The NICE guideline on borderline personality disorder (BPD) tells us more about what not to use to treat the condition than it does really help to recommend proven therapies.

The guideline recommends the following: “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 (Section 1.3.4.4)”

And it goes on to say that: “Drug treatment should not be used specifically for borderline personality disorder or for the individual symptoms or behaviour associated with the disorder (Section 1.3.5.1)”

But that: “Drug treatment may be considered in the overall treatment of comorbid conditions (Section 1.3.5.3)”

There is clearly a role for talking treatments in this group of patients. The question is, which psychotherapies have the best chance of working for people with borderline personality disorder?

Fortunately, a new Cochrane review has been published that tackles this very topic. The authors carried out the usual thorough Cochrane literature search and found 28 studies (including a total of 1,804 patients) to include.

They included randomised controlled trials of patients with BPD that compared a specific psychotherapy against a control treatment without any specific mode of action or against a comparative specific psychotherapy.

They were interested in a number of outcomes including:

• Overall BPD severity
• Symptoms (defined by DSM-IV)
• Other mental health problems associated with but not specific to BPD
• Side effects

The trials they found covered a wide range of different talking treatments and there was only enough data for one treatment (dialectical behaviour therapy) to pool the results and carry out a meta-analysis. Here’s what they found in that analysis:

• Dialectical behaviour therapy performed better than treatment as usual on the following criteria:
  • Anger (n = 46, two RCTs; standardised mean difference (SMD) -0.83, 95% confidence interval (CI) -1.43 to -0.22; I2 = 0%)
  • Parasuicidality (n = 110, three RCTs; SMD -0.54, 95% CI -0.92 to -0.16; I2 = 0%)
  • Mental health (n = 74, two RCTs; SMD 0.65, 95% CI 0.07 to 1.24 I2 = 30%)
• Dialectical behaviour therapy did no better than treatment as usual at:
  • Keeping participants in treatment (n = 252, five RCTs; risk ratio 1.25, 95% CI 0.54 to 2.92)

The remaining analysis was all based on single studies:

• The following psychotherapies were all effective at reducing core BPD symptoms and associated mental health problems, when compared to control:
  • Dialectical behaviour therapy
  • Dialectical behaviour therapy for PTSD
  • Mentalisation-based treatment in a partial hospitalisation setting
  • Outpatient MBT
  • Transference-focused therapy
  • Interpersonal therapy for BPD
• Interpersonal psychotherapy was effective in the treatment of associated depression
• No statistically significant effects were found for cognitive behavioural therapy or dynamic deconstructive psychotherapy on either outcome, with the effect sizes moderate for DDP and small for CBT
• A few trials compared the effectiveness of different psychotherapies and these found that:
  • Dialectical behaviour therapy was better than client-centered therapy at reducing core BPD symptoms and associated mental health problems
  • Schema-focused therapy was better than transference-focused therapy at reducing BPD severity and keeping patients in treatment

The authors concluded:

There are indications of beneficial effects for both comprehensive psychotherapies as well as non-comprehensive psychotherapeutic interventions for BPD core pathology and associated general psychopathology. Dialectical behaviour therapy has been studied most intensely, followed by Mentalisation-based treatment, Transference-focused therapy, Schema-focused therapy and Systems training for emotional predictability and problem solving for borderline personality disorder.

However, none of the treatments has a very robust evidence base, and there are some concerns regarding the quality of individual studies. Overall, the findings support a substantial role for psychotherapy in the treatment of people with BPD but clearly indicate a need for replicatory studies.

Link

Stoffers JM, Völlm BA, Rücker G, Timmer A, Huband N, Lieb K. Psychological therapies for people with borderline personality disorder. Cochrane Database of Systematic Reviews 2012, Issue 8. Art. No.: CD005652. DOI: 10.1002/14651858.CD005652.pub2.

Borderline personality disorder: treatment and management (CG78). NICE, Jan 2009. (Section on assessment and management by community mental health services).