Adaptation of interpersonal psychotherapy to borderline personality disorder: a comparison of combined therapy and single pharmacotherapy

Group interpersonal psychotherapy (IPT-G) for borderline personality disorder: A randomized controlled study

Recent evidence supported the notion that add-on group therapy should be provided to individuals with borderline personality disorder (BPD) who already undergo individual psychotherapy. The present 20 week-study was aimed to evaluate the efficacy of the adjunction of group interpersonal psychotherapy (IPT-G) to individual interpersonal psychotherapy adapted for BPD - revised (IPT-BPD-R) in comparison with individual IPT-BPD-R alone in a group of BPD patients. In addition, demographical and clinical characteristics that can be considered predictors of response to add-on group therapy were investigated. Forty-six patients were randomly assigned to 1) IPT-BPD-R plus IPT-G or to 2) IPT-BPD-R in the waiting list for IPT-G. Patients were assessed at baseline and after 20 weeks with: the Clinical Global Impression Scale, Severity item (CGI-S); the Social Occupational Functioning Assessment Scale (SOFAS); the Satisfaction Profile (SAT-P); the Borderline Personality Disorder Severity Index (BPDSI); the Modified Overt Aggression Scale (MOAS); the Childhood Trauma Questionnaire - Short Form (CTQ-SF); the Inventory of Interpersonal Problems (IIP-32); and the Reading the Mind in the Eyes Test (RMET). Statistical analyses included: ANOVA for repeated measures to compare score changes of the rating scales within groups (trial duration) and between groups (treatment modalities), and multiple regression analysis to identify which clinical factors are significantly and independently related to the difference of BPDSI score between baseline and week 20 (Δ BPDSI). The significance level was P ≤ 0.05. Both significant within-subjects effects (duration) and between-subjects effects (treatment modalities) were found for the following rating scales: MOAS; BPDSI items "feelings of emptiness", "outbursts of anger," and "affective instability"; RMET; SAT-P items "work" and "sleep, food, free time"; and IIP-32 scale "domineering/controlling". At the multiple regression analysis BPDSI item "impulsivity", RMET, and the subscale "socially inhibited" of the IIP-32 were significantly and independently related to Δ BPDSI score. In conclusion, the add-on of IPT-G produced higher improvement in core BPD symptoms, social cognition, a dysfunctional interpersonal style, and subjective quality of life. Subjects who were less impulsive, less socially inhibited, and with higher abilities in social cognition obtained greater benefits from the adjunction of group therapy. CLINICAL TRIALS REGISTRATION NUMBER: ACTRN12623000002684, Australian New Zealand Clinical Trials Registry (ANZCTR).

Genetic Influences on Outcomes of Psychotherapy in Borderline Personality Disorder: A Narrative Review of Implications for Personalized Treatment

Borderline personality disorder (BPD) manifests as instability in mood, relationships, self-image, and behavior, representing a challenging mental health issue. This review scrutinizes genetic factors influencing BPD and the corresponding treatment outcomes. The primary objective of this narrative review is to illuminate the association between genetic factors and BPD treatment outcomes, discussing the potential of genetic testing for personalized therapy. The review is derived from observational and experimental studies on BPD, genetic factors, and psychotherapy from 2000 to 2023, sourced primarily through PubMed. Reviews and meta-analyses were excluded. Our review suggests that genetic factors account for 40-60% of BPD variation, with significant roles played by epigenetic alterations like DNA methylation and microRNAs, particularly in the context of childhood trauma. Gene-environment interactions are also vital for BPD's development. Treatments such as dialectical behavior therapy, mentalization-based therapy, and schema therapy have shown efficacy, with success variability possibly linked to genetic factors. However, existing research is constrained by recall bias, diverse methodologies, and limited sample sizes. Future research necessitates long-term follow-up, diverse populations, and controlled variables to enhance our comprehension of BPD treatment outcomes' genetic foundations. The review underlines the promise of personalized medicine in BPD treatment, driven by genetic insights.

Which psychotherapy is most effective and acceptable in the treatment of adults with a (sub)clinical borderline personality disorder? A systematic review and network meta-analysis

A broad range of psychotherapies have been proposed and evaluated in the treatment of borderline personality disorder (BPD), but the question which specific type of psychotherapy is most effective remains unanswered. In this study, two network meta-analyses (NMAs) were conducted investigating the comparative effectiveness of psychotherapies on (1) BPD severity and (2) suicidal behaviour (combined rate). Study drop-out was included as a secondary outcome. Six databases were searched until 21 January 2022, including RCTs on the efficacy of any psychotherapy in adults (⩾18 years) with a diagnosis of (sub)clinical BPD. Data were extracted using a predefined table format. PROSPERO ID:CRD42020175411. In our study, a total of 43 studies (N = 3273) were included. We found significant differences between several active comparisons in the treatment of (sub)clinical BPD, however, these findings were based on very few trials and should therefore be interpreted with caution. Some therapies were more efficacious compared to GT or TAU. Furthermore, some treatments more than halved the risk of attempted suicide and committed suicide (combined rate), reporting RRs around 0.5 or lower, however, these RRs were not statistically significantly better compared to other therapies or to TAU. Study drop-out significantly differed between some treatments. In conclusion, no single treatment seems to be the best choice to treat people with BPD compared to other treatments. Nevertheless, psychotherapies for BPD are perceived as first-line treatments, and should therefore be investigated further on their long-term effectiveness, preferably in head-to-head trials. DBT was the best connected treatment, providing solid evidence of its effectiveness.

Pharmacologic and Non-Pharmacologic Interventions for Emotional Lability: A Meta-Analysis

Emotional Lability (EL) is a common symptom dimension in a variety of psychiatric disorders. However, as it is not typically a diagnosis in its own right, it lacks a consistently applied clinical definition and treatment approach. Therefore, in this review we performed a meta-analysis to determine the effect size for treatments of EL across diagnostic categories. We then conducted subgroup analyses to compare effect sizes for pharmacologic (MED) and behavioral (BEH) treatments, according to underlying diagnosis, and according to medication class. We found that pharmacologic and non-pharmacologic treatments are effective for EL, and that the effect sizes were similar - a finding with implications for clinical practice. Our finding also supports future research which approaches EL as an important construct independent of underlying diagnosis.

Psychotherapies for borderline personality disorder: a focused systematic review and meta-analysis

BACKGROUND

A recently updated Cochrane review supports the efficacy of psychotherapy for borderline personality disorder (BPD).

AIMS

To evaluate the effects of standalone and add-on psychotherapeutic treatments more concisely.

METHOD

We applied the same methods as the 2020 Cochrane review, but focused on adult samples and comparisons of active treatments and unspecific control conditions. Standalone treatments (i.e. necessarily including individual psychotherapy as either the sole or one of several treatment components) and add-on interventions (i.e. complementing any ongoing individual BPD treatment) were analysed separately. Primary outcomes were BPD severity, self-harm, suicide-related outcomes and psychosocial functioning. Secondary outcomes were remaining BPD diagnostic criteria, depression and attrition.

RESULTS

Thirty-one randomised controlled trials totalling 1870 participants were identified. Among standalone treatments, statistically significant effects of low overall certainty were observed for dialectical behaviour therapy (self-harm: standardised mean difference (SMD) -0.54, P = 0.006; psychosocial functioning: SMD -0.51, P = 0.01) and mentalisation-based treatment (self-harm: risk ratio 0.51, P < 0.0007; suicide-related outcomes: risk ratio 0.10, P < 0.0001). For adjunctive interventions, moderate-quality evidence of beneficial effects was observed for DBT skills training (BPD severity: SMD -0.66, P = 0.002; psychosocial functioning: SMD -0.45, P = 0.002), and statistically significant low-certainty evidence was observed for the emotion regulation group (BPD severity: mean difference -8.49, P < 0.00001), manual-assisted cognitive therapy (self-harm: mean difference -3.03, P = 0.03; suicide-related outcomes: SMD -0.96, P = 0.005) and the systems training for emotional predictability and problem-solving (BPD severity: SMD -0.48, P = 0.002).

CONCLUSIONS

There is reasonable evidence to conclude that psychotherapeutic interventions are helpful for individuals with BPD. Replication studies are needed to enhance the certainty of findings.

Non-response to psychotherapy for borderline personality disorder: A systematic review

HIGHLIGHT

This is the first systematic review to investigate non-response to psychotherapy for borderline personality disorder.

BACKGROUND

Psychotherapy is the recommended treatment for borderline personality disorder. While systematic reviews have demonstrated the effectiveness of psychotherapy for borderline personality disorder, effect sizes remain small and influenced by bias. Furthermore, the proportion of people who do not respond to treatment is seldom reported or analysed.

OBJECTIVE

To obtain an informed estimate of the proportion of people who do not respond to psychotherapy for borderline personality disorder.

METHODS

Systematic searches of five databases, PubMed, Web of Science, Scopus, PsycINFO and the Cochrane Library, occurred in November 2020. Inclusion criteria: participants diagnosed with borderline personality disorder, treated with psychotherapy and data reporting either (a) the proportion of the sample that experienced 'reliable change' or (b) the percentage of sample that no longer met criteria for borderline personality disorder at conclusion of therapy. Exclusion criteria: studies published prior to 1980 or not in English. Of the 19,517 studies identified, 28 met inclusion criteria.

RESULTS

Twenty-eight studies were included in the review comprising a total of 2436 participants. Average treatment duration was 11 months using well-known evidence-based approaches. Approximately half did not respond to treatment; M = 48.80% (SD = 22.77).

LIMITATIONS

Data regarding within sample variability and non-response are seldom reported. Methods of reporting data on dosage and comorbidities were highly divergent which precluded the ability to conduct predictive analyses. Other limitations include lack of sensitivity analysis, and studies published in English only.

CONCLUSION

Results of this review suggest that a large proportion of people are not responding to psychotherapy for borderline personality disorder and that factors relating to non-response are both elusive and inconsistently reported. Novel, tailored or enhanced interventions are needed to improve outcomes for individuals not responding to current established treatments.

Impulsivity and its Therapeutic Management in Borderline Personality Disorder: a Systematic Review

No treatment has been approved and recognized as effective in borderline personality disorder (BPD). Impulsivity is a key dimension because it is a predictor of remission but also suicide. The purpose of this review is to establish an inventory on the management of impulsivity in BPD and determine the effective treatments. A systematic review on the PubMed and Ovid databases was conducted up to September 2019 to December 2019 using the PRISMA guidelines. The inclusion criteria were: studies with patients with borderline personality disorder, were published between 1989 and 2019, used English-language and evaluated impulsivity before and after treatment. 41 articles selected were included for pharmacological treatment. 24 articles were found for psychotherapeutic management and one randomized study of transcranial magnetic stimulation. Based on this review, we must focus on psychotherapy in BPD, particularly the schema therapy, dialectical behavioral therapy, psychoeducation, system training of emotional predictability and problem solving and psychotherapy using mentalisation. The use of neuroleptics and mood stabilizers appears to be more effective than antidepressants. Another approach, such as transcranial magnetic stimulation, may prove useful in the near future if this technique is studied further.

Prescribing Practices for Patients With Borderline Personality Disorder During Psychiatric Hospitalizations

This study aimed to understand prescribing practices during acute psychiatric hospitalization in a large cohort of patients (N = 569) with borderline personality disorder (BPD) at a tertiary care psychiatry unit from January 1, 2013, through January 1, 2015. The mean number of hospitalizations per patient was 1.5 (range, 1-7). The odds of being prescribed antidepressants, antipsychotics, mood stabilizers, hypnotics, or anxiolytics were higher at discharge than at admission. The rate of psychotropic prescriptions was also higher at discharge than at admission (incidence rate ratio, 1.9). This pattern was true for the combined psychotropic and nonpsychotropic ("medical") prescriptions. Further guidelines are needed regarding optimal psychosocial, medical, and psychopharmacological care of patients with BPD during acute psychiatric hospitalizations.

Psychological therapies for people with borderline personality disorder

BACKGROUND

Over the decades, a variety of psychological interventions for borderline personality disorder (BPD) have been developed. This review updates and replaces an earlier review (Stoffers-Winterling 2012).

OBJECTIVES

To assess the beneficial and harmful effects of psychological therapies for people with BPD.

SEARCH METHODS

In March 2019, we searched CENTRAL, MEDLINE, Embase, 14 other databases and four trials registers. We contacted researchers working in the field to ask for additional data from published and unpublished trials, and handsearched relevant journals. We did not restrict the search by year of publication, language or type of publication.

SELECTION CRITERIA

Randomised controlled trials comparing different psychotherapeutic interventions with treatment-as-usual (TAU; which included various kinds of psychotherapy), waiting list, no treatment or active treatments in samples of all ages, in any setting, with a formal diagnosis of BPD. The primary outcomes were BPD symptom severity, self-harm, suicide-related outcomes, and psychosocial functioning. There were 11 secondary outcomes, including individual BPD symptoms, as well as attrition and adverse effects.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected trials, extracted data, assessed risk of bias using Cochrane's 'Risk of bias' tool and assessed the certainty of the evidence using the GRADE approach. We performed data analysis using Review Manager 5 and quantified the statistical reliability of the data using Trial Sequential Analysis.

MAIN RESULTS

We included 75 randomised controlled trials (4507 participants), predominantly involving females with mean ages ranging from 14.8 to 45.7 years. More than 16 different kinds of psychotherapy were included, mostly dialectical behaviour therapy (DBT) and mentalisation-based treatment (MBT). The comparator interventions included treatment-as-usual (TAU), waiting list, and other active treatments. Treatment duration ranged from one to 36 months. Psychotherapy versus TAU Psychotherapy reduced BPD symptom severity, compared to TAU; standardised mean difference (SMD) -0.52, 95% confidence interval (CI) -0.70 to -0.33; 22 trials, 1244 participants; moderate-quality evidence. This corresponds to a mean difference (MD) of -3.6 (95% CI -4.4 to -2.08) on the Zanarini Rating Scale for BPD (range 0 to 36), a clinically relevant reduction in BPD symptom severity (minimal clinical relevant difference (MIREDIF) on this scale is -3.0 points). Psychotherapy may be more effective at reducing self-harm compared to TAU (SMD -0.32, 95% CI -0.49 to -0.14; 13 trials, 616 participants; low-quality evidence), corresponding to a MD of -0.82 (95% CI -1.25 to 0.35) on the Deliberate Self-Harm Inventory Scale (range 0 to 34). The MIREDIF of -1.25 points was not reached. Suicide-related outcomes improved compared to TAU (SMD -0.34, 95% CI -0.57 to -0.11; 13 trials, 666 participants; low-quality evidence), corresponding to a MD of -0.11 (95% CI -0.19 to -0.034) on the Suicidal Attempt Self Injury Interview. The MIREDIF of -0.17 points was not reached. Compared to TAU, psychotherapy may result in an improvement in psychosocial functioning (SMD -0.45, 95% CI -0.68 to -0.22; 22 trials, 1314 participants; low-quality evidence), corresponding to a MD of -2.8 (95% CI -4.25 to -1.38), on the Global Assessment of Functioning Scale (range 0 to 100). The MIREDIF of -4.0 points was not reached. Our additional Trial Sequential Analysis on all primary outcomes reaching significance found that the required information size was reached in all cases. A subgroup analysis comparing the different types of psychotherapy compared to TAU showed no clear evidence of a difference for BPD severity and psychosocial functioning. Psychotherapy may reduce depressive symptoms compared to TAU but the evidence is very uncertain (SMD -0.39, 95% CI -0.61 to -0.17; 22 trials, 1568 participants; very low-quality evidence), corresponding to a MD of -2.45 points on the Hamilton Depression Scale (range 0 to 50). The MIREDIF of -3.0 points was not reached. BPD-specific psychotherapy did not reduce attrition compared with TAU. Adverse effects were unclear due to too few data. Psychotherapy versus waiting list or no treatment Greater improvements in BPD symptom severity (SMD -0.49, 95% CI -0.93 to -0.05; 3 trials, 161 participants), psychosocial functioning (SMD -0.56, 95% CI -1.01 to -0.11; 5 trials, 219 participants), and depression (SMD -1.28, 95% CI -2.21 to -0.34, 6 trials, 239 participants) were observed in participants receiving psychotherapy versus waiting list or no treatment (all low-quality evidence). No evidence of a difference was found for self-harm and suicide-related outcomes. Individual treatment approaches DBT and MBT have the highest numbers of primary trials, with DBT as subject of one-third of all included trials, followed by MBT with seven RCTs. Compared to TAU, DBT was more effective at reducing BPD severity (SMD -0.60, 95% CI -1.05 to -0.14; 3 trials, 149 participants), self-harm (SMD -0.28, 95% CI -0.48 to -0.07; 7 trials, 376 participants) and improving psychosocial functioning (SMD -0.36, 95% CI -0.69 to -0.03; 6 trials, 225 participants). MBT appears to be more effective than TAU at reducing self-harm (RR 0.62, 95% CI 0.49 to 0.80; 3 trials, 252 participants), suicidality (RR 0.10, 95% CI 0.04, 0.30, 3 trials, 218 participants) and depression (SMD -0.58, 95% CI -1.22 to 0.05, 4 trials, 333 participants). All findings are based on low-quality evidence. For secondary outcomes see review text.

AUTHORS' CONCLUSIONS

Our assessments showed beneficial effects on all primary outcomes in favour of BPD-tailored psychotherapy compared with TAU. However, only the outcome of BPD severity reached the MIREDIF-defined cut-off for a clinically meaningful improvement. Subgroup analyses found no evidence of a difference in effect estimates between the different types of therapies (compared to TAU) . The pooled analysis of psychotherapy versus waiting list or no treatment found significant improvement on BPD severity, psychosocial functioning and depression at end of treatment, but these findings were based on low-quality evidence, and the true magnitude of these effects is uncertain. No clear evidence of difference was found for self-harm and suicide-related outcomes. However, compared to TAU, we observed effects in favour of DBT for BPD severity, self-harm and psychosocial functioning and, for MBT, on self-harm and suicidality at end of treatment, but these were all based on low-quality evidence. Therefore, we are unsure whether these effects would alter with the addition of more data.

Interpersonal Psychotherapy as a Single Treatment for Borderline Personality Disorder: A Pilot Randomized-Controlled Study

Recent guidelines share the recommendations that psychotherapy plays a central role in the treatment of borderline personality disorder (BPD). In recent years, interpersonal psychotherapy adapted for treating BPD (IPT-BPD) was added to specific psychotherapies and was tested in combination with pharmacotherapy. The present study is aimed to assess the efficacy of IPT-BPD revised (IPT-BPD-R) as single treatment in a sample of BPD patients. Results obtained in a group of patients receiving IPT-BPD-R were compared with those observed in a control group in waiting list plus clinical management (WL/CM). Forty-three BPD subjects were randomly allocated to one of the two arms. Patients were assessed at baseline and after 10 months with the following assessment instruments: Clinical Global Impression Scale, Severity item (CGI-S), Social Occupational Functioning Assessment Scale (SOFAS), Borderline Personality Disorder Severity Index (BPDSI), Barratt Impulsiveness Scale, version 11 (BIS-11), Modified Overt Aggression Scale (MOAS), and Self Harm Inventory (SHI). Statistical analysis was performed with one-way analysis of variance (ANOVA) or chi-square test to compare baseline characteristics of the two treatment groups. Comparison of score changes at the end of the trial between the two groups was calculated for each rating scale with the analysis of variance for repeated measures. Seven patients (16.3%) discontinued the treatment in the first month of the trial for non-adherence. We found a significant effect within subjects (trial duration) for all rating scales, except for the MOAS. A significant effect between subjects (treatment modality) was found for CGI-S; SOFAS; BIS-11 total score and subscale "non-planning impulsivity"; BPDSI total score and items "interpersonal relationships," "impulsivity," and "identity." So, results showed differences between groups in favor of psychotherapy in terms of reduction of severity of general psychopathology, improvement of social and occupational functioning, and decrease of global BPD symptoms and three specific domains. On the other hand, we did not find any differences between groups for self-harm behaviors and aggressive behaviors.

Pharmacotherapy of personality disorders: what we know and what we have to search for

Pharmacotherapy for personality disorders is in the early stage of development because the evidence base for effective drug treatment is insufficient, biased toward borderline personality disorder and rampant with methodological issues. In this paper, we reviewed randomized, placebo-controlled trials of drugs efficacy in patients with personality disorders published between 1990 and 2016. Overwhelming majority of studies focused on borderline personality disorder, and the accumulation of evidence resulted in seven meta-analyses, which are interpreted into better strategies for evidence-based practice. Little research attention was given to schizotypal and antisocial personality disorders, with only indirect treatment efficacy evidence for the obsessive–compulsive and avoidant personality disorders. Some avenues for future efficacy research are indicated.

A Focused Systematic Review of Pharmacological Treatment for Borderline Personality Disorder

BACKGROUND

Medicines are routinely prescribed to treat borderline personality disorder (BPD) despite a relative lack of high-quality evidence and in breach of some treatment guidelines. An earlier Cochrane review of pharmacotherapy in BPD underlined the lack of evidence, encouraged the replication of earlier studies, but also emphasised the pressing need for more randomised placebo-controlled trials, and for those studies to employ broadened inclusion criteria.

METHOD

The authors searched bibliographic databases, reference lists of articles and trials registers. Records were screened to identify those that met the inclusion criteria. Full-text articles were screened and assessed for eligibility. On-going trials of pharmacotherapy in BPD were also identified.

RESULTS

Fifteen new studies of pharmacotherapy for BPD were identified since the earlier review. Eight of those examined second generation antipsychotics, two investigated mood stabilisers, three investigated antidepressants and two studied the effectiveness of opioid antagonists. Results for the effectiveness of antipsychotics appeared to be mixed. There has been little recent evidence to support the use of mood stabilisers. There is a lack of new placebo-controlled, randomised controlled trials investigating antidepressants and limited new evidence to support the use of opioid antagonists.

CONCLUSIONS

The review revealed that there remains a dearth of high-quality research evidence to help patients, carers and clinicians make sound and safe evidence-based decisions about medicines to treat BPD.

Combined therapy with interpersonal psychotherapy adapted for borderline personality disorder: A two-years follow-up

Few investigations evaluated the long-term effects of psychotherapies in borderline personality disorder (BPD). In a previous study, we compared efficacy of combination of fluoxetine and interpersonal psychotherapy adapted to BPD (IPT-BPD) versus single fluoxetine administered for 32 weeks. This study is aimed to investigate whether the results obtained with the addition of IPT-BPD persist during a follow-up period. Forty-four patients who completed the 32 weeks trial underwent 24 months of follow-up receiving fluoxetine 20-40 mg/day. Clinical Global Impression Severity (CGI-S), Hamilton Rating Scales for Depression and Anxiety (HDRS, HARS), Social and Occupational Functioning Assessment Scale (SOFAS), Satisfaction Profile (SAT-P), and Borderline Personality Disorder Severity Index (BPDSI) were repeated at 6, 12, and 24 months. Statistical analysis was performed with the general linear model. Results showed that most of the differences between combined therapy and single pharmacotherapy at the end of the 32 weeks trial were maintained after 24 months follow-up. The addition of IPT-BPD to medication produced greater effects on BPD symptoms (impulsivity and interpersonal relationships) and quality of life (perception of psychological and social functioning) that endured after termination of psychotherapy. On the contrary, different effects on anxiety symptoms and affective instability were lost after 6 months.

Change in interpersonal functioning during psychological interventions for borderline personality disorder—a systematic review of measures and efficacy

OBJECTIVE

To provide a systematic review of measures of interpersonal functioning used in treatments for people diagnosed with borderline personality disorder (BPD) and to report the effectiveness of treatments on these measures of interpersonal functioning.

METHOD

Literature was reviewed using the online databases and reference lists of previous systematic reviews. Selected studies were randomized controlled trials (RCTs) that examined psychotherapeutic interventions for people with BPD and contained quantitative outcomes on various aspects of interpersonal functioning and reported their results in peer-reviewed journals. Reliability and validity of the results were evaluated.

RESULTS

Nineteen RCTs met our inclusion criteria. We found 16 different (sub)scales that measured some aspect of interpersonal functioning. Only four instruments were used by more than one research team. There is some evidence that psychotherapeutic interventions have beneficial effects on some aspects of interpersonal functioning in people diagnosed with BPD, both after individual and group therapy. Generalizability of these findings is limited.

CONCLUSION

There is preliminary evidence that psychotherapeutic interventions have beneficial effects on various aspects of interpersonal reactivity that characterize people diagnosed with BPD. However, none of these effects have a robust evidence base. There are serious concerns about the lack of agreed-upon concepts and instruments.

Combined treatment of borderline personality disorder with interpersonal psychotherapy and pharmacotherapy: predictors of response

Borderline personality disorder (BPD) is characterized by affective instability, impulsive behaviors, and disturbed interpersonal relationships. A previous study of our group found that combined therapy with interpersonal psychotherapy adapted to BPD (IPT-BPD) and fluoxetine was superior to single pharmacotherapy in BPD patients. The aim of the present study was to examine what clinical factors predicted response to combined therapy in patients evaluated in the previous efficacy study. The subgroup of 27 patients allocated to combined therapy was analyzed. Patients were treated for 32 weeks with fluoxetine 20-40 mg/day plus IPT-BPD. Patients were assessed at baseline and week 32 with an interview for demographic and clinical variables, CGI-S, HDRS, HARS, SOFAS, BPDSI, and SAT-P. Statistical analysis was performed with multiple regression. The difference of CGI-S score between baseline and week 32 (∆CGI-S) was the dependent variable. Factors significantly and independently related to ∆CGI-S were the BPDSI total score and the items abandonment, affective instability, and identity. Patients with more severe BPD psychopathology and with a higher degree of core symptoms such as fear of abandonment, affective instability, and identity disturbance have a better chance to improve with combined therapy with fluoxetine and IPT-BPD.

Pharmacotherapy for borderline personality disorder--current evidence and recent trends

Drug treatment of patients with borderline personality disorder (BPD) is common but mostly not supported by evidence from high-quality research. This review summarises the current evidence up to August 2014 and also aims to identify research trends in terms of ongoing randomised controlled trials (RCTs) as well as research gaps. There is some evidence for beneficial effects by second-generation antipsychotics, mood stabilisers and omega-3 fatty acids, while the overall evidence base is still unsatisfying. The dominating role SSRI antidepressants usually play within the medical treatment of BPD patients is neither reflected nor supported by corresponding evidence. Any drug treatment of BPD patients should be planned and regularly evaluated against this background of evidence. Research trends indicate increasing attention to alternative treatments such as dietary supplementation by omega-3 fatty acids or oxytocin.

Psychiatrists' and psychologists' practice patterns: different profiles in a Spanish clinical sample

Important differences in clinical practice exist between psychiatrists and psychologists. However, there is scarce information on the characteristics of patients receiving treatment from these two groups of professionals. We examined the diagnoses assigned to the patients who received treatment from psychiatrists and psychologists in outpatient settings of Madrid, Spain, from 1980 to 2008. The psychologists were more likely to see anxiety-related disorders, whereas the psychiatrists tended to see disorders with a more prominent biological underpinning, such as schizophrenia or bipolar disorder. The profile of the patients seen by the psychologists is different from that of the psychiatrists. Disorders whose development is more related to distress were usually treated by the psychologists, whereas disorders with a more prominent biological underpinning were usually treated by the psychiatrists. In addition, the dramatic increase in the diagnosis of adjustment disorder might be related to the increasing "psychologization" and "medicalization" of the difficulties of everyday life.

Treatment of borderline personality disorder and co-occurring anxiety disorders

Anxiety disorders are highly prevalent among individuals with borderline personality disorder, with comorbidity rates of up to 90%. Anxiety disorders have been found to reduce the likelihood of achieving remission from borderline personality disorder over time and to increase the risk of suicide and self-injury in this population. Evidence-based treatments for borderline personality disorder have not sufficiently focused on targeting anxiety disorders, and their effects on these disorders are either limited or unknown. Conversely, evidence-based treatments for anxiety disorders typically exclude suicidal, self-injuring, and seriously comorbid patients, thereby limiting their generalizability to individuals with borderline personality disorder. To address these limitations, recent research has begun to emerge focused on developing and evaluating treatments for individuals with co-occurring borderline personality disorder and anxiety disorders, specifically posttraumatic stress disorder (PTSD), with promising initial results. However, there is a need for additional research in this area, particularly studies evaluating the treatment of anxiety disorders among high-risk and complex borderline personality disorder patients.

Borderline personality disorder and depression: an update

To review the literature related to recent temperamental and biological findings on borderline personality disorder (BPD) and major depression, the close link between the two disorders, and the latest therapeutical findings on BPD, focusing on the conditions of co-morbidity between depression and BPD. The National Institutes of Health's PubMed database was used to identify indexed studies on BPD, depression and the co-morbidity between the two. Only studies published between 2000 and 2011 were assessed. Similar temperamental features have been demonstrated in BPD and depression. The strong link between the two disorders seems to be widely recognized by scientific community. Psychotherapy and new antipsychotics are the topics of current major interest of research. The therapeutic targets in the case of co-morbidity are BPD features associated with depressive symptoms, thus influencing prognosis. A global assessment is, in fact, fundamental for a successful therapy for the treatment of the several aspects of a complex psychopathological phenomenon.

Psychological therapies for people with borderline personality disorder

BACKGROUND

Psychotherapy is regarded as the first-line treatment for people with borderline personality disorder. In recent years, several disorder-specific interventions have been developed. This is an update of a review published in the Cochrane Database of Systematic Reviews in 2006.

OBJECTIVES

To assess the effects of psychological interventions for borderline personality disorder (BPD).

SEARCH METHODS

We searched the following databases: CENTRAL 2010(3), MEDLINE (1950 to October 2010), EMBASE (1980 to 2010, week 39), ASSIA (1987 to November 2010), BIOSIS (1985 to October 2010), CINAHL (1982 to October 2010), Dissertation Abstracts International (31 January 2011), National Criminal Justice Reference Service Abstracts (15 October 2010), PsycINFO (1872 to October Week 1 2010), Science Citation Index (1970 to 10 October 2010), Social Science Citation Index (1970 to 10 October 2010), Sociological Abstracts (1963 to October 2010), ZETOC (15 October 2010) and the metaRegister of Controlled Trials (15 October 2010). In addition, we searched Dissertation Abstracts International in January 2011 and ICTRP in August 2011.

SELECTION CRITERIA

Randomised studies with samples of patients with BPD comparing a specific psychotherapeutic intervention against a control intervention without any specific mode of action or against a comparative specific psychotherapeutic intervention. Outcomes included overall BPD severity, BPD symptoms (DSM-IV criteria), psychopathology associated with but not specific to BPD, attrition and adverse effects.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, assessed the risk of bias in the studies and extracted data.

MAIN RESULTS

Twenty-eight studies involving a total of 1804 participants with BPD were included. Interventions were classified as comprehensive psychotherapies if they included individual psychotherapy as a substantial part of the treatment programme, or as non-comprehensive if they did not.Among comprehensive psychotherapies, dialectical behaviour therapy (DBT), mentalisation-based treatment in a partial hospitalisation setting (MBT-PH), outpatient MBT (MBT-out), transference-focused therapy (TFP), cognitive behavioural therapy (CBT), dynamic deconstructive psychotherapy (DDP), interpersonal psychotherapy (IPT) and interpersonal therapy for BPD (IPT-BPD) were tested against a control condition. Direct comparisons of comprehensive psychotherapies included DBT versus client-centered therapy (CCT); schema-focused therapy (SFT) versus TFP; SFT versus SFT plus telephone availability of therapist in case of crisis (SFT+TA); cognitive therapy (CT) versus CCT, and CT versus IPT.Non-comprehensive psychotherapeutic interventions comprised DBT-group skills training only (DBT-ST), emotion regulation group therapy (ERG), schema-focused group therapy (SFT-G), systems training for emotional predictability and problem solving for borderline personality disorder (STEPPS), STEPPS plus individual therapy (STEPPS+IT), manual-assisted cognitive treatment (MACT) and psychoeducation (PE). The only direct comparison of an non-comprehensive psychotherapeutic intervention against another was MACT versus MACT plus therapeutic assessment (MACT+). Inpatient treatment was examined in one study where DBT for PTSD (DBT-PTSD) was compared with a waiting list control. No trials were identified for cognitive analytical therapy (CAT).Data were sparse for individual interventions, and allowed for meta-analytic pooling only for DBT compared with treatment as usual (TAU) for four outcomes. There were moderate to large statistically significant effects indicating a beneficial effect of DBT over TAU for anger (n = 46, two RCTs; standardised mean difference (SMD) -0.83, 95% confidence interval (CI) -1.43 to -0.22; I(2) = 0%), parasuicidality (n = 110, three RCTs; SMD -0.54, 95% CI -0.92 to -0.16; I(2) = 0%) and mental health (n = 74, two RCTs; SMD 0.65, 95% CI 0.07 to 1.24 I(2) = 30%). There was no indication of statistical superiority of DBT over TAU in terms of keeping participants in treatment (n = 252, five RCTs; risk ratio 1.25, 95% CI 0.54 to 2.92).All remaining findings were based on single study estimates of effect. Statistically significant between-group differences for comparisons of psychotherapies against controls were observed for BPD core pathology and associated psychopathology for the following interventions: DBT, DBT-PTSD, MBT-PH, MBT-out, TFP and IPT-BPD. IPT was only indicated as being effective in the treatment of associated depression. No statistically significant effects were found for CBT and DDP interventions on either outcome, with the effect sizes moderate for DDP and small for CBT. For comparisons between different comprehensive psychotherapies, statistically significant superiority was demonstrated for DBT over CCT (core and associated pathology) and SFT over TFP (BPD severity and treatment retention). There were also encouraging results for each of the non-comprehensive psychotherapeutic interventions investigated in terms of both core and associated pathology.No data were available for adverse effects of any psychotherapy.

AUTHORS' CONCLUSIONS

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. DBT has been studied most intensely, followed by MBT, TFP, SFT and STEPPS. 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.

Psicoterapia interpessoal no tratamento da perturbação depressiva maior

A terapia interpessoal é um modelo de terapia breve formulado para o tratamento da perturbação depressiva maior, tendo como precursores Gerald Klerman e Mirna Weissman. Esta visa o alívio dos sintomas associados à depressão abordando os problemas interpessoais que os originaram e perpetuam. Esta modalidade de terapia refere as perturbações como resultantes da existência de problemas numa das quatro áreas interpessoais principais: luto, transição de papéis, disputas de papéis interpessoais e défices interpessoais. Deste modo, a terapia incidirá na área afectada. Esta demonstra bons indicadores de eficácia e apesar de formulada para o tratamento da depressão, a terapia interpessoal tem sido adaptada e expandida a outras perturbações.

The role of personality pathology in depression treatment outcome with psychotherapy and pharmacotherapy

BACKGROUND

Depressed patients with comorbid personality pathology may fare worse in treatment for depression than those without this additional pathology, and comorbid personality pathology may be associated with superior response in one form of treatment relative to another, though recent findings have been mixed. We aimed to evaluate the effect of personality pathology on time to remission of patients randomly assigned to 1 of 2 treatment strategies for depression and to determine whether personality pathology moderated the effect of treatment assignment on outcome.

METHOD

Individuals undergoing an episode of unipolar major depression (n = 275) received interpersonal psychotherapy (Klerman, Weissman, Rounsaville, & Chevron, 1984) or selective serotonin reuptake inhibitor (SSRI) pharmacotherapy for depression. Depressive symptoms were measured with the HRSD-17. Remission was a mean HRSD-17 score of 7 or below over a period of 3 weeks. Personality disorders were measured according to SCID-II diagnoses, and personality pathology was measured dimensionally by summing the positive probes on the SCID-II.

RESULTS

The presence of at least 1 personality disorder was not a significant predictor of time to remission, but a higher level of dimensionally measured personality pathology and the presence of borderline personality disorder were associated with a longer time to remission. Personality pathology did not moderate the effect of treatment assignment on time to remission.

CONCLUSIONS

The findings suggest that depressed individuals with comorbid personality pathology generally fare worse in treatment for depression, although in this report, the effect of personality pathology did not differ by the type of treatment received.

Interpersonal psychotherapy for borderline personality disorder

This paper outlines an approach to the treatment of borderline personality disorder (BPD) based on principles of interpersonal psychotherapy. The rationale for using a modified version of interpersonal psychotherapy (IPT) is described-BPD is a disorder of attachment, depression is commonly associated with BPD and the primary symptoms of BPD such as rapid mood fluctuations, impulsivity and cognitive distortions are manifested within interpersonal relationships. A focus on interpersonal dysfunction between self and others may improve the quality of relationships for these patients and improve their capacity to manage the instability engendered by depressed mood. It is argued that the normal structure of IPT meets the basic requirements of any psychotherapy for BPD but that the current four foci of IPT are inadequate to address the complexity of the problems of the person with BPD. A case is made to extend the focal areas of IPT to increase the specificity of treatment tailoring it to the core pathology of the disorder. It is suggested that consideration of regulation of the self within interpersonal interactions becomes the primary focus for treatment.

KEY PRACTITIONER MESSAGE

Borderline personality disorder is manifested through problems on interpersonal relationships. Interpersonal psychotherapy may be a useful treatment for BPD. Interpersonal psychotherapy uses a focus for treatment. A new focus of problems of self/other regulation is suggested. Further research is needed to determine if this approach is effective.

State of the art in the pharmacologic treatment of borderline personality disorder

This article reviews the most recent studies of the pharmacologic treatment of borderline personality disorder (BPD). Although research continues using randomized controlled trials with a placebo arm as well as active medication, meta-analyses and systematic reviews have revealed that the use of any specific medication or medication class in BPD remains at best uncertain and inconclusive. Studies indicate that the selective serotonin reuptake inhibitors have fallen out of favor, and researchers have turned their attention to the study of mood stabilizers and atypical antipsychotics. Thus, it is not surprising that trends in prescribing appear to be shifting toward the use of these two classes over the selective serotonin reuptake inhibitors; yet we remain without any medication that has a specific indication for treatment of BPD or an indication for any symptom that is seen as part of the BPD syndrome.