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Cited by 450Personality Disorders and PsychopathologyPsychotherapy Techniques and ApplicationsBipolar Disorder and Treatment

Psychological therapies for people with borderline personality disorder

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Storebø, Ole Jakob, Stoffers-Winterling, Jutta M, Völlm, Birgit A, Kongerslev, Mickey T, Mattivi, Jessica T, Jørgensen, Mie S, Faltinsen, Erlend, Todorovac, Adnan +4 more·2020·Cochrane Database of Systematic Reviews
DOI 10.1002/14651858.cd012955.pub2
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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 We contacted researchers working in the field to ask for additional data from published and unpublished trials, and handsearched relevant journals.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 (

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  • Despite evidence of larger reductions in BPD symptom severity by active psychotherapies than treatment as usual, the average reduction of 3.6 points on a 0-36 scale was only slightly higher than the threshold for a minimal clinically relevant difference (MIREDIF; 3.0 points).

    “Overall, despite evidence of larger reductions in BPD symptom severity by active psychotherapies than treatment as usual, the average reduction of 3.6 points on a 0–36 scale was only slightly higher than the threshold for a minimal clinically relevant difference (MIREDIF; 3.0 points).”

    From Complex PTSD and borderline personality disorder (2021) · cites this paper as [163]

  • Despite evidence of reduced suicidality, self-harm, and depression, and improved psychosocial functioning, the observed benefits of psychotherapy for BPD were less than those required by MIREDIF.

    “Moreover, despite evidence of reduced suicidality, self-harm, and depression, and improved psychosocial functioning, the observed benefits were less than those required by MIREDIF.”

    From Complex PTSD and borderline personality disorder (2021) · cites this paper as [163]

  • A systematic review of 75 randomized clinical trials testing psychotherapy for BPD identified 16 approaches to treatment, with Dialectical Behavior Therapy and Mentalization-Based Therapy most often the focus.

    “A systematic review of 75 randomized clinical trials testing psychotherapy for BPD [163] identified 16 approaches to treatment, with Dialectical Behavior Therapy [105, 106] and Mentalization-Based Therapy (MBT) [185] most often the focus.”

    From Complex PTSD and borderline personality disorder (2021) · cites this paper as [163]

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Authors
Storebø, O. J., Stoffers-Winterling, J. M., Völlm, B. A., Kongerslev, M. T., Mattivi, J. T., Jørgensen, M. S., Faltinsen, E., Todorovac, A., Sales, C. P., Callesen, H. E., Lieb, K., & Simonsen, E.
Affiliations
  • University of Southern Denmark (DK)
  • University Medical Center of the Johannes Gutenberg University Mainz (DE)
  • Department of Forensic Psychiatry, Center for Neurology; University Rostock; Rostock Germany
  • Region Zealand (DK)
  • University of Nottingham (GB)
  • Psychiatric Research Unit; Psychiatry of Region Zealand; Slagelse Denmark
  • Leibniz Institute for Resilience Research (DE)
ORCID
Venue
Cochrane Database of Systematic Reviews
Publisher
Wiley
Published
2020-05-04
Volume
2020
Issue
11
ISSN
  • 1361-6137 (ISSN-L)
  • 1465-1858
DOI
10.1002/14651858.cd012955.pub2
OpenAlex
W4253966971
Semantic Scholar
1f2b096423317b332672582b4f3034f2e2a8f9c7
Cited by
450
References
501
Citations by year
2026: 56 · 2025: 75 · 2024: 100 · 2023: 81 · 2022: 73 · 2021: 49 · 2020: 13 · 2019: 1 · 2012: 1
FWCI
4.22
Type
journal article
Language
en
Open access
Locations
  • Cochrane Database of Systematic Reviews (publishedVersion)
  • Research at the University of Copenhagen (University of Copenhagen) (publishedVersion, other-oa)
  • University of Southern Denmark Research Portal (University of Southern Denmark) (submittedVersion, other-oa)
Funders
  • Bundesministerium für Bildung und Forschung
  • Queen's University
Topics
  • Social Sciences › Psychology › Clinical Psychology › Personality Disorders and Psychopathology
  • Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
  • Health Sciences › Medicine › Psychiatry and Mental health › Bipolar Disorder and Treatment
Keywords
borderline personality disorder, psychotherapy, dialectical behavior therapy, mentalization-based treatment, self-harm, suicide attempts, psychosocial functioning, treatment discontinuation, adverse effects, usual care, waitlist control, adolescents, adults, children

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