The DOI matches its Crossref record; 70 of the 72 references it cites were found in a registry or an index; none of the 27 sources its claims cite is checked for support yet.
Efficacy of Psychotherapies for Borderline Personality Disorder: A Systematic Review and Meta-analysis
Open accessAbstract
IMPORTANCE: Borderline personality disorder (BPD) is a debilitating condition, but several psychotherapies are considered effective. OBJECTIVE: To conduct an updated systematic review and meta-analysis of randomized clinical trials to assess the efficacy of psychotherapies for BPD populations. DATA SOURCES: Search terms were combined for borderline personality and randomized trials in PubMed, PsycINFO, EMBASE, and the Cochrane Central Register of Controlled Trials (from database inception to November 2015), as well as the reference lists of earlier meta-analyses. STUDY SELECTION: Included were randomized clinical trials of adults with diagnosed BPD randomized to psychotherapy exclusively or to a control intervention. Study selection differentiated stand-alone designs (in which an independent psychotherapy was compared with control interventions) from add-on designs (in which an experimental intervention added to usual treatment was compared with usual treatment alone). DATA EXTRACTION AND SYNTHESIS: Data extraction coded characteristics of trials, participants, and interventions and assessed risk of bias using 4 domains of the Cochrane Collaboration Risk of Bias tool (independent extraction by 2 assessors). Outcomes were pooled using a random-effects model. Subgroup and meta-regression analyses were conducted. MAIN OUTCOMES AND MEASURES: Standardized mean differences (Hedges g) were calculated using all outcomes reported in the trials for borderline symptoms, self-harm, suicide, health service use, and general psychopathology at posttest and follow-up. Differential treatment retention at posttest was analyzed, reporting odds ratios. RESULTS: Thirty-three trials (2256 participants) were included. For borderline-relevant outcomes combined (symptoms, self-harm, and suicide) at posttest, the investigated psychotherapies were moderately more effective than control interventions in stand-alone designs (g = 0.32; 95% CI, 0.14-0.51) and add-on designs (g = 0.40; 95% CI, 0.15-0.65). Results were similar for other outcomes, including stand-alone designs: self-harm (g = 0.32; 95% CI, 0.09-0.54), suicide (g = 0.44; 95% CI, 0.15-0.74), health service use (g = 0.40; 95% CI, 0.22-0.58), and general psychopathology (g = 0.32; 95% CI, 0.09-0.55), with no differences between design types. There were no significant differences in the odds ratios for treatment retention (1.32; 95% CI, 0.87-2.00 for stand-alone designs and 1.01; 95% CI, 0.55-1.87 for add-on designs). Thirteen trials reported borderline-relevant outcomes at follow-up (g = 0.45; 95% CI, 0.15-0.75). Dialectical behavior therapy (g = 0.34; 95% CI, 0.15-0.53) and psychodynamic approaches (g = 0.41; 95% CI, 0.12-0.69) were the only types of psychotherapies more effective than control interventions. Risk of bias was a significant moderator in subgroup and meta-regression analyses (slope β = -0.16; 95% CI, -0.29 to -0.03; P = .02). Publication bias was persistent, particularly for follow-up. CONCLUSIONS AND RELEVANCE: Psychotherapies, most notably dialectical behavior therapy and psychodynamic approaches, are effective for borderline symptoms and related problems. Nonetheless, effects are small, inflated by risk of bias and publication bias, and particularly unstable at follow-up.
Overview
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Written from the paper’s full text.
TL;DR
This updated systematic review and meta-analysis of 33 RCTs (2256 adults with BPD) found that psychotherapies produced small posttest benefits over control for borderline-relevant outcomes (all trials g=0.35; 95% CI, 0.20-0.50), with dialectical behavior therapy and psychodynamic approaches effective. Effects were attenuated by risk of bias and publication bias and became unstable/nonsignificant at follow-up after adjustment.
Key findings
- Across 33 trials (2256 participants), posttest borderline-relevant outcomes favored psychotherapy: stand-alone designs g=0.32 (95% CI, 0.14-0.51); add-on designs g=0.40 (95% CI, 0.15-0.65); all trials combined g=0.35 (95% CI, 0.20-0.50; 27 trials).
- In stand-alone designs, effects were significant for self-harm g=0.32 (95% CI, 0.09-0.54), suicide g=0.44 (95% CI, 0.15-0.74), health service use g=0.40 (95% CI, 0.22-0.58), and general psychopathology g=0.32 (95% CI, 0.09-0.55); treatment retention was not significantly different (OR, 1.32; 95% CI, 0.87-2.00 for stand-alone; OR, 1.01; 95% CI, 0.55-1.87 for add-on).
- Only DBT (g=0.34; 95% CI, 0.15-0.53) and psychodynamic approaches (g=0.41; 95% CI, 0.12-0.69) were significantly more effective than control; CBT (g=0.24; 95% CI, -0.01 to 0.49) and other interventions (g=0.38; 95% CI, -0.15 to 0.92) were not.
- Follow-up effects were significant across 13 trials (g=0.45; 95% CI, 0.15-0.75), but risk of bias moderated outcomes (slope β=-0.16; 95% CI, -0.29 to -0.03; P=.02), with low-RoB trials (3-4 domains) showing g=0.11 (95% CI, -0.12 to 0.35) versus g=0.48 (95% CI, 0.33-0.64) for 0-2 domains (P=.01); trim-and-fill reduced posttest g from 0.35 to 0.23 (95% CI, 0.07-0.38) and made follow-up nonsignificant (g=0.19; 95% CI, -0.15 to 0.53).
Methods
- Systematic review and meta-analysis of RCTs identified from PubMed, PsycINFO, EMBASE, and Cochrane Central Register of Controlled Trials (inception to November 2015) plus reference lists; included adults with diagnosed BPD randomized to psychotherapy exclusively or to a control intervention, excluding adolescent/partially adolescent samples, head-to-head comparisons of BPD-specific therapies, and trials with standardized combined medication protocols.
- Included 33 trials (2256 participants; 1169 treatment, 1087 control): 22 stand-alone and 11 add-on designs; DBT (12 trials), psychodynamic (8), CBT (5); control was TAU in 21 trials and manualized in 10; treatment developer was an author in 20 trials.
- Random-effects meta-analysis calculated Hedges g for outcome categories at posttest and follow-up, odds ratios for treatment retention, subgroup and meta-regression analyses, Cochrane risk-of-bias assessment across 4 domains, and publication-bias assessment via funnel plots, trim-and-fill, and Egger test.
Limitations
- Stated in the paper: some outcome categories or subgroups included few trials; 5 trials lacked data needed for effect-size calculation; most trials were not registered, so selective outcome reporting could not be rated; the search may have missed trials; therapies were grouped into broad categories, effacing subtler differences; schema-focused therapy was underrepresented; and adjunct medication use was neither standardized nor consistently reported.
- Stated in the paper: effects were small, inflated by publication bias, and particularly unstable at follow-up; effects were no longer sustained in trials with low risk of bias.
- Evident from the text: heterogeneity was moderate to high across many analyses (e.g., 70% for all-trial follow-up borderline-relevant outcomes and 79% for add-on follow-up), and several key findings rested on small numbers of trials, making some estimates tentative.
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Claims the paper makes
48 Own result · 15 Own method · 13 Not checked yet · 13 Own interpretation · 2 No basis given
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“health service use (g = 0.40; 95% CI, 0.22-0.58),”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Abstract
plaindirectn = 2,256- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“and 1.01; 95% CI, 0.55-1.87for add-on designs).”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Abstract
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
- Rests on an assumption: Treatment retention is a valid indicator of treatment acceptability or effectiveness.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“with no differences between design types.”
- Also stated in: § All Trials · plain
“There were no significant differences between the 2 design types on any of the symptom outcome categories or on treatment retention.”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Abstract
plainn = 2,256- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
- Also stated in: § All Trials · plain
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Thirty-three trials (2256 participants) were included.”
- Also stated in: § Selection and Inclusion of Studies · plain
“Consequently, 33 trials (2256 participants) met our inclusion criteria, and 28 of them had enough data for calculating effect sizes (eFigure 1 in the”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Abstract
plainn = 2,256- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
- Also stated in: § Selection and Inclusion of Studies · plain
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“suicide (g = 0.44; 95% CI, 0.15-0.74),”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Abstract
plaindirectn = 2,256- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“while CBT (g = 0.24; 95% CI, -0.01 to 0.49 [5 trials]) and other interventions (g = 0.38; 95% CI, -0.15 to 0.92 [6 trials]) were not.”
- Also stated in: § Discussion · plain
“Surprisingly, CBT was not superior to control conditions.”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Subgroup Analyses
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
- The authors state this as an assumption: Grouping different psychotherapies into broad categories yields meaningful and comparable efficacy estimates.
- Also stated in: § Discussion · plain
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“while CBT (g = 0.24; 95% CI, -0.01 to 0.49 [5 trials]) and other interventions (g = 0.38; 95% CI, -0.15 to 0.92 [6 trials]) were not.”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Subgroup Analyses
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
- The authors state this as an assumption: Grouping different psychotherapies into broad categories yields meaningful and comparable efficacy estimates.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“psychodynamic approaches (g=0.41;95% CI, 0.12-0.69)”
- Also stated in: § Subgroup Analyses · plain
“The DBT (g=0.34;95% CI, 0.15-0.53[9 trials]) and psychodynamic approaches (g=0.41;95% CI, 0.12-0.69[7 trials]) were more effective than control interventions”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Abstract
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
- The authors state this as an assumption: Grouping different psychotherapies into broad categories yields meaningful and comparable efficacy estimates.
- Also stated in: § Subgroup Analyses · plain
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“For add-on designs, 2 studies were imputed, resulting in a Hedges g of 0.30 (95% CI, 0.05-0.56).”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Publication Bias
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Risk of bias was a significant moderator in subgroup and meta-regression analyses (slope β = -0.16;95% CI,”
- Also stated in: § Meta-regression Analyses · plain
“Risk of bias (the number of criteria with low RoB) had a significant negative association with outcomes at posttest (slope β = -0.16;95% CI, -0.29 to -0.03; P = .02)(eFigure 5 in the Supplement).”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Abstract
plaincorrelationaln = 2,256 ·- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
- Rests on an assumption: The Cochrane risk-of-bias domains and the summed overall score adequately capture bias in psychotherapy trials.
- Also stated in: § Meta-regression Analyses · plain
- It may state two separate claims as one. 26
- Probably not a substantial claim. 8
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Follow-up results for all borderline-relevant outcomes showed significant medium effects for stand-alone designs and nonsignificant results for add-on designs.”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Discussion
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Results were not significant for self-harm and parasuicidal behavior or for health service use, but the number of trials was small (range, 3-6).”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Add-on Designs
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“There were 2 deaths by suicide in the treatment group and 5 deaths by suicide in the control group.The treatment group and the control group each had 6 all-cause deaths.”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Main Effects at Follow-up
plainn = 5- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“At followup, considering all trials, adjustment for missing studies (n = 3) led to a nonsignificant Hedges g of 0.19 (95% CI, -0.15 to 0.53), and Egger test was significant (intercept β = 2.78; 95% CI, 0.18-5.39;P = .04).”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Publication Bias
plaindirectn = 3 ·- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Dropout rates in the treatment group, treatment duration, treatment exposure in the treatment group or the control group, and difference in treatment exposure between groups were not significantly related to outcomes.”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Meta-regression Analyses
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Results showed significant effects for all outcome categories, ranging from 0.31 (0.04-0.57) for borderline symptoms to 0.44 (0.15-0.74) for suicide outcomes (Table 1).”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Main Effects at Posttest
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Six trials had a nonsignificant effect (g = 0.35; 95% CI, -0.15 to 0.85) for all borderline-relevant outcomes (Table 1).Heterogeneity was high (79%).”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Add-on Designs
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Seven trials had a significant effect of 0.56 (95% CI, 0.17-0.95)for all borderline-relevant outcomes (Table 1).Heterogeneity was high (62%).”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Stand-alone Designs
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Thirteen trials reported borderline-relevant outcomes at follow-up (g = 0.45; 95% CI, 0.15-0.75).”
- Also stated in: § All Trials · plain
“Combining both design types yielded a significant effect (g = 0.45; 95% CI, 0.15-0.75[13 trials]), with high heterogeneity (70%).”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Abstract
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
- Also stated in: § All Trials · plain
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Trials with an ad hoc control group developed as part of the study, trials in which the control intervention was manualized, or trials in which the study team was involved in treating the control group, as well trials with low RoB for 3 or 4 domains, generated nonsignificant between-group effects.”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Subgroup Analyses
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Nonetheless, the number of trials for some outcome categories was small, and these findings should be viewed as tentative and possibly spurious.”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Discussion
hedgedconditional- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“Interrater agreement κ statistics were computed (eMethods in the Supplement), and disagreement was resolved by discussion among assessors and with the senior author (P.C.).”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Key Points
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Heterogeneity was high, reflecting substantial differences in follow-up duration and type among trials, with some being naturalistic and others including booster interventions, which in some cases were intensive.”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Discussion
plaincorrelational- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“Studies were identified through searches in 4 bibliographical databases”
- Also stated in: § Identification and Selection of Studies · plain
“We also checked the reference lists of earlier meta-analyses.22,23”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Identification and Selection of Studies
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
- Also stated in: § Identification and Selection of Studies · plain
In the paper
“One meta-analysis 22 of DBT for BPD reported moderate effects for borderline-relevant outcomes, suicidality, and self-harm.However, analysis restricted to randomized clinical trials (RCTs) showed reduced effects, with nonsignificance for suicidality and self-harm.”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > B
What the sources say
- Not checked yetcites [22]
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“Trial risk of bias (RoB) was evaluated within 4 domains of the Cochrane Collaboration Risk of Bias tool, 26 which assesses sources of bias in RCTs.”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Risk of Bias and Data Extraction
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
- Rests on an assumption: The Cochrane risk-of-bias domains and the summed overall score adequately capture bias in psychotherapy trials.
None of the sources cited for this claim have been checked yet.
In the paper
“Previous metaanalyses of psychotherapeutic treatments for BPD have been scarce and used focused criteria for assessing effectiveness, avoiding combining treatments.”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > B
What the sources say
- Not checked yetcites [22]
- Not checked yetcites [23]
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“Risk of bias assessment and data extraction were performed by 2 independent assessors.”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Key Points
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“We examined publication bias through visual funnel plot inspection, the trim-and-fill procedure 32 (which produces an effect size estimate after accounting for publication bias), and Egger test for funnel plot asymmetry.”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Meta-analysis
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“Two independent assessors (I.A.C. and C.D.C.) examined the full texts and selected eligible RCTs.”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Identification and Selection of Studies
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim.
None of the sources cited for this claim have been checked yet.
In the paper
“Moreover, because the study collection dates of the 2 previous meta-analyses 22,23 preceded 2012, new trials or follow-ups of older trials published since then should be considered.”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > B
What the sources say
- Not checked yetcites [22]
- Not checked yetcites [23]
hedged- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“contradicting systematic claims from individual trials.”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Conclusions
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim.
In the paper
“One meta-analysis 60 of treatment completion in BPD reported high treatment completion rates (approximately 75%) but with substantial betweenstudy heterogeneity.”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Discussion
What the sources say
- Not checked yetcites [60]
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Various independent psychotherapies demonstrated efficacy for borderline-relevant symptoms, self-harm, suicide, health service use, and general psychopathology in BPD.”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Conclusions
boosteddirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“Our search was broad, but we may have missed trials that addressed personality disorders in general but ultimately had a sample composed of patients with BPD.”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Limitations
hedged- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“Owing to the small number of trials, we grouped therapies in broader categories, effacing subtler differences between orientations.”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Limitations
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: passes — The paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“The use of adjunct medication was neither standardized nor consistently reported and could have confounded psychotherapy effects.”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Limitations
hedgedconditional- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
In the paper
“However, included studies were both observational and controlled trials, randomized or not.”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Discussion
What the sources say
- Not checked yetcites [60]
plain- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“Furthermore, most trials had not been registered in clinical trial registries, so we could not rate RoB because of selective outcome reporting.”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Limitations
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
None of the sources cited for this claim have been checked yet.
In the paper
“Instead, they pooled absolute rates for the former, a procedure that is discouraged because it can lead to extremely high levels of heterogeneity.61”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Discussion
What the sources say
- Not checked yetcites [60]
- Not checked yetcites [61]
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: fails — The paper’s conclusions may not depend on it.
- Based: passes — The paper gives a reason why it holds.
Probably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“Frequently cited approaches, such as schema-focused therapy, were underrepresented, mainly because they were mostly studied in head-to-head trials.”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Limitations
plaindirect- Asserted: passes — The authors put it forward as true.
- Checkable: passes — It can be checked against evidence.
- Load-bearing: unclear — It is unclear whether the paper’s conclusions depend on it.
- Based: passes — The paper gives a reason why it holds.
It may state two separate claims as one.
The paper relies on this without support.
Most trials that showed effectiveness had the treatment developer directly involved.
“However, most trials demonstrating effectiveness were conducted with the direct participation of the treatment developer.”
The authors state this as an assumption.
Grouping different psychotherapies into broad categories yields meaningful and comparable efficacy estimates.
“Conversely, because effectiveness differences between therapies appear to be limited and because variations of the same intervention are to be expected in diverse implementation settings, we believe that a broader effectiveness evaluation grouping therapies into theoretically intelligible categories is germane.”
The paper relies on this without support.
The control conditions across included trials are sufficiently comparable to be pooled as a single control category.
“No constraints were placed on the control group, which could include (but was not restricted to) TAU or other treatments not specifically developed for BPD.”
The paper relies on this without support.
The Cochrane risk-of-bias domains and the summed overall score adequately capture bias in psychotherapy trials.
“Trial risk of bias (RoB) was evaluated within 4 domains of the Cochrane Collaboration Risk of Bias tool, 26 which assesses sources of bias in RCTs.”
The paper relies on this without support.
Treatment retention is a valid indicator of treatment acceptability or effectiveness.
“Treatment retention was computed as the comparative dropout rates between the intervention and control groups.”
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
The source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“the efficacy of DBT-A for treating BPD symptoms among adolescents who self-injure remains to be evaluated (Cristea et al., 2017).”
From Efficacy of dialectical behavior therapy for adolescent self-harm and suicidal ideation: a systematic review and meta-analysis (2021) · cites this paper as Cristea et al., 2017
Experimental — accuracy not yet measuredThe cited source says what the claim attributes to it.
In the citing paper
“although DBT has shown success in treating BPD symptoms in adults”
From Efficacy of dialectical behavior therapy for adolescent self-harm and suicidal ideation: a systematic review and meta-analysis (2021) · cites this paper as Cristea et al., 2017
In the citing paper
“Over the past twenty years, treatment studies have flourished showing that a diverse range of manualized treatments for BPD such as dialectical behaviour therapy (DBT), transference-focused psychotherapy (TFP), mentalization based therapy (MBT), or schema therapy are effective with medium to large effect sizes and remission achievable in a high percentage of cases [28, 29].”
From Euthanasia and assisted suicide in patients with personality disorders: a review of current practice and challenges (2020) · cites this paper as [28]
In the citing paper
“Today, a range of effective psychotherapeutic interventions are available for people with personality disorders in most of the countries that have so far legalized EAS.”
From Euthanasia and assisted suicide in patients with personality disorders: a review of current practice and challenges (2020) · cites this paper as [28]
In the citing paper
“in a recent meta-analysis it was concluded that both DBT and psychodynamic approaches (the last category defined very broadly and including both MBT and brief therapy based on psychoanalytic principles) are effective for BPD symptoms [25].”
From European guidelines for personality disorders: past, present and future (2019) · cites this paper as [25]
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
Each contradiction between two passages listed here was confirmed by an independent check.
Rated minor: it would not touch a result — a value no result rests on, a p-value that stays on the same side of the significance level, or a conflict that is clerical, resolved elsewhere in the paper, or outside its own findings.
In the paper
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > All Trials
“Combining both design types yielded a significant effect (g = 0.45; 95% CI, 0.15-0.75[13 trials]), with high heterogeneity (70%).”
§ Efficacy of Psychotherapies for Borderline Personality Disorder A Systematic Review and Meta-analysis > Meta-analysis
“with 25%, 50%, and 75% defining thresholds for low, moderate, and high.”
Citations
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Metadata
- Authors
- Cristea, I. A., Gentili, C., Cotet, C. D., Palomba, D., Barbui, C., & Cuijpers, P.
- Affiliations
- University of Padua (IT)
- Department of Clinical Psychology and Psychotherapy, Babes-Bolyai University, Cluj-Napoca, Romania
- University of Verona (IT)
- Amsterdam Public Health (NL)
- Corresponding author
- Cristea, Ioana A.
- Venue
- JAMA Psychiatry
- Publisher
- American Medical Association (AMA)
- Published
- 2017-04-01
- Volume
- 74
- Issue
- 4
- Pages
- 319
- ISSN
- 2168-622X (ISSN-L)
- OpenAlex
- W2592963919
- Semantic Scholar
- 464a03e120510e87d9085d8a94d7e412e2f34bbd
- Cited by
- 655
- References
- 72
- Citations by year
- 2026: 48 · 2025: 57 · 2024: 64 · 2023: 60 · 2022: 76 · 2021: 86 · 2020: 102 · 2019: 80 · 2018: 59 · 2017: 22
- FWCI
- 10.99
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- JAMA Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- VU Research Portal (publishedVersion, other-oa)
- Padua Research Archive (University of Padova) (submittedVersion)
- Data Archiving and Networked Services (DANS) (submittedVersion, other-oa)
- Funders
- National Authority for Scientific Research and Innovation
- Università degli Studi di Padova
- Autoritatea Natională pentru Cercetare Stiintifică
- Topics
- Social Sciences › Psychology › Clinical Psychology › Personality Disorders and Psychopathology
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Social Sciences › Psychology › Clinical Psychology › Psychoanalysis and Psychopathology Research
- Keywords
- borderline personality disorder, psychotherapy efficacy, dialectical behavior therapy, transference-focused psychotherapy, self-harm, suicide, borderline symptoms, treatment retention, health care utilization, general psychopathology, risk of bias, subgroup analysis, meta-regression, risk of bias in meta-analysis
- MeSH terms
- Suicide Prevention, Behavior Therapy, Borderline Personality Disorder, Humans, Psychotherapy, Suicide, Randomized Controlled Trials as Topic, Self-Injurious Behavior, Treatment Outcome, Psychotherapy, Psychodynamic
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