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How Do Psychotherapies for Borderline Personality Disorder Compare?

Transference-focused psychotherapy, a psychodynamically based therapy, seems effective.

Despite claims for various psychotherapies in treating borderline personality disorder (BPD), only dialectic behavior therapy (DBT) and intensive psychotherapies during partial hospitalization have been effective in systematic trials. These investigators randomized 90 patients with BPD to 1 year of DBT (weekly individual and group sessions with telephone sessions as needed), transference-focused psychotherapy (TFP; twice-weekly sessions), or supportive treatment (ST; weekly sessions with additional sessions as needed). TFP aims to help patients develop greater self-control by better integrating self and other representations as they are activated within the therapeutic relationship. Exclusions were active substance dependence and comorbid psychotic, bipolar 1, and cognitive disorders.

At entry, blinded study psychiatrists prescribed medications to 70% of DBT recipients, 65% of ST recipients, and 52% of TFP recipients. The groups did not differ significantly in severity of symptoms (12 domains covering suicidality, aggression, impulsivity, anxiety, depression, and social functioning). Similar percentages of patients in each group remained on medications throughout the study. In a complex "individual growth curve" analysis of patients treated for at least 9 months (23 TFP, 17 DBT, and 22 ST patients), all three therapies were associated with broad improvements, with moderate-to-large effect sizes — TFP with improvements in 10 symptom domains, DBT in 5, and ST in 6. Only TFP was associated with improved impulsivity, irritability, verbal assault, and direct assault. Results in an intent-to-treat analysis were similar.

Comment: Without a medication-only control group, attributing change to the psychotherapies is problematic. However, the growth curves of patients medicated at study entry resembled those of the entire cohort. Some nonspecific factors — e.g., one-to-one contact time — were not equivalent between treatments. Still, the findings suggest that various carefully administered psychotherapies may benefit BPD patients. For some symptoms, the psychodynamically based TFP may be at least the equal of DBT.

— Joel Yager, MD

Published in Journal Watch Psychiatry July 30, 2007

Citation(s):

Clarkin JF et al. Evaluating three treatments for borderline personality disorder: A multiwave study. Am J Psychiatry 2007 Jun; 164:922-8.

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