Talking treatments are a key component of the therapy offered to people with borderline personality disorder and there are now a number of studies that point to the importance of these interventions for this complex and hard to manage condition.
A new randomised controlled trial conducted by a research team from the Centre for Addiction and Mental Health in Toronto looks at the impact that dialectical behaviour therapy and general psychiatric management can have on borderline personality disorder (BPD).
The authors randomised 180 adults with a DSM-IV diagnosis of BPD (86% female, 65% unemployed, mean age 30 years old). The trial participants had all tried to kill themselves or self-harmed at least twice in the last 5 years, with the most recent episode in the last 3 months.
People were excluded if they had:
- A diagnosis of bipolar disorder, dementia, delirium or learning disabilities
- Abused substances in the last month
- Been into hospital with another serious medical condition in the following year
The trial participants were randomised to one of two treatments:
- Dialectical behaviour therapy (DBT) – a talking therapy based on CBT that aims to balance ‘acceptance techniques’ with ‘change techniques’
- General psychiatric management (GPM) – psychodynamic psychotherapy, case management and drug therapy
It was unclear whether randomisation was adequately concealed, but outcome assessors were blinded to treatment.
Patients attended weekly therapy sessions for 1 year and were then followed-up for 2 more years (so called naturalistic follow-up). There was a significant loss to follow-up over the total 3 year period with 48% of participants completing all 4 assessments.
The main outcomes of interest were self-reported suicide and self-harm, BPD remission, use of healthcare services, general symptoms and functioning, depression, anger, interpersonal functioning and quality of life.
Here’s what they found:
- Suicide attempts were reduced in both groups:
- Dialectical behaviour therapy (DBT) – from 39.3% to 10.1%
- General psychiatric management (GPM) – from 37.5% to 6.6%
- After 2 years of follow-up these reductions were maintained and suicide attempts did not differ between the groups
- Self-harm rates also fell:
- DBT – from 84.3% to 47.8%
- GPM – 87.5% to 44.7%
- After 2 years of follow-up these reductions were maintained and self-harm rates were similar between the groups
- Remission rates were similar after 2 years of follow-up:
- DBT – 57%
- GPM – 68%
- However, the treatments appeared to have little impact on employment or disability benefit rates. Ater 2 years of follow-up:
- 53% were unemployed or not in school
- 39% were receiving psychiatric disability support
The authors concluded:
One year of either dialectical behaviour therapy or general psychiatric management was associated with long-lasting positive effects across a broad range of outcomes. Despite the benefits of these specific treatments, one important finding that replicates previous research is that participants continued to exhibit high levels of functional impairment. The effectiveness of adjunctive rehabilitation strategies to improve general functioning deserves additional study.
McMain SF, Guimond T, Streiner DL, Cardish RJ, Links PS. Dialectical behavior therapy compared with general psychiatric management for borderline personality disorder: clinical outcomes and functioning over a 2-year follow-up. Am J Psychiatry. 2012 Jun;169(6):650-61. doi: 10.1176/appi.ajp.2012.11091416. [PubMed abstract]