A randomized controlled trial of cognitive behavior therapy for borderline personality disorder: rationale for trial, method, and description of sample

This paper describes the rationale for a randomized controlled trial, comparing cognitive behavior therapy in addition to treatment as usual with treatment as usual alone, for borderline personality disorder. Previous pioneering randomized controlled trials of psychotherapies have suffered from methodological weaknesses and have not always been reported clearly to allow adequate evaluation of either the individual study or comparisons across studies to be undertaken. We report on the recruitment and randomization, design, and conduct of an ongoing randomized controlled trial of one hundred and six patients with borderline personality disorder. Primary and secondary hypotheses and their planned analyses are stated. The baseline characteristics of 106 patients meeting diagnostic criteria for borderline personality disorder are described.     

Differential effects of manual assisted cognitive behavior therapy in the treatment of recurrent deliberate self-harm and personality disturbance: the POPMACT study

A total of 480 patients were treated in a large, multicenter randomized trial of a brief form of cognitive therapy, manual-assisted cognitive behavior therapy (MACT) versus treatment as usual (TAU) for recurrent deliberate self-harm. Each patient was randomized after a self-harm episode assessed at an accident and emergency center and followed up over 1 year. The main hypothesis tested was that those allocated to MACT would have a lower proportion of self-harm episodes in the succeeding year. A total of 60% of those allocated to MACT had face-to-face treatment and 430 (90%) of all patients had self-harm data recorded after 1 year. Although the results showed no significant difference between those repeating self-harm in the MACT group (39%) compared with the TAU group (46%) (P = 0.20), the treatment was cost effective (10% cheaper than TAU) and the frequency of self-harm episodes was fewer (50%) in the MACT group. A total of nine of 10 patients had some personality disturbance (42% of these with disorder), and for those where information on parasuicide events was collected, the proportion having a repeat episode ranged from 33% to 63% for different personality disorders. Those with BPD were most likely to repeat episodes quickly (mean 89 days for 25% to repeat) with dissocial personality disorder (equivalent mean 384 days) the slowest to repeat. Total costs were significantly greater in those with personality disorder and were reduced in those allocated to MACT; this saving was reversed in those with borderline disorder. On average, MACT appeared to increase the cost of those patients with BPD (BPD) and reduce the cost of those with other personality disorders. It is concluded that MACT has value in preventing self-harm cost effectively but this appears to be confined mainly to those who do not have BPD.     

Healthcare utilization following cognitive-behavioral treatment for panic disorder with agoraphobia

The aim of this study was to examine the overall changes in healthcare services utilization after providing an empirically supported cognitive-behavioral treatment for panic disorder with agoraphobia. Data on healthcare utilization were collected for a total of 84 adults meeting DSM-IV criteria. Participants were completers of a cognitive-behavioral treatment for panic disorder with agoraphobia. Data on utilization of healthcare services and medication were obtained from semi-structured interviews from baseline to 1-year after treatment. Results of the Friedman non-parametric analysis reveal a significant decrease in overall and mental health-related costs following treatment. This study shows a significant reduction in healthcare costs following cognitive behavior therapy for panic disorder with agoraphobia. More studies are needed to examine the potential long-term cost-offset effect of empirically supported treatments for panic disorder.     

Perceived trauma: its etiology and treatment

Female adolescents in treatment for emotional disturbances are often diagnosed as suffering from borderline personality disorder. The usual treatment plan for such a diagnosis is based upon limit setting and boundary reinforcement. When this fails to produce results, the diagnosis comes into question. The present paper investigated 85 female adolescents who were being treated for problems associated with differentiation and emancipation in an inpatient setting. A treatment variation was introduced which suggested that these females were more likely to be suffering from a variety of post-traumatic stress disorder (PTSD). When their ritualistic behavioral repetitions were addressed by cognitive behavioral approaches, the behavior decreased. The struggle with boundary issues and references to the historical context of misery and deprivation became less frequent when the focus shifted to current behavior. Two groups emerged through the analysis of data. No difference in behavior or response to treatment could be established, but one group lacked a specific troubling experience which is essential for a diagnosis of PTSD. Maladaptive social behavior (e.g., splitting and projection) were accepted as confounding factors associated with cognitive style rather than "borderline" symptoms. With the new approach, recidivism decreased 14% and the number of outbursts diminished 10% to 12%. The altered treatment approach confirmed the hypothesis that these adolescents were experiencing the effects of trauma (actual or perceived) rather than some disabling personality disorder.     

An open clinical trial of cognitive therapy for borderline personality disorder

Although borderline personality disorder (BPD) is a major public health concern, psychotherapeutic trials have been limited. The present uncontrolled clinical trial examines whether cognitive therapy for BPD is associated with significant improvement on measures of psychopathology. A total of 32 patients with BPD, who also reported suicide ideation or who engaged in self-injury behavior, received weekly cognitive therapy sessions over a 1-year period as described by Layden et al. (1993). The results revealed significant and clinically important decreases on measures of suicide ideation, hopelessness, depression, number of borderline symptoms and dysfunctional beliefs at termination and 18-month assessment interviews. Implications for further research with this difficult-to-treat patient population are discussed.     

Dialectical behavior therapy adapted for suicidal adolescents

We report a quasi-experimental investigation of an adaptation of Dialectical Behavior Therapy (DBT) with a group of suicidal adolescents with borderline personality features. The DBT group (n = 29) received 12 weeks of twice weekly therapy consisting of individual therapy and a multifamily skills training group. The treatment as usual (TAU) group (n = 82) received 12 weeks of twice weekly supportive-psychodynamic individual therapy plus weekly family therapy. Despite more severe pre-treatment symptomatology in the DBT group, at post-treatment this group had significantly fewer psychiatric hospitalizations during treatment, and a significantly higher rate of treatment completion than the TAU group. There were no significant differences in the number of suicide attempts made during treatment. Examining pre-post change within the DBT group, there were significant reductions in suicidal ideation, general psychiatric symptoms, and symptoms of borderline personality. DBT appears to be a promising treatment for suicidal adolescents with borderline personality characteristics.     

Behandlungsleitlinie Persönlichkeitsstörungen

The S2 guidelines for the treatment of personality disorders (PD) are summarized. In the diagnostic assessment of personality disorders a clinical interview should be supplemented by (semi-) structured clinical interviews and self-report measures for the categorical and dimensional assessment of PDs. The results of the assessment process should be communicated to the patient based on a psycho-educational framework. The diagnosis should always be linked to the patient’s individual history. Psychotherapy is the treatment of choice for personality disorders. A detailed analysis of the patient’s problems as well as the definition of a hierarchy of treatment goals are part of the process of treatment planning. For three PDs empirical evidence for treatment approaches is available: (1) dialectical behavior therapy, mentalization-based therapy, schema focused therapy and transference focused therapy all proved beneficial in the treatment of borderline personality disorder. Cognitive-behavior therapy proved helpful in the treatment of (2) dissociative personality disorder and (3) avoidant personality disorder. There is limited evidence for interpersonal therapy and psychodynamic therapies in the treatment of avoidant personality disorder.     

The effectiveness of dialectical behaviour therapy in routine public mental health settings: An Australian controlled trial

Randomised controlled studies in research environments have demonstrated dialectical behaviour therapy (DBT) to be more efficacious than treatment as usual in reducing suicidal behaviour in patients with borderline personality disorder (BPD). Limited evidence exists for the effectiveness of DBT in the treatment of BPD within routine clinical settings. This study examines the clinical and cost effectiveness of providing DBT over treatment as usual in a routine Australian public mental health service. Forty-three adult patients with BPD were provided with outpatient DBT for six months with patient outcomes compared to those obtained from patients in a wait list group receiving treatment as usual (TAU) from the same service. After six months of treatment the DBT group showed significantly greater reductions in suicidal/non-suicidal self-injury, emergency department visits, psychiatric admissions and bed days. Self-report measures were administered to a reduced sample of patients. With this group, DBT patients demonstrated significantly improved depression, anxiety and general symptom severity scores compared to TAU at six months. Average treatment costs were significantly lower for those patients in DBT than those receiving TAU. Therapists who received intensive DBT training were shown to produce significantly greater improvements in patients’ suicidal and non-suicidal self-injury than therapists who received only 4 day basic training. Further clinical improvements were achieved in patients offered an additional six months of DBT. This study demonstrates that providing DBT to patients within routine public mental health settings can be both clinically effective and cost effective.     

The almost untreatable narcissistic patient

Clinical experience in the Personality Disorders Institute at Weill Cornell Medical College suggests that patients with borderline personality organization and a narcissistic personality disorder have a more serious prognosis than all other personality disorders functioning at the borderline level, and that those who in addition present significant antisocial behavior have an even worse prognosis (Clarkin, Yeomans, and Kernberg 1999; Stone 1990). This negative trend culminates in a group of practically untreatable patients with antisocial personality disorder, who represent the most severe cases of pathological narcissism. There are also patients with severe narcissistic personality disorder, functioning at an overt borderline level with significant antisocial features, but not presenting an antisocial personality disorder proper, who at times respond to treatment, while others do not. These patients are explored here, with a focus on particular psychotherapeutic techniques that have proven helpful, as well as on the limits of these technical approaches.     

The effectiveness of cognitive behavior therapy for borderline personality disorder: results from the borderline personality disorder study of cognitive therapy (BOSCOT) trial

The outcome of a randomized controlled trial of cognitive behavior therapy in addition to treatment as usual (CBT plus TAU) compared with TAU alone (TAU) in one hundred and six participants meeting diagnostic criteria for borderline personality disorder is described. We anticipated that CBT plus TAU would decrease the number of participants with in-patient psychiatric hospitalizations or accident and emergency room contact or suicidal acts over twelve months treatment and twelve months follow-up, compared with TAU. We also anticipated that CBT plus TAU would lead to improvement in a range of secondary outcomes of mental health and social functioning compared to TAU. Of the 106 participants randomized, follow-up data on 102 (96%) was obtained at two years. Those randomized to CBT were offered an average of 27 sessions over 12 months and attended on average 16 (range 0 to 35). We found that the global odds ratio of a participant in the CBT plus TAU group compared with the TAU alone group having any of the outcomes of a suicidal act, in-patient hospitalization, or accident and emergency contact in the 24 months following randomization was 0.86 (95% confidence interval [CI] 0.45 to 1.66, p = 0.66). The corresponding global odds ratio, excluding accident and emergency room contact, was 0.75 (95% CI 0.37 to 1.54, p = 0.44). In terms of the number of suicidal acts, there was a significant reduction over the two years in favor of CBT plus TAU over TAU, with a mean difference of -0.91 (95% CI -1.67 to -0.15, p = 0.020). Across both treatment arms there was gradual and sustained improvement in both primary and secondary outcomes, with evidence of benefit for the addition of CBT on the positive symptom distress index at one year, and on state anxiety, dysfunctional beliefs and the quantity of suicidal acts at two year follow-up. CBT can deliver clinically important changes in relatively few clinical sessions in real clinical settings.     

The relationship between comorbid personality disorders and treatment received in patients with anxiety disorders

Few studies have addressed the relationship between the presence of a comorbid personality disorder and the amount of psychiatric treatment received by patients with an Axis I disorder. This issue has not been studied in patients with anxiety disorders. In a prospective, naturalistic, longitudinal study of anxiety disorders, 526 subjects were assessed with the Personality Disorder Examination, and types of treatment received in 1991 and 1996 were identified. In 1991, compared to subjects without a personality disorder, subjects with a personality disorder were as likely to receive medication and they received a greater number of medications. Subjects with borderline personality disorder were more likely to receive heterocyclic antidepressants and interventions characteristic of psychodynamic psychotherapy and cognitive therapy; they also reported receiving a greater number of medications and types of psychosocial treatment than other subjects. In 1996, subjects with borderline personality disorder were more likely to receive psychodynamic interventions. These findings suggest that in patients with an anxiety disorder, the presence of a comorbid personality disorder is associated with receiving a greater number of medications but not with a greater likelihood of receiving pharmacologic or psychosocial treatment. However, the presence of borderline personality disorder is associated with a greater likelihood of receiving, and receiving a greater number of, certain types of somatic and psychosocial treatments.     

Schematherapie

Schema therapy is a cognitive behavioral therapy (CBT) development mainly for the treatment of personality disorders and other chronic mental disorders. It is characterized by an integration of cognitive, emotional and behavioral intervention methods derived from different therapeutic approaches with an emphasis on a specifically supportive therapeutic relationship. The original approach focused mainly on early maladaptive schemas. Current developments, however, concentrate on the concept of schema modes, describing different schema-associated emotional states. The schema mode approach is also used for specific case concepts for personality disorders. Effectiveness of schema therapy has been shown for borderline personality disorder. Current studies investigate the effectiveness of schema therapy for patients with other chronic mental conditions and as a group therapy approach. This paper provides an overview about case conceptualization and treatment, presents main research findings and discusses open questions and problems.     

Recent life events, social adjustment, and suicide attempts in patients with major depression and borderline personality disorder

This study investigated the impact of recent life events and social adjustment on suicide attempter status in 34 patients with major depression, 24 patients with borderline personality disorder, and 22 patients with co-morbid major depression and borderline personality disorder. Suicide attempters reported more recent life events and scored lower on a measure of social adjustment in their families and overall social adjustment, compared with non-attempters. Borderline disordered and borderline or depressed patients were more likely to have attempted suicide than patients with major depression only. Recent life events did not predict attempter status. Lower social adjustment in the immediate family and lower overall social adjustment were predictive of suicide attempter classification, regardless of diagnosis. Borderline disordered patients low on overall social adjustment were over 16 times more likely to have attempted suicide than patients diagnosed with major depression only. Recent life events may elevate suicide risk in groups already at high risk for suicide completion, whereas high levels of social adjustment may be protective against stress-related suicidal behavior.     

The burden of disease in personality disorders: diagnosis-specific quality of life

A generic quality of life measure was used to investigate the burden of disease in a large sample of patients with personality disorders. The 1,708 subjects included in this study were recruited from six different mental health care institutes in the Netherlands. The burden of disease was measured using the EuroQol EQ-5D. Personality disorders were diagnosed using the Structured Interview for DSM-IV Personality (SIDP-IV). The mean EQ-5D index value was 0.56. Primarily the total number of personality disorder diagnoses rather than the specific type determined the quality of life. Notably borderline personality disorder was not associated with the highest burden. The findings indicate that patients with personality disorders experience a high burden of disease, comparable to that of severe somatic illnesses. The results call into question the primary focus in literature on borderline personality disorder. The current study yields a strong argument in favor of reimbursing (effective) treatments for this patient population.     

A comparison of depressed patients with and without borderline personality disorder: implications for interpreting studies of the validity of the bipolar spectrum

The nosological status of borderline personality disorder as it relates to the bipolar disorder spectrum has been controversial. Studies have supported, in part, the validity of the bipolar spectrum by demonstrating that these patients, compared to patients with nonbipolar depression, are characterized by earlier age of onset of depression, recurrent depressive episodes, comorbid anxiety and substance use disorders and increased suicidality. However, all of these factors have likewise been found to distinguish depressed patients with and without borderline personality disorder. A family history of bipolar disorder is one of the few disorder specific validators. In the present study from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we compared the demographic and clinical characteristics of depressed patients with and without borderline personality disorder. We hypothesized that many of the factors used to validate the bipolar spectrum will also distinguish depressed patients with and without borderline personality disorder except, however, a family history of bipolar disorder. Two thousand nine hundred psychiatric outpatients at Rhode Island Hospital were evaluated with the Structured Clinical Interview for DSM-IV (SCID) and Structured Interview for DSM-IV Personality Disorders (SIDP-IV). Family history information regarding first-degree relatives was obtained from the patient using the Family History Research Diagnostic Criteria. One hundred and one patients with borderline personality disorder plus major depressive disorder were compared to 947 patients with major depressive disorder alone on the prevalence of bipolar disorder validators. Compared to depressed patients without borderline personality disorder, depressed patients with borderline personality disorder had a younger age of onset, more depressive episodes, a greater likelihood of experiencing atypical symptoms and had a higher prevalence of comorbid anxiety disorders, substance use disorders, and number of previous suicide attempts. The depressed patients with borderline personality disorder did not significantly differ from the patients without borderline personality disorder on morbid risk for bipolar disorder in first degree relatives. In addition, patients with a diagnosis of bipolar disorder had a significantly higher morbid risk of bipolar disorder in first degree relatives than the borderline personality disorder group. The findings indicate that many factors used to validate the bipolar spectrum are not disorder specific. These results raise questions about studies of the validity of the broad bipolar spectrum that do not assess borderline personality disorder. Our results do not support inclusion of borderline personality disorder as part of the bipolar spectrum.     

Frontal lobe dysfunctions in borderline personality disorder? Neuropsychological findings

This study aims to determine whether specific neuropsychological performance impairments in borderline patients can be objectified and whether these findings indicate frontal dysfunctions. Twenty-three patients with borderline personality disorder and 23 normal controls were examined using a neuropsychological test battery to assess intelligence, attentiveness, proneness to interference, learning and memory, as well as planning and problem solving. All subjects filled out standardized questionnaires to assess aggressiveness and impulsiveness in the context of these cognitive performance areas. The neuropsychological test results of the borderline patients were comparable to those of the controls. Although there were no indications of frontal dysfunction of cognitive information processing, inverse correlations were found between the severity of borderline-related personality traits regarding impulsiveness and various areas of cognitive performance. Borderline personality patients show no indications of frontal cognitive dysfunction. Further research is needed to clarify the relationship between impulsiveness and cognitive information processing in borderline personality disorder, including a dimensional approach to personality and personality disorder.     

Role of structure in disordered thinking in borderline and schizophrenic disorders

Qualitative studies have noted that individuals with "borderline" psychopathology exhibit extreme thought disorder on unstructured tests, yet manifest relatively normal performance on more structured tests of cognitive performance. The present study provides empirical support for this clinical observation. Borderline syndrome patients, defined by DSM-III criteria for borderline personality disorder and/or schizotypal personality disorder, demonstrated significantly greater thought disorder on the Rorschach, as measured by Johnston and Holzman's (1979) Thought Disorder Index (TDI), than did nonpsychiatric controls and were indistinguishable from patients with schizophrenic disorder of relatively recent onset. Borderline patients did not differ from controls on a structured test of cognitive slippage. Further examination of the role of structure in the assessment and treatment of borderline syndrome disorders seems warranted.     

Cost-effectiveness of Internet-based cognitive behavior therapy vs. cognitive behavioral group therapy for social anxiety disorder: results from a randomized controlled trial

Social anxiety disorder (SAD) is highly prevalent and associated with a substantial societal economic burden, primarily due to high costs of productivity loss. Cognitive behavior group therapy (CBGT) is an effective treatment for SAD and the most established in clinical practice. Internet-based cognitive behavior therapy (ICBT) has demonstrated efficacy in several trials in recent years. No study has however investigated the cost-effectiveness of ICBT compared to CBGT from a societal perspective, i.e. an analysis where both direct and indirect costs are included. The aim of the present study was to investigate the cost-effectiveness of ICBT compared to CBGT from a societal perspective using a prospective design. We conducted a randomized controlled trial where participants with SAD were randomized to ICBT (n = 64) or CBGT (n = 62). Economic data were assessed at pre-treatment, immediately following treatment and six months after treatment. Results showed that the gross total costs were significantly reduced at six-month follow-up, compared to pre-treatment in both treatment conditions. As both treatments were equivalent in reducing social anxiety and gross total costs, ICBT was more cost-effective due to lower intervention costs. We conclude that ICBT can be more cost-effective than CBGT in the treatment of SAD and that both treatments reduce societal costs for SAD.     

Positive affective and cognitive states in borderline personality disorder

The aim of the current study was to compliment previous studies identifying negative states present in borderline personality disorder (BPD) by investigating the presence of positive affective and cognitive states. Ninety-six patients with criteria-defined borderline personality disorder and 24 axis II comparison participants completed the Positive Affect Scale, a 50-item self-report measure designed to assess positive states thought to be characteristic of and discriminating for BPD. Seventeen positive states (4 affective, 10 cognitive, and 3 mixed) were found to be significantly more common among axis II comparison participants than borderline patients. Twelve of these states were common to both borderline patients and axis II comparison participants. Furthermore, four positive states, when co-occurring together, were particularly strongly associated with borderline personality disorder (three negatively and one positively): (a) Fond of myself, (b) That things around me are real, (c) That I've forgiven others, and (d) Assertive. Finally, the overall mean score on the PAS significantly distinguished patients with borderline personality disorder from axis II comparison participants. Taken together, these results suggest that borderline patients are far less likely to report experiencing positive states of an affective, cognitive, and mixed nature than axis II comparison participants. They also suggest that being assertive is a positive state particularly discriminating for borderline personality disorder.