Efficacy of Psychotherapies for Borderline Personality Disorder - JAMA

[iluminati]

While I'm not around here as much anyone, since I've been split with my BPD exw for almost 4 years, I still do keep abreast of developments in the field, if only because of my daughter. There was this recent study (see www.jamanetwork.com/journals/jamapsychiatry/article-abstract/2605200) where they looked at all of the studies of therapy with BPD.  

The secret sauce with this therapy appears to be manualization of the therapy.  
In plain English, it means that the best treatment for BPD was the enforcement of clear rules and regulations.  I know it works in my experience with my BPD exw, and it's backed up with data.  

You HAVE to put your foot down.

Is it painful?  YES.  

Does she not really comprehend what she's doing?  Probably not, at least until she seeks professional help.  

However, you have to take care of yourself.  Nothing more or less.  She doesn't have the right to your feelings.

[Skip]

Efficacy of Psychotherapies for Borderline Personality DisorderA Systematic Review and Meta-analysis
Ioana A. Cristea, PhD1,2,3; Claudio Gentili, MD, PhD2; Carmen D. Cotet, PhD1; et al Daniela Palomba, MD2; Corrado Barbui, MD4; Pim Cuijpers, PhD5
Author Affiliations
JAMA Psychiatry. 2017;74(4):319-328. doi:10.1001/jamapsychiatry.2016.4287
April 2017

Key Points

Question  What is the efficacy of psychotherapy for borderline personality disorder?

Findings  In this systematic review and meta-analysis of randomized clinical trials, outcomes of psychotherapies (most notably dialectical behavior therapy and psychodynamic approaches) significantly improved borderline-relevant outcomes (symptoms, self-harm, and suicide) compared with control interventions. However, differences dissipated in well-designed and implemented trials or if the control group was balanced for manualization of treatment or the involvement of the study team in treatment.

Meaning  Psychotherapies specifically designed for borderline personality disorder have significant yet modest benefits over treatment as usual, and future independent and well-conducted trials are needed to clarify the stability and practical relevance of their effects.

Abstract

Importance  Borderline personality disorder (BPD) is a debilitating condition, but several psychotherapies are considered effective.

Objective  To conduct an updated systematic review and meta-analysis of randomized clinical trials to assess the efficacy of psychotherapies for BPD populations.

Data Sources  Search terms were combined for borderline personality and randomized trials in PubMed, PsycINFO, EMBASE, and the Cochrane Central Register of Controlled Trials (from database inception to November 2015), as well as the reference lists of earlier meta-analyses.

Study Selection  Included were randomized clinical trials of adults with diagnosed BPD randomized to psychotherapy exclusively or to a control intervention. Study selection differentiated stand-alone designs (in which an independent psychotherapy was compared with control interventions) from add-on designs (in which an experimental intervention added to usual treatment was compared with usual treatment alone).

Data Extraction and Synthesis  Data extraction coded characteristics of trials, participants, and interventions and assessed risk of bias using 4 domains of the Cochrane Collaboration Risk of Bias tool (independent extraction by 2 assessors). Outcomes were pooled using a random-effects model. Subgroup and meta-regression analyses were conducted.

Main Outcomes and Measures  Standardized mean differences (Hedges g) were calculated using all outcomes reported in the trials for borderline symptoms, self-harm, suicide, health service use, and general psychopathology at posttest and follow-up. Differential treatment retention at posttest was analyzed, reporting odds ratios.

Results Thirty-three trials (2256 participants) were included. For borderline-relevant outcomes combined (symptoms, self-harm, and suicide) at post test, the investigated psychotherapies were moderately more effective than control interventions in stand-alone designs (g = 0.32; 95% CI, 0.14-0.51) and add-on designs (g = 0.40; 95% CI, 0.15-0.65). Results were similar for other outcomes, including stand-alone designs: self-harm (g = 0.32; 95% CI, 0.09-0.54), suicide (g = 0.44; 95% CI, 0.15-0.74), health service use (g = 0.40; 95% CI, 0.22-0.58), and general psychopathology (g = 0.32; 95% CI, 0.09-0.55), with no differences between design types. There were no significant differences in the odds ratios for treatment retention (1.32; 95% CI, 0.87-2.00 for stand-alone designs and 1.01; 95% CI, 0.55-1.87 for add-on designs). Thirteen trials reported borderline-relevant outcomes at follow-up (g = 0.45; 95% CI, 0.15-0.75). Dialectical behavior therapy (g = 0.34; 95% CI, 0.15-0.53) and psychodynamic approaches (g = 0.41; 95% CI, 0.12-0.69) were the only types of psychotherapies more effective than control interventions. Risk of bias was a significant moderator in subgroup and meta-regression analyses (slope β = −0.16; 95% CI, −0.29 to −0.03; P = .02). Publication bias was persistent, particularly for follow-up.

Conclusions and Relevance  Psychotherapies, most notably dialectical behavior therapy and psychodynamic approaches, are effective for borderline symptoms and related problems. Nonetheless, effects are small, inflated by risk of bias and publication bias, and particularly unstable at follow-up.

[Skip]

The secret sauce with this therapy appears to be manualization of the therapy.  In plain English, it means that the best treatment for BPD was the enforcement of clear rules and regulations.

I don't think the authors were making that point. Manualized treatments are treatments that have exact steps, so that each person has relatively the same treatment. This differs from customized treatment where each patient and each therapist is participating in a one-off customized treatment sessions.

Conclusions and Relevance  Psychotherapies, most notably dialectical behavior therapy and psychodynamic approaches, are effective for borderline symptoms and related problems. Nonetheless, effects are small, inflated by risk of bias and publication bias, and particularly unstable at follow-up.

This is not a very promising conclusion, at least for now and where the state of the art is currently. "Psychotherapies specifically designed for borderline personality disorder have significant yet modest benefits over other general treatments.These therapies are making small but significant improvements , but the benefits are inflated by risk of bias and publication bias."

[Portent]

I don't think the authors were making that point. Manualized treatments are treatments that have exact steps, so that each person has relatively the same treatment. This differs from customized treatment where each patient and each therapist is participating in a one-off customized treatment sessions.

Correct but it still is very much a bounded program that first and foremost prevents the pwBPD from using any kind of manipulation against the therapist. I've seen first hand how well a high functioning pwBPD can manipulate a therapist.

This is not a very promising conclusion, at least for now and where the state of the art is currently. "Psychotherapies specifically designed for borderline personality disorder have significant yet modest benefits over other general treatments.These therapies are making small but significant improvements , but the benefits are inflated by risk of bias and publication bias."

One thing I have noticed popping up in relationship to DBT is that its very hard to get patients to move beyond the first phase. My therapist mentioned a piece published just this month on that very problem. They get past the first phase and its "I'm cured" but they have only gotten to the point that they are not ruled by their emotions and are finally capable of some introspection. Its stages 2, 3, & 4 where that capability for introspection is used and the actually personality disorder is addressed.

[Portent]

Quick question did this include schema therapy? I've found that schema therapy provides at least in my case the best explanation of what is actually happening in the BPD psyche. I found with my pwBPDex that she would bounce between personalities, the only difference between her and someone with DID was that her personalities knew and remembered what the others did ... .most of the time at least.

And results from schema therapy that I have read were quite promising.

[Skip]

I'm sure it did, but it would not be respresented in the same numbers as DBT - they make that points.

Have you taken our Schema test?
https://bpdfamily.com/message_board/index.php?topic=202548.0

[Portent]

I'm sure it did, but it would not be respresented in the same numbers as DBT - they make that points.

Have you taken our Schema test?
https://bpdfamily.com/message_board/index.php?topic=202548.0

Mode   Tendency   Avg
Vulnerable child    Mod    3.8
Angry Child    Mod    3.2
Enraged Child    --    1.0
Impulsive Child    --    1.6
Undisciplined Child    Mod    3.0
Happy Child    --    2.1
Compliant Surrender     High    4.0
Detached Protector    High    3.6
Detached Self-Soother    Mod    4.0
Self-aggrandizer    Mod    3.1
Bully and Attack mode     --    2.7
Punishing Parent     --    2.3
Demanding Parent     High    3.8
Healthy Adult    Mod    3.4

[flourdust]

Interesting that they specifically call out publication bias. There is concern about the "file drawer effect," where negative study results aren't submitted for publication or aren't accepted if submitted. (Research effects are sexy! Not finding effects ... .less sexy.) This can inflate how representative positive results appear to be.

[Portent]

Interesting that they specifically call out publication bias. There is concern about the "file drawer effect," where negative study results aren't submitted for publication or aren't accepted if submitted. (Research effects are sexy! Not finding effects ... .less sexy.) This can inflate how representative positive results appear to be.

Very true but I have been heartened by studies that do show an increase in brain activity in the inpusle and stress control centers of the brain after 6 months of DBT. That is much more believable than subjective tests.

[statsattack]

That's why gunderson is worth every penny because they are stuck there for 60-120 days and they are held accountable for the therapy and showing up while regular therapist can't hold them accountable round the clock

[Portent]

That's why gunderson is worth every penny because they are stuck there for 60-120 days and they are held accountable for the therapy and showing up while regular therapist can't hold them accountable round the clock

My wife's ex-husband tried to get her into there after her DUI with the kids. She would never ever go there.

[Skip]

... .the best treatment for BPD was the enforcement of clear rules and regulations.  I know it works in my experience with my BPD exw, and it's backed up with data.  ... //... You HAVE to put your foot down. Is it painful?  YES.

I think if we walk away from this article thinking the message is that "enforcement" is the best treatment, we are doing ourselves a disservice.

McLean Hospital ("gunderson" says this:

Independent motivation to change is an essential requirement and while family members or clinicians may see the Gunderson Residence as a good fit, the individual must be ready to actively participate in her recovery—regardless of outside factors such as pending legal charges. In addition, adequate levels of physical health and sobriety are reviewed to determine whether this level of care is appropriate for the individual.
www.mcleanhospital.org/programs/gunderson-residence/admission-cost

Additionally, studies organized by McLean has show that a trusted and loving support person (family member) is the single most predictable marker of success. This person has to be both benevolent and strong.

Additionally, it is mentioned in several texts that "structure" is very important. Expectations and rules are certainly part of that, but just a part. Nutrition, sleep, exercise, no drugs, employment, obligations, etc. are also part of that.

Good discussion.

(Don't forget to vote / rate the atticle)