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.     

A preliminary, randomized trial of psychoeducation for women with borderline personality disorder

The main objective of this study was to determine whether being taught the latest information concerning borderline personality disorder (BPD) leads to a decline in core BPD symptoms and an improvement in psychosocial functioning. Fifty-five late adolescent women participated in a rigorous diagnostic assessment and 50 met DIB-R and DSM-IV criteria for BPD. All 50 were informed that they met criteria for BPD. Then 30 were randomized to a psychoeducation workshop that took place within a week of diagnostic disclosure. The other 20 were assigned to a waitlist and participated in the workshop at the end of this 12-week study. The two primary outcome measures were readministered each week of the trial: the Zanarini Rating Scale for DSM-IV Borderline Personality Disorder (ZAN-BPD) and the Sheehan Disability Scale (SDS). Immediate psychoeducation concerning the BPD diagnosis was associated with a significantly greater decline in general impulsivity and the storminess of close relationships. However, it did not result in significantly improved psychosocial functioning. Taken together, the results of this study suggest that informing patients about BPD soon after diagnostic disclosure may help to alleviate the severity of two of the core elements of borderline psychopathology-general impulsivity and unstable relationships. They also suggest that such instruction may prove to be a useful and cost-efficient form of pre-treatment.     

Associations Between Symptoms of Borderline Personality Disorder,Externalizing Disorders,and Suicide-Related Behaviors

Borderline personality disorder and externalizing disorders are associated with suicide-related behaviors. The present study examined whether symptoms of borderline personality disorder mediate the relationship between externalizing disorders and suicide-related behaviors. Diagnostic interviews were administered to 344 participants (n = 233 women). Results indicated that symptoms of antisocial personality disorder, alcohol use disorders, and drug use disorders each were significantly associated with suicide threats and self-injurious behavior in women and symptoms of antisocial personality disorder were associated with suicide attempts in women. With the exception of the association between symptoms of alcohol dependence and self-injurious behaviors, borderline personality disorder symptoms mediated or partially mediated all associations between externalizing disorders and suicide-related behaviors in women. These results highlight the importance of assessment and treatment of borderline personality disorder symptoms in individuals with externalizing disorders, particularly in the presence of suicide-related behaviors.

The MMPI,Prototypal Typology,and Borderline Personality Disorder

This study demonstrates inherent features in the DSM-III diagnostic criteria for personality disorders (i.e., overlapping diagnoses and heterogeneous symptomatology) that limit efforts to identify a sensitive and specific MMPI profile for the borderline personality disorder. A sample of 71 inpatients was administered an MMPI and a semistructured interview that systematically evaluated each of 81 symptoms for the 11 DSM-III personality disorders. Interrater reliability was substantially higher than has been obtained with unstructured interviews. The effect on the borderline MMPI profile of (a) variation in the number of borderline symptoms and (b) overlap with the schizotypal, histrionic, and antisocial diagnoses was demonstrated. We discuss implications with respect to a prototypal model of classification.     

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 MMPI, prototypal typology, and borderline personality disorder

This study demonstrates inherent features in the DSM-III diagnostic criteria for personality disorders (i.e., overlapping diagnoses and heterogeneous symptomatology) that limit efforts to identify a sensitive and specific MMPI profile for the borderline personality disorder. A sample of 71 inpatients was administered an MMPI and a semistructured interview that systematically evaluated each of 81 symptoms for the 11 DSM-III personality disorders. Interrater reliability was substantially higher than has been obtained with unstructured interviews. The effect on the borderline MMPI profile of variation in the number of borderline symptoms and overlap with the schizotypal, histrionic, and antisocial diagnoses was demonstrated. We discuss implications with respect to a prototypal model of classification.     

Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD): a continuous measure of DSM-IV borderline psychopathology

The purpose of this study was to assess the psychometric properties of the Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD), the first clinician-administered scale for the assessment of change in DSM-IV borderline psychopathology. The questions for the measure were adapted from the BPD module of the Diagnostic Interview for DSM-IV Personality Disorders (DIPD-IV) to reflect a 1-week time frame and each of the nine criteria for BPD is rated on a five-point anchored rating scale of 0 to 4, yielding a total score of 0 to 36. Two diagnostic interviews that assess the presence of BPD were administered to 200 nonpsychotic patients: the BPD module of the DIPD-IV and the Revised Diagnostic Interview for Borderlines (DIB-R). The ZAN-BPD was also administered, blind to diagnostic information. In addition, each patient filled out a self-report measure of general psychopathology that is often used in borderline treatment studies, the Symptom Checklist 90 (SCL-90). The convergent validity of the ZAN-BPD and relevant scales of the SCL-90 and the DIB-R was assessed and found to be highly significant. The discriminant validity of the various scores of the ZAN-BPD was also found to be highly significant, easily discriminating the 139 patients who met the DSM-IV criteria for BPD from the 61 patients who did not. In addition, internal consistency of the ZAN-BPD was found to be high (Cronbach's alpha=0.85). The interrater reliability of the ZAN-BPD was assessed using 32 conjoint interviews, while same day test-retest reliability was assessed in a separate sample of 40 patients. All reliability raters were blind to all previously collected information concerning each subject. All intraclass correlations were in the good to excellent range. Finally, the sensitivity of the ZAN-BPD to change was assessed using a third sample of 41 patients who were reinterviewed by a blind rater 7 to 10 days after the ZAN-BPD was first administered. The SCL-90 was also readministered at this time. The correlations between difference scores of the ZAN-BPD and difference scores of the SCL-90 were found to be significant, indicating that the ZAN-BPD measures change in a clinically meaningful manner. Taken together, the results of this study suggest that the ZAN-BPD is a promising clinician-administered scale for the assessment of change in borderline psychopathology over time.     

Development and first results of the Borderline Personality Inventory: a self-report instrument for assessing borderline personality organization.

This article reports the development of a short 53-item true-false self-report instrument, the Borderline Personality Inventory (BPI). The BPI is based on Kernberg's (1984) concept of borderline personality organization. However, the diagnostic criteria are compatible with both the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) and Gunderson's (Gunderson & Kolb, 1978) concept of borderline personality disorder (BPD). The BPI contains scales for assessing identity diffusion, primitive defense mechanisms, and reality testing. Another scale refers to the fear of closeness. The construction of the scales is based on the results of a factor analysis. As a result of several studies, a cutoff score is proposed to make the diagnosis of a BPD. Thus, the BPI combines dimensional and categorical models of BPD. The BPI was tested in several studies. According to the results, internal consistency and retest reliability are satisfactory (Cronbach's alpha = .68-.91, rtt = .73-.89). Results for sensitivity are .85 to .89, and results for specificity .78 to .89. The BPI identifies borderline patients in high agreement with Kernberg's criteria of borderline personality organization, Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev.; American Psychiatric Association, 1987) criteria of BPD and Gunderson's criteria of BPD. The BPI is recommended as a screening instrument for borderline personality organization and BPD and for dimensional research of borderline features in Axis I and Axis II disorders.     

The cost-effectiveness of cognitive behavior therapy for borderline personality disorder: results from the BOSCOT trial

Borderline personality disorder places a significant burden on healthcare providers and other agencies. This study evaluated the cost-effectiveness of cognitive behavior therapy plus treatment as usual compared to treatment as usual alone for patients with borderline personality disorder. The economic analysis was conducted alongside a multi-center, randomized controlled trial. The costs of primary and secondary healthcare utilization, alongside the wider economic costs, were estimated from medical records and patient self-report. The primary outcome measure used was the quality-adjusted life year (QALY), assessed using EuroQol. On average, total costs per patient in the cognitive behavior therapy group were lower than patients receiving usual care alone (-689 pounds sterling), although this group also reported a lower quality of life (-0.11 QALYs). These differences were small and did not approach conventional levels of statistical significance. The use of cognitive therapy for borderline personality disorder does not appear to demonstrate any significant cost-effective advantage based on the results of this study.     

Effectiveness of inpatient dialectical behavioral therapy for borderline personality disorder: a controlled trial

Dialectical Behavioral Therapy (DBT) was initially developed and evaluated as an outpatient treatment program for chronically suicidal individuals meeting criteria for borderline personality disorder (BPD). Within the last few years, several adaptations to specific settings have been developed. This study aims to evaluate a three-month DBT inpatient treatment program. Clinical outcomes, including changes on measures of psychopathology and frequency of self-mutilating acts, were assessed for 50 female patients meeting criteria for BPD. Thirty-one patients had participated in a DBT inpatient program, and 19 patients had been placed on a waiting list and received treatment as usual in the community. Post-testing was conducted four months after the initial assessment (i.e. four weeks after discharge for the DBT group). Pre-post-comparison showed significant changes for the DBT group on 10 of 11 psychopathological variables and significant reductions in self-injurious behavior. The waiting list group did not show any significant changes at the four-months point. The DBT group improved significantly more than participants on the waiting list on seven of the nine variables analyzed, including depression, anxiety, interpersonal functioning, social adjustment, global psychopathology and self-mutilation. Analyses based on Jacobson's criteria for clinically relevant change indicated that 42% of those receiving DBT had clinically recovered on a general measure of psychopathology. The data suggest that three months of inpatient DBT treatment is significantly superior to non-specific outpatient treatment. Within a relatively short time frame, improvement was found across a broad range of psychopathological features. Stability of the recovery after one month following discharge, however, was not evaluated and requires further study.     

Borderline Personality Disorder,Divorce and Family Therapy: The Need for Family Crisis Intervention Strategies

Recent literature reviews, point out the lack of crisis intervention and crisis prevention programs that are in existence to address crises experienced by first-degree and divorced family members of Borderline Personality Disorder (BPD) probands. The focus of such intervention programs should be to facilitate the improved ability of the first-degree and divorced family members to manage and transcend the unstable family environment. Correlations between personal instability and frequency of psychosocial crises have been examined, as well as the ripple effect of frequent individual crises on family environments. Reviews of current therapeutic interventions, as well as a synthesis of practical family therapy interventions focusing on breaking the cycle of dysfunctional multi-generational family environments are also examined.     

Borderline Personality Disorder in 3-D: Dimensions,Symptoms, and Measurement Challenges

Borderline personality disorder (BPD) is a pervasive pattern of psychopathology characterized by unstable affect, suicidal behaviors, and identity problems (Diagnostic and statistical manual of mental disorders. Washington, DC: Author; 2000). BPD is heterogeneous in nature, highly prevalent in clinical settings, and increasingly studied by clinical and social psychologists. This review highlights affective instability, impulsivity, and interpersonal hypersensitivity, the interaction of which we believe accounts for the symptoms of BPD, the BPD criteria most associated with these features, and the interrelationships among these underlying dimensions. We also discuss difficulties in measurement of these dimensions. Real-world assessment methods will assist in the measurement of time-dependent processes and identify causes, covariates, or consequences of these processes to determine how these features manifest themselves in real life.     

Clinical,neuropsychological and structural convergences and divergences between Attention Deficit/Hyperactivity Disorder and Borderline Personality Disorder: A systematic review

Attention Deficit/Hyperactivity Disorder (ADHD) symptoms overlap with Borderline Personality Disorder (BPD). Since ADHD presents earlier than BPD, ADHD might be either a risk factor or a prodromal stage in the development of BPD or in the reinforcement of its symptoms. However, despite the similar phenomenological origin of the two disorders, ADHD and BPD patients often present discrete profiles. The present study reviews literature data of the clinical, neuropsychological and structural convergences and divergences of ADHD and BPD. A total of 185 studies were identified that address the association of ADHD and BPD and relate to clinical, neuropsychological and structural parameters. The total number of articles included was 45. ADHD exhibits a more outwardly expressed symptomatology, with difficulties in inhibition control and dysfunction in ventrolateral prefrontal regions. BPD presents a more mixed picture of externalizing and interrelating clinical features with emotionally conditioned cognitive disturbances and dysfunction in the orbitofrontal and dorsolateral prefrontal regions. When considering the three abovementioned parameters there is no unique clear-cut point that can differentiate the two disorders in a definitive way. Both disorders share impulsivity, emotional dysregulation, deficits in attention and decision making, brain volume reductions and connectivity impairments in prefrontal and limbic areas.     

A comparison of interview and self-report methods for the assessment of borderline personality disorder criteria

Interview methods are widely regarded as the standard for the diagnosis of borderline personality disorder (BPD), whereas self-report methods are considered a time-efficient alternative. However, the relative validity of these methods has not been sufficiently tested. The current study used data from the Collaborative Longitudinal Personality disorder Study to compare diagnostic base rates and the relative validity of interview and self-report methods for assessing functional outcome in BPD. Although self-report yielded higher base rates of criteria endorsement, results did not support the common assumption that diagnostic interviews are more valid than self-reports, but instead indicated the combined use of these methods optimally identifies BPD criteria.     

Between Subjugation and Survival: Women, Borderline Personality Disorder and High Security Mental Hospitals

Women in high security mental health care are frequently diagnosed with borderline personality disorder. Such women commonly report histories of child abuse, in particular child sexual abuse, and the vast majority also self-harm. In this paper, we draw on social constructionist theory to develop a framework for understanding these women, the effects of abuse and the reasons they self-harm. We demonstrate how a social model of intervention provides a comprehensive framework for identifying and exploring relevant factors within therapy. We argue that diagnostic categorisation has limited utility in directing therapeutic work with this particular group of women, because it directs attention away from the social world to internal pathology. We demonstrate that it is with reference to women's past and current relationships that borderline behaviour can be understood to be meaningful and partially adaptive. We conclude that treatment is more usefully organised around and directed towards those factors, such as abuse and self-harm, that are implicated in women's ongoing relationship difficulties.