New treatments for borderline personality disorder

I have written twice before about research pertaining to Borderline Personality Disorder (BPD).. Here, I want to summarize two recent studies on treatment. First, Keefe et al. (2022) published “Reflective Functioning and Its Potential to Moderate the Efficacy of Manualized Psychodynamic Therapies Versus Other Treatments for Borderline Personality Disorder” in Journal of Consulting and Clinical Psychology. 

In their impact statement, they note:

Reflective functioning (RF) is an important facet of social cognition and self-knowledge, which is sometimes disrupted among patients with borderline personality disorder (BPD). Across two randomized clinical trials, patients entering treatment with poor RF had relatively better symptom and RF outcomes in manualized psychodynamic therapies (transference-focused psychotherapy; supportive dynamic therapy) compared to dialectical behavior therapy and clinical care in the community, and vice versa for normal RF. Manualized psychodynamic therapies that focus on improving RF may be an especially good first option for treating BPD among patients with poor RF, while patients with normative RF may be able to more easily take advantage of other treatment modalities. 

In their abstract, they begin with the observation that, “Impaired reflective functioning (RF) is common among patients with borderline personality disorder (BPD).” This is consistent with the work of Seiffert et al. (2022) on object constancy and Jańczak, Soroko, & Górska’s (2022) work on metacognition. Their study compares transference-focused psychotherapy (TFP), dialectical behavior therapy (DBT), supportive psychodynamic therapy (SPT), and enhanced treatment as usual (eTAU). They begin by citing previous research finding TFP superior to other treatments, but add that, “differences in pretreatment RF may also serve as a prescriptive factor for TFP’s effects.” To study this hypothesis, they randomized assignment of patients with BPD to two clinical trials of TFP (n = 83), dialectical behavior therapy (DBT; n = 31), supportive psychodynamic therapy (SPT; n = 28), or an enhanced treatment as usual (eTAU; n = 52). 

They examined slopes in responses to the Brief Symptom Inventory (BSI) and found that treatment interacted with baseline RF to predict BSI slopes. In both transference-focused and supportive dynamic therapies, RF failed to predict outcomes, though higher RF was associated with relatively better outcomes in dialectical behavior therapy and enhanced treatment as usual. They point out that, “Patients with poor RF (scores of 0/1) benefitted more from TFP/SPT, while patients with relatively ordinary RF (score of 4) had better outcomes in DBT/eTAU. Treatment effects on RF change were also moderated by baseline RF (p = .014), such that TFP improved RF most strongly among poor RF patients, SPT only among very poor RF patients, and DBT/eTAU not at all.” In their discussion, they suggest that, “Low RF may reflect a deficit that may be targeted by TFP and other manualized psychodynamic treatments for BPD, which may be especially helpful among patients presenting with low RF.”

These data may be important given the prevalence of dialectical-behavior therapy, since patients with lower reflective functioning fared better with transference-focused or supportive psychodynamic therapy. They also suggest that baseline functioning may be important in determining the order in which to utilize alternative therapies. 

The second study also contrasts DBT with an alternative treatment. Schmeck et al. (2022) published “Effectiveness of Adolescent Identity Treatment (AIT) Versus DBT-a for the Treatment of Adolescent Borderline Personality Disorder” in Personality Disorders: Theory, Research, and Treatment. Susanne Schlüter-Müller developed Adolescent Identity Treatment to focus on identity pathology in adolescence that might predict adult personality disorders. Here’s Schmeck et al.’s abstract:

Borderline personality disorder (BPD) is among the most severe mental health problems with long-lasting deterioration of functioning. According to a Cochrane review, evidence for methods focused on treatment for adolescent BPD patients is very limited. Aims of the study were to demonstrate the noninferiority of adolescent identity treatment (AIT) compared with dialectical behavior therapy for adolescents (DBT-A), and that intensive early treatment of BPD leads to significant improvement of psychosocial and personality functioning in adolescent patients. In a nonrandomized controlled trial using a noninferiority approach, we compared 37 patients treated with DBT-A with 23 patients treated with AIT. Both treatments included 25 weekly individual psychotherapy sessions and five to eight family sessions. Patients were assessed at four timepoints: baseline, posttreatment, 1- and 2-year follow-up. Primary outcome was psychosocial functioning at 1-year follow-up. We performed both intention-to-treat analyses and per-protocol analyses (completers). Baseline characteristics of both groups were not significantly different except for age and self-injurious behavior. In all, six AIT patients (26%) and 10 DBT-A patients (27%) dropped out of treatment. Both DBT-A and AIT significantly improved adolescents’ psychosocial functioning (AIT: d = 1.82; DBT-A: d = 1.73) and personality functioning. BPD criteria and depression were significantly reduced by both treatments. Overall, AIT was found to be not inferior to DBT-A and even more efficient in reducing BPD criteria. Both treatments are highly effective in improving psychosocial functioning and personality functioning in adolescent BPD patients. AIT is a promising approach and not inferior to DBT-A in respect to treatment efficiency. 

Schlüter-Müller notes that, “This model integrates specific techniques for the treatment of adolescent personality pathology on the background of object-relation theories and modified elements of Transference-Focused Psychotherapy. Moreover, psychoeducation, a behavior-oriented homeplan and intensive family work is part of AIT.” Each of these studies illustrates nuanced methods for addressing adolescents with symptoms of BPD