Psychological and Psychosocial Treatments in the Treatment of Borderline Personality Disorder

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1 Psychological and Psychosocial Treatments in the Treatment of Borderline Personality Disorder The Nice Guidance for the Psychological and Psychosocial treatment of Borderline Personality Disorder (BPD) recognises some of the criteria of DSM-IV, including sensitivity to rejection, unstable self structure, need for development of boundaries and structure, and the powerful feelings generated in others when working with people with these difficulties. It recognises that there is no CORE dimension (only needing 5 out of 9 criteria to be met) and the wide range of interventions and outcome measures which make it difficult to survey the field. They suggest: Ensure that the following service characteristics are in place, especially for people with multiple comorbidities and/or severe impairment: an explicit and integrated theoretical approach used by both treatment team and therapist and shared with the service user structured care in accordance with this guideline provision for therapist supervision. Consider twice-weekly psychotherapy sessions, although the frequency should be adapted to the person s needs and context of living. Do not use brief psychological interventions (of less than 3 months duration) specifically for borderline personality disorder or for the individual symptoms of the disorder outside a service that has the characteristics outlined above. The Therapies surveyed in the guidance includes: Besides arts therapies, complementary therapies and therapeutic communities, the GDG and review team delineated three broad classes of psychological therapies: first, brief psychological interventions, which were defined as low-intensity interventions given for less than 6 months; second, individual psychological therapies, usually offered weekly but sometimes twice-weekly, in an outpatient setting (individual psychological interventions can also be configured in different ways, including standard interventions and brief interventions, and these are reported separately); third, psychological therapy programmes that combine more than one treatment (for example, individual therapy plus group therapy) (Campbell et al., 2000) and are delivered by more than one therapist. Arts Therapies There is very little research on the effectiveness of arts therapies for people with borderline personality disorder and therefore no recommendations could be made. Brief Psychological Interventions For the purposes of this review therapy lasting less than 6 months is defined as brief. (This is distinguished from time-limited therapies lasting more than 6 months but less than 1 year).

2 Manual-assisted cognitive therapy was developed as a public health intervention for the large numbers of people who repeatedly attempt suicide (parasuicide) Summary of Evidence There is some evidence that a low-intensity intervention (MACT) has some effect on reducing self-harm and suicidal acts (reported together as a continuous measure), but no effect when reported as parasuicide as a dichotomous measure. Both these outcomes were reported by a single study; therefore it is difficult to draw firm conclusions without further research. There was no evidence of other effects on the symptoms of borderline personality disorder. Complimentary Therapies Complementary therapies, such as aromatherapy, acupuncture and homeopathy are not widely used in the treatment of people with borderline personality disorder. Summary of Evidence There is no evidence on the use of complementary therapies as a treatment in people with a personality disorder; therefore no recommendations could be made. Individual Psychological Therapies These Include: Cognitive behavioural therapy (connects, thoughts, feelings and behaviour) Systems training for emotional predictability and problem solving (CBT + family session) Problem-solving therapy (cognitive behavioural) Schema-focused cognitive therapy (emphasises role of dysfunctional schemas) Cognitive analytic therapy (CBT and dynamic) Interpersonal therapy structured time limited supportive therapy) Psychodynamic Interpersonal Therapy (conversational Mode) Psychodynamic/psychoanalytic psychotherapy Including Transference Focused Psychotherapy (unconscious conflicts) RCT Evidence Individual psychological interventions had very little effect on symptoms compared with treatment as usual, other than for general functioning which showed some improvement. Individual psychological interventions also showed little effect on reducing self harm or suicide attempts compared with treatment as usual, although

3 there was some effect when the two outcomes were reported together. There was little effect on service use outcomes. Non-RCT Evidence There is very little evidence for the efficacy of individual psychological interventions in the treatment of people with borderline personality disorder because almost all studies are uncontrolled. The RCT evidence showed some weak evidence that CAT (in young people) and STEPPS may help to improve general functioning, and reduce self-harm and suicide. The effect size for self-harm and suicide outcome was not quite statistically significant for CAT, which was compared with a manualised treatment and good clinical practice. Other outcomes from the studies of CAT and STEPPS, and outcomes from RCTs of other therapies (CBT, schema-focused psychotherapy and individual dynamic psychotherapy), did not show any benefit of treatment. Data from the study of transference-focused psychotherapy were not extractable so effect sizes could not be calculated and the study was excluded from the analysis. It should also be noted that the studies had few outcomes in common making the dataset as a whole hard to evaluate. The non-rct evidence suggests that individual psychological interventions are acceptable to people with borderline personality disorder. They showed generally positive outcomes (based on authors conclusions from statistical significance testing rather than calculating effect sizes from extracted data), which need to be tested against control conditions in randomised trials before firm conclusions about the efficacy of these treatments can be drawn. Combination Therapy There are few studies comparing the effects of adding a drug to a psychological therapy on symptoms of borderline personality disorder. Consequently the evidence for an effect is weak. There was no evidence of an effect on symptoms of adding fluoxetine or olanzapine to DBT. However, adding IPT to fluoxetine showed some efficacy (compared with fluoxetine alone) in reducing depression symptoms (clinician-rated measure only), and psychological and social functioning aspects of the quality-of-life measure used (self-rated measures). However, the number of participants in this latter trial is very low (n _ 25) and therefore further research is needed to replicate this finding. In the trial comparing IPT with CT, the effect of treatment on outcomes was inconclusive, other than for social functioning where CT improved scores more than IPT. However, this trial is also very small. The evidence does not support any recommendations specifically about the combined use of psychotropic medication and a psychological therapy in the treatment of borderline personality disorder. Psychological Therapy programmes Dialectical behaviour therapy (Individual/group and support) Mentalisation-based therapy and partial hospitalisation (attachment based therapy and day hospital)

4 Compared with treatment as usual, psychological therapy programmes showed some effect on anxiety, depression and symptoms of borderline personality disorder, although the evidence quality was moderate. These interventions also retained people in treatment compared with treatment as usual. People with borderline personality disorder also reported better employment outcomes (number of years in employment) following a psychological therapy programme (specifically MBT with partial hospitalisation) at 5-year follow-up. Psychological therapy programmes also showed some benefit on the rate of self harm and suicidal ideation, with benefits persisting at follow-up (measured at 5 years for MBT with partial hospitalisation only). Psychological therapy programmes also had some benefit on service-use outcomes such as hospital admissions and emergency department visits. MBT with partial hospitalisation also reduced the amount of psychiatric outpatient treatment required and the number of years on three or more drugs at 5-year follow-up. There was some benefit for psychological therapy programmes on social functioning outcomes on employment performance, but not on other outcomes. Non RCT Evidence of Psychological Therapy Programmes The papers provide some evidence to suggest that it is feasible to apply DBT (with minor modifications described) in a variety of settings (inpatient, outpatient and community). However, none of these papers provides evidence as to whether DBT is an effective treatment for borderline personality disorder. This is because methodological quality was poor many of the papers reached conclusions that were not justified on the basis of the data presented or the quality of the methods used. Therapeutic Communities Although the cohort studies provide some interesting data, there are a number of factors that limit their usefulness in evaluating residential therapeutic community treatment. There would be methodological difficulties with setting up such trials, including ethical problems associated with withholding residential treatment for those most in need and the related problem of creating adequate control groups. There are no RCTs of treatment in therapeutic communities. Caution must therefore be exercised in drawing conclusions from the cohort studies for five reasons. First, the studies lack meaningful comparison groups; in several studies all those referred for treatment are included in the study, with those admitted compared with those not admitted. Admission is based on criteria set by the individual therapeutic community. This is likely to mean that those not admitted are dissimilar in some ways to those admitted, thus weakening the use of this group as a control. Second, simple comparisons of pre- versus post-treatment changes in outcome for the residential treatment group are problematic because there is a possibility that changes may be because of spontaneous recovery or some systematic bias in the selection of those who entered residential treatment. For example, admittance to the Henderson Hospital depended partly on availability of funding from the local health authority, and so it is possible that districts with less available funding either have alternative

5 non-residential treatment programmes for those with personality disorders or have fewer resources for other reasons. This may reduce the generalisability of the available data further. Third, many of the studies examined follow-up patients over a relatively short period of time (for example, 1 year). Fourth, the necessarily multicomponent nature of many the therapeutic community programmes makes it difficult to identify the active components. For example, it is unclear whether admitting an individual into a hospital, the nature of the hospital environment, the therapeutic relationships with staff or other patients, the use of psychotropic medication, or a combination of these factors, contribute to the effectiveness of the treatment. Lastly, the number of residentially-based communities is being reduced (for example, the Henderson Hospital has closed) and while several new nonresidential community treatment programmes have been established, there is as yet no evidence on their effectiveness. Consideration of these limitations means that conclusions about the efficacy of therapeutic community treatment remain tentative. Overall Clinical Summary The overall evidence base for psychological therapies in the treatment of borderline personality disorder is relatively poor: there are few studies; low numbers of patients and therefore low power; multiple outcomes with few in common between studies; and a heterogeneous diagnostic system that makes it hard to target a specific treatment on patients with specific sets of symptoms because the trials may be too all inclusive. This means that the state of knowledge about the current treatments available is in a development phase rather than one of consolidation. Conclusions are, therefore, provisional and more and better-designed studies need to be undertaken before stronger recommendations can be made. Research recommendations Psychological therapy programmes for people with borderline personality disorder Outpatient psychosocial interventions Development of an agreed set of outcomes measures Pharmacological Treatments There was some evidence that pharmacological treatments can help to reduce specific symptoms experienced by people with borderline personality disorder including anger, anxiety, depression symptoms, hostility and impulsivity, although this is largely based on single studies. However, there is no evidence that they alter the fundamental nature of the disorder in either the short or longer term. The evidence is weak, and it is far from clear if the effects found are the consequence of treating comorbid disorders. Research Recommendations Mood stabilisers for people with borderline personality disorder