Psychological therapies for people with borderline personality disorder

Ole Jakob Storebø, Jutta M Stoffers-Winterling, Birgit A Völlm, Mickey T Kongerslev, Jessica T Mattivi, Mie S Jørgensen, Erlend Faltinsen, Adnan Todorovac, Christian P Sales, Henriette E Callesen, Klaus Lieb, Erik Simonsen, Ole Jakob Storebø, Jutta M Stoffers-Winterling, Birgit A Völlm, Mickey T Kongerslev, Jessica T Mattivi, Mie S Jørgensen, Erlend Faltinsen, Adnan Todorovac, Christian P Sales, Henriette E Callesen, Klaus Lieb, Erik Simonsen

Abstract

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 We contacted researchers working in the field to ask for additional data from published and unpublished trials, and handsearched relevant journals.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.

Trial registration: ClinicalTrials.gov NCT01356069 NCT00378248 NCT00055315 NCT00481000 NCT03363230 NCT00131781 NCT00538135 NCT00714311 NCT02397031 NCT00145678 NCT01896024 NCT00494650 NCT00183651 NCT00154154 NCT00675129 NCT02033044 NCT01904227 NCT00533117 NCT01719731 NCT01512602 NCT00360399 NCT01342809 NCT00736918 NCT02272179 NCT00521417 NCT03498937 NCT00603421 NCT01531634 NCT01823120 NCT02068326 NCT02125942 NCT02126787 NCT02134223 NCT02387736 NCT02517723 NCT02685943 NCT02771691 NCT02985047 NCT02991586 NCT03011190 NCT03092271 NCT03185026 NCT03191565 NCT03297840 NCT03376113 NCT03418142 NCT03677037 NCT03833453.

Conflict of interest statement

Jutta M Stoffers‐Winterling is a board‐certified psychologist, who has worked on a dialectical behaviour therapy (DBT) ward, and attended courses on DBT and schema‐focused therapy (SFT).

Ole Jakob Storebø (OJS) is an Editor with Cochrane Developmental, Psychosocial and Learning Problems (CDPLP). He is involved in a trial investigating group mentalisation‐based treatment (MBT) for adolescents with borderline personality disorder (BPD). This trial is included in the review as an ongoing study. OJS was not involved in the evaluation of this trial. The assessment of eligibility of the trial was done by Erlend Faltinsen and Adnan Todorovac.

Jessica T Mattivi's institution received a grant from the German Federal Ministry of Education and Research for a systematic review on psychosocial interventions for self‐harm in adolescents and a systematic review on pharmacological and non‐pharmacological interventions for post‐operative delirium in older patients.

Birgit A Völlm ‒ none known.

Mickey Kongerslev is a certified specialist in psychotherapy from the Danish Psychological Association. He has received training in group analysis, cognitive behavioural therapy, and MBT. He received money, from private and public agencies, for teaching MBT for BPD, including supervising psychologists under training to becoming licenced 'special psykolog' certified by the Danish National Health Authorities, and has published scientific articles together with the developers of this treatment. He also receives money for teaching and supervision in assessment and management of personality disorder.

Mie Poulsgaard Jørgensen (MPJ) is a trained DBT therapist and currently conducting a trial on group MBT for adolescents with BPD. This trial is included in the review as an ongoing study. MPJ was not involved in the evaluation of this trial. The assessment of eligibility of the trial was done by Erlend Faltinsen and Adnan Todorovac.

Henriette Edemann Callesen ‐ none known.

Adnan Todorovac ‐ none known.

Christian Sales ‐ none known.

Erlend Faltinsen ‒ none known.

Klaus Lieb (KL) is an Editor with CDPLP. He is a board‐certified cognitive behaviour therapist with a special interest in schema therapy. KL has been involved in trials investigating inpatient DBT (Bohus 2004); and inpatient SFT (Reiss 2014). He was not involved in the evaluation of these trials (Bohus 2004: Jutta M Stoffers‐Winterling and Birgit A Völlm did eligibility assessments for the previous version of this review; Reiss 2014: Signe Sofie Nielsen and Mickey Kongerslev did the eligibility assessment for this study for the current review).

Erik Simonsen is a board‐certified therapist in group analysis.