Psychiatr News January 19, 2007
Volume 42, Number 2, page 26
© 2007 American Psychiatric Association
Psychotherapy for BPD Gets Growing Evidence Base
Mark Moran
Schema therapy, which has been described as "CBT with a
psychodynamic component," is the newest of the psychotherapies for
borderline personality disorder.
Psychotherapy is emerging
in randomized, controlled trials within the last year as the most effective
treatment for borderline personality disorder (BPD).
| |
Joel Paris, M.D.: "The field is coming into its own because we are
doing randomized, controlled trials to determine what actually
works."
David Hathcox
|
|
Several forms of psychotherapy— including dialectical-behavioral
therapy (DBT), cognitive-behavioral therapy (CBT), transference-focused
therapy, and mentalization-based therapy—have been found effective for
BPD and have been or are being replicated.
All of the psychotherapies proving successful for BPD strive to address
underlying deficits in the ability of patients to relate to others and manage
emotions, longstanding problems that are typically rooted in childhood
experience.
In 2006 effectiveness of DBT was replicated in a study in the July 2006
Archives of General Psychiatry, and transference-focused therapy was
proven effective in a study published in the February 2006 Journal of
Clinical Psychology. A replication of early studies of
mentalization-focused therapy is ongoing in an outpatient setting.
Schema therapy, the newest innovation integrating elements of several
psychotherapies for BPD, was found highly effective in a first randomized,
controlled trial, reported in the August 2006 Archives of General
Psychiatry.
Experts say the new crop of trials has propelled the field into the era of
evidence-based medicine.
"The field is coming into its own because we are doing randomized,
controlled trials to determine what actually works," Joel Paris, M.D.,
told Psychiatric News. "In the past we were dependent on the
charisma of therapeutic gurus."
Paris is a professor and chair of the Department of Psychiatry at McGill
University in Montreal and editor in chief of the Canadian Journal of
Psychiatry. He is also a past president of the Association for Research
in Personality Disorders.
He said there is no consensus about whether one therapy is any better than
the others, though DBT has been around the longest and is widely taught.
"Most patients are probably receiving a mix of eclectic
therapies," Paris said.
DBT Targets Dangerous Behaviors
In the July Archives report on DBT, patients received either DBT
or treatment by community experts. The latter were therapists who were
experienced in the treatment of BPD but used methods other than DBT to treat
randomly assigned patients.
Subjects receiving DBT were half as likely to make a suicide attempt,
required fewer hospitalizations for suicide ideation, and had lower medical
risk across all suicide attempts and self-injurious acts combined. They were
also less likely to drop out of treatment and had fewer psychiatric
hospitalizations and psychiatric emergency department visits, according to the
report.
An abstract of the he study, "Two-Year Randomized Controlled Trial
and Follow-Up of Dialectical Behavior Therapy vs. Therapy by Experts for
Suicidal Behaviors and Borderline Personality Disorder," is posted at
<http://archpsyc.ama-assn.org/cgi/content/abstract/63/7/757>.
Developed by Marcia Linehan, Ph.D., of the Department of Psychology at the
University of Washington, DBT directly targets suicidal and other dangerous,
severe, or destabilizing behaviors. Standard DBT strives to increase
behavioral capabilities, improve motivation for skillful behavior through
management of issues and problems as they come up in day-to-day life and
reduction of interfering emotions and cognitions, and structure the treatment
environment so that it reinforces functional rather than dysfunctional
behaviors.
Therapy consists of weekly individual psychotherapy, group skills training,
telephone consultation, and weekly meetings between therapist and a
consultation team to enhance therapist motivation and skills and to provide
therapy for the therapists.
Mentalization-based therapy, pioneered by Andrew Bateman, M.A., and Peter
Fonagy, Ph.D., seeks to facilitate the capacity for
"mentalization"—the ability to perceive the mind of others
as distinct from one's own and hence to reconsider and reassess one's own
perceptions of reality. Transference-focused psychotherapy, championed by Otto
Kernberg, M.D., among others, is an adaptation of psychoanalysis that aims to
correct distortions in the patient's perception of significant others and of
the therapist.
Schema Therapy Builds on CBT
Schema therapy, the newest of the psychotherapies for BPD, appears to
synthesize elements of several successful therapies. Paris has described it as
"CBT with a psychodynamic component."
Schema therapy founder Jeffrey Young, Ph.D., who is on the faculty of the
Department of Psychiatry at Columbia University College of Physicians and
Surgeons, was one of the first students of Aaron Beck, M.D., the founder of
cognitive therapy.
"I found that cognitive therapy was extremely effective with many
Axis I disorders, as research has since substantiated, but was much less
effective by itself with Axis II personality disorders," he told
Psychiatric News. "I began to look for ways to expand
cognitive-behavior therapy to work with Axis II issues by integrating elements
drawn from other approaches as well as CBT, including psychodynamic therapies
such as object relations, emotion-focused/gestalt therapies, and attachment
theory."
Young described schema therapy as an active, structured therapy for
assessing and changing deep-rooted psychological problems by looking at
repetitive life patterns and core life themes, called "schemas."
Schema therapists use an inventory to assess the schemas that cause persistent
problems in a patient's life.
"Once we have determined what schemas a patient has, we use a range
of techniques for changing these schemas," Young said. "These
include cognitive restructuring, limited re-parenting, changing schemas as
they arise in the therapy relationship, intensive imagery work to access and
change the source of schemas, and creating dialogues between the `schema,' or
dysfunctional, side of patients and the healthy side."
He added that systematic behavioral techniques are also employed to change
dysfunctional coping styles, especially maladaptive behaviors in intimate
relationships.
More information about schema therapy is posted at
<www.schematherapy.com>.
In a randomized trial of schema therapy versus transference-focused therapy
published in the Archives in June 2006, statistically and clinically
significant improvements were found for both treatments on all measures after
one, two, and three-year treatment periods. Data on 44 schema therapy patients
and 42 transference-focused therapy patients were available.
Main outcome measures included scores on the Borderline Personality
Disorder Severity Index, quality of life, and general psychopat hologic dysf
unction. Patient assessments were made before randomization and then every
three months for three years.
Significantly more schema therapy patients fully recovered (46 percent
versus 26 percent) or showed reliable clinical improvement (66 percent versus
33 percent) on the Borderline Personality Disorder Severity Index than
patients receiving transference-focused therapy. They also improved more in
general psychopathologic dysfunction and showed greater increases in quality
of life.
Statistical analysis also revealed a higher dropout risk among
transference-focused therapy (52 percent) patients than among patients
receiving schema therapy (29 percent), according to the study report.
The report, "Outpatient Psychotherapy for Borderline Personality
Disorder: Randomized Trial of Schema-Focused Therapy vs. Transference-Focused
Psychotherapy," is posted at
<http://archpsyc.ama-assn.org/cgi/content/abstract/63/6/649>.
"This is the first controlled study demonstrating that a treatment is
capable of reducing all of the BPD manifestations as defined by
DSM-IV, reduces associated personality features and general
psychopathology, and increases quality of life," study co-author Arnoud
Arntz, Ph.D., told Psychiatric News.
He is with the Department of Medical, Clinical, and Experimental Psychology
at the University of Maastricht, in the Netherlands.
The authors also stated that, in a separate analysis, schema therapy was
found to be highly cost-effective for society, despite the length and
intensity of the treatment.
Young, who was not involved in the study, said it is the first to
demonstrate "deep personality change" in a high percentage of
patients long considered untreatable.
"Up until now, existing therapies for BPD have proven to lead to only
partial recovery or have only been able to reduce self-harming
behaviors," he said. "This should be of great interest to
psychiatrists because patients with BPD are usually considered the most
difficult, frustrating, and risky patients within most therapists'
practices.
"The second important implication for psychiatrists is that the use
of a neutral stance toward the BPD patient, which is advocated in most
psychody namic approaches to BPD, is clearly much less effective than the more
engaged, warm, and nurturing stance of schema therapy," Young said.
"This was demonstrated by the dramatic differences in dropout rates
between the two treatments."
Despite their proven effectiveness, all of the psychotherapies for BPD are
time and labor intensive.
"All suffer from the need for highly trained therapists, specialized
settings, human resources, and time," Paris told Psychiatric
News. "There are many barriers to psychotherapy for BPD. Most
involve money, since only a small number of these patients can pay, and few
have adequate insurance. Another barrier is the failure of psychiatrists and
other professionals to recognize and diagnose BPD. Still another is the
current tendency to treat BPD with medication alone."
Paris said in an address at APA's annual meeting last year in Toronto that
drugs were vastly overused in treatment of all the personality disorders
(Psychiatric News, July 7, 2006).
"The problem is that there is no science to support polypharmacy, and
it's probably bad for patients," he said at the meeting. "When you
give patients with classical depression an antidepressant, they may be cured
in a few weeks. But you never see that in patients with borderline
personality. It might take the edge off, but patients never go into
remission." 
Get information about faster international access.
Privacy Policy
Copyright © 2007
American Psychiatric Association.
All rights reserved.
Home
| Search
| Current Issue
| Past Issues
| Subscribe
| All APPI Journals
| Help
| Contact Us
| 
