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Outpatient Psychotherapy May Be Helpful for Borderline Personality Disorder

Laurie Barclay, MD

Medscape Medical News 2006. © 2006 Medscape

October 23, 2006 — Patients with borderline personality disorder (BPD) had improved quality of life and reduced dysfunction after 3 years of 2 outpatient psychotherapy treatments, according to the results of a multicenter, randomized study reported in the June issue of the Archives of General Psychiatry.

"Borderline personality disorder is a severe and chronic psychiatric condition, prevalent throughout health care settings," write Josephine Giesen-Bloo, MSc, from the Academic Hospital Maastricht in the Netherlands, and colleagues. "Only limited effects of current treatments have been documented.... We compared the effectiveness of 2 prolonged outpatient treatments that aim at achieving full recovery from BPD: schema-focused therapy (SFT)13-15 and transference-focused psychotherapy (TFP)."

The authors describe schema-focused therapy as an integrative cognitive therapy, and TFP as a psychodynamically based psychotherapy, with both treatments intended to result in a structural change in the patient's personality.

At 4 general community mental health centers, 88 patients with a Borderline Personality Disorder Severity Index, fourth version (BPDS), score greater than a predetermined cutoff score underwent 3 years of either SFT or TFP with sessions twice weekly. The primary end points were BPDS score, quality of life, general psychopathologic dysfunction, and measures of SFT/TFP personality concepts. Patients were evaluated before randomization and then every 3 months for 3 years. Data were available for 44 patients randomized to SFT and for 42 patients randomized to TFP.

Both groups had similar sociodemographic and clinical characteristics at baseline. Survival analyses revealed a higher risk of dropout for TFP patients than for SFT patients (P = .01). Intention-to-treat analysis showed statistically and clinically significant improvements for both treatments on all measures after 1-, 2-, and 3-year treatment periods.

After 3 years of treatment, survival analyses showed that significantly more SFT patients recovered (relative risk = 2.18; P = .04) or showed reliable clinical improvement (relative risk = 2.33; P = .009) on the BPDS. Robust analysis of covariance (ANCOVA) revealed that the SFT group also improved more in general psychopathologic dysfunction and measures of SFT/TFP personality concepts (P < .001), and that they had greater increases in quality of life than did TFP patients (robust ANCOVAs, P = .03 and P < .001).

"Three years of SFT or TFP proved to be effective in reducing borderline personality disorder–specific and general psychopathologic dysfunction and measures of SFT/TFP concepts and in improving quality of life; SFT is more effective than TFP for all measures," the authors write. "Schema-focused therapy had a significantly lower attrition rate than TFP. However, both treatments demonstrate that patients with BPD can be motivated for and continue prolonged outpatient treatment."

Study limitations include incomplete blinding of most research assistants and study psychiatrists, and the absence of a natural-course control group.

"This study contributes to a positive treatment perspective for BPD by lending support to SFT as a valid evidence-based practice," the authors conclude. "However, straightforward recommendations for clinical practice cannot and should not be made on the basis of only 1 effectiveness study.... Future research needs to identify factors that facilitate optimal treatment indication."

The Dutch Health Care Insurance Board funded this research, and the Dutch National Fund of Mental Health supported central training of the therapists.

Arch Gen Psychiatry. 2006;63:649-658.
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