for patients with BPD who cannot tolerate outpatient treatment However, the current literature suggests that evidence-based treatment for BPD may be difficult to access. The present study aims to characterize the accessibility of dialectical behavioral therapy (DBT) in day-treatment and residential programs in the United States in the last 7 years and examines whether day-treatment and residential programs that accept state benefits (i.e., Medicaid) are significantly less likely to offer DBT. Using mixed logistic regression, we examined trends in the National Mental Health Services Survey data from 2014 to 2021, a survey of U.S. mental health facilities which tracks whether facilities provide DBT. We found that the likelihood that a residential or day-hospital facility offers DBT has been growing over time at the national level. We also found significant variability in these trends at the state level. In addition, we found that facilities accepting state benefits were less likely to offer DBT. Consistent with previous literature, our study suggests that these programs are very scarce across the United States and difficult to access for those with Medicaid. Guidelines on borderline personality disorder (BPD) recommend day-hospital or residential treatments for patients with BPD who cannot tolerate outpatient treatment. However, the current literature suggests that evidence-based treatment for BPD may be difficult to access. The present study aims to characterize the accessibility of dialectical behavioral therapy (DBT) in day-treatment and residential programs in the United States in the last 7 years and examines whether day-treatment and residential programs that accept state benefits (i.e., Medicaid) are significantly less likely to offer DBT. Using mixed logistic regression, we examined trends in the National Mental Health Services Survey data from 2014 to 2021, a survey of U.S. mental health facilities which tracks whether facilities provide DBT. We found that the likelihood that a residential or day-hospital facility offers DBT has been growing over time at the national level. 

The present study is the first to evaluate whether residential and day-hospital programs in the United States have become more likely to provide evidence-based treatment for borderline personality disorder (BPD) over time. Our findings suggest that the likelihood that residential and day-hospital programs provide dialectical behavioral therapy (DBT) has grown nationally since 2014. However, some states show significantly less growth relative to other states in the likelihood of residential and day-hospital programs to provide DBT, suggesting areas of disparity for patients with BPD needing a higher level of care. Our findings also suggest that residential and day-treatment programs which accept state benefits (i.e., Medicaid) tend to be significantly less likely to offer DBT. Targeting states with slower growth rates in these programs and states which have a greater number of consumers with Medicaid may increase access and reduce treatment disparities. 

I’ve written about dialectical behavior therapy before and find it intriguing. While this is not the kind of research study BPD compass addressed, it identifies disparities in availability of treatment, especially for those who rely on Medicaid.