Experts Discuss Evidence-Based Psychotherapies for Borderline Personality Disorder

Increasing lines of evidence demonstrate the effectiveness of psychotherapy as the primary, core treatment for borderline personality disorder (BPD), said past APA President John Oldham, M.D., and four other panel members in the symposium “Evidence-Based Psychotherapies for BPD” at APA’s 2014 annual meeting.

But since then, he said, randomized, controlled trials have shown that other forms of psychotherapy also are effective for BPD, including transference-focused psychotherapy (TFP), schema-based therapy (SBT), cognitive-behavioral therapy (CBT), general psychiatric management (GPM), and many others. In 2009, the United Kingdom National Institute for Health and Clinical Excellence published a guideline on the treatment of BPD, endorsing the recommendation of psychotherapy for BPD, as did similar guidelines developed in the Netherlands (2008) and Germany (2009).

Additionally, in 2013, the National Health and Medical Research Council of the Australian government published a clinical practice guideline for management of BPD in which it recommended DBT, MBT, TFP, CBT, SBT, and other forms of psychotherapy, such as manual-assisted cognitive therapy (MACT).

At the annual meeting symposium, Peter Fonagy, Ph.D., of the Research Department of Clinical, Educational, and Health Psychology at University College London, discussed randomized and nonrandomized controlled and correlational studies that provide the evidence base for MBT. A number of studies suggest that, on balance, MBT is effective beyond generic psychological therapies in the treatment of BPD, but Fonagy said there are limitations to its effectiveness and to the evaluation studies that have been reported.

“We urgently need independent replication of [randomized, controlled trials] not involving the developers and further evidence that the treatment works for the reasons suggested by the originators of the approach,” he said. “More generally, other evidence-based treatments for BPD may involve a mentalization component, and evaluating changes in mentalizing associated with the implementation of these protocols may be important.”

John Clarkin, Ph.D., a clinical professor of psychology in psychiatry at Weill Medical College of Cornell University, discussed transference-based psychotherapy. “TFP compares well with other treatments in reduction of symptoms and is superior to treatment by community therapists in treating individuals with borderline personality disorder,” he said. “In addition to reducing symptoms, TFP has been found to significantly increase reflective functioning and improve personality functioning. Our most recent research indicates that change in symptom domains in TFP is accompanied by changes in neurocognitive processes as measured by functional magnetic resonance imaging.”

Martin Bohus, M.D., of the Central Institute of Mental Health in Mannheim, Germany, discussed DBT. He said DBT was initially designed and evaluated as an outpatient treatment for women who are chronically suicidal, but has been adapted and extended for a range of pathological manifestations of emotion dysregulation.

John Gunderson, M.D., director of psychosocial and personality research at McLean Hospital, talked about “Good Psychiatric Management (GPM).” He identified the characteristics of GPM that overlap with other evidence-based treatments of BPD and elaborated on GPM’s distinctive characteristics. These include its theoretical model (interpersonal hypersensitivity) and establishing reasonable boundaries for expectations of change based on the disorder’s natural course and its significant heritability. “GPM offers a model of treatment to be used by all clinicians with the promise that it will be effective for the vast majority of BPD patients,” he said.

Oldham is co-editor of the American Psychiatric Publishing Textbook of Personality Disorders, Second Edition. APA members can purchase it at a discount here or at the annual meeting.