New Treatment Promising for Borderline Personality Disorder

Pauline Anderson

July 10, 2014

Adding individualized therapy to a short version of a good psychiatric management model improves mood, emotional control, and some interpersonal skills in patients with borderline personality disorder (BPD), although it does not appear to further reduce borderline symptoms, a new study shows.

Dr. Ueli Kramer

"The good psychiatric model was developed by John Gunderson and Paul Links and is one of several effective treatment options to intervene with BPD, and for a short version, it seems good enough for quite rapidly reducing specific borderline symptoms, such as impulsive behaviors," lead author Ueli Kramer, PhD, currently adjunct professor in clinical psychology at the University of Windsor, Ontario, Canada, and at the Institute of Psychotherapy and General Psychiatry Services, Department of Psychiatry-CHUV, University of Lausanne, Switzerland, told Medscape Medical News.

"However, for broader problems in interpersonal relationships, social role, along with depression and anxiety, which are all problems that may go along with borderline symptomatology, there's a benefit of adding an individualized way of intervening, based on the motive-oriented therapeutic relationship [MOTR]."

The study was published in the July issue of Psychotherapy and Psychosomatics.

Angry Outbursts

Patients with BPD typically experience interpersonal relationships as challenging and have difficulty with mood regulation and with expressing emotions in effective ways, along with having identity disturbances.

They may suffer from angry outbursts, exhibit self-harm behaviors such as cutting, and feel abandoned or rejected by harmless gestures from others. A number will make dangerous suicide attempts. Experts agree that BPD is best treated by structured psychological and psychotherapeutic interventions.

BPD affects about 1% to 2% of the population, a prevalence that is just above that of schizophrenia.

Patients with BPD vary tremendously in their symptom span and ways of interacting. Therefore, researchers wanted to test the hypothesis that tailoring therapy to the individual patient, according to the case formulation model of plan analysis developed by Klaus Grawe and Franz Caspar in Switzerland and satisfying their underlying motives, would result in lessening their problematic behaviors, said Dr. Kramer.

The study enrolled 85 adults with a confirmed diagnosis of BPD, as determined on the basis of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnostic criteria. They were randomly assigned into 1 of 2 groups: a group receiving good psychiatric management (GPM), or a group receiving GPM plus MOTR (based on the plan analysis case formulation). Both groups received 10 therapy sessions.

"We were interested in studying the optimizing of patient engagement in treatment from the very first contact on, up until session 10," explained Dr. Kramer. Engagement in therapy is a central aspect of clinical work with patients presenting with BPD.

According to the authors, this short version of psychiatric intervention includes identifying the main problems to be treated, establishing a treatment focus, defining short-term objectives, and formulating relational interpretations of core conflictual themes.

"The interpersonal is at the center of the GPM model" when working with BPD clients, said Dr. Kramer. "It's a way of dealing with a client's problems in a useful and straightforward way."

The MOTR element assumes that every client is different and tailors the treatment approach accordingly. For each patient, a unique case formulation (the plan analysis) is established by the therapist. On the basis of this formulation, the therapist implements the motive-oriented therapeutic relationship.

The principle behind MOTR is to ensure that therapy provides a means to satisfy the patient's needs and motives within the limits of the therapeutic relationship, without reinforcing problematic behaviors and plans.

Self-Harm

Dr. Kramer used the example of 2 female patients with BPD who both engage in self-cutting, but their underlying motives may be quite different – one cuts in order to gain attention that may serve her by allowing her to get close to others who try to soothe her, whereas the other cuts to let off steam and control her emotions, which may serve her by maintaining perceived integrity and control. Whereas the behaviors are identical, the underlying motives are not.

This, according to the MOTR model, calls for a different, individualized, therapeutic intervention. First, the therapist may intervene by explicitly affirming his presence; second, the therapist may ensure explicitly that the patient maintains her integrity in the therapy room.

For both interventions, the model assumes that if the motivational basis of the problematic behavior (the self-cutting) is taken away by a proactive therapist through complementarity to the motives, the behavior lessens.

In the study, MOTR was "infused" into the process after the intake session, from session 2 to session 10.

A comparable percentage of patients in both groups were taking psychiatric medications (around 60%), receiving alcohol or drug counseling, and getting short-term inpatient treatment. "The therapist gives what is useful," commented Dr. Kramer.

Study participants, coordinators, and MOTR adherence raters were all blinded to the treatment allocation, but the principal investigator and the 22 trained therapists involved were not. Each therapist conducted treatment sessions for only 1 condition.

The intent-to-treat (ITT) analysis included 74 patients (38 in the GPM group and 36 in the GPM plus MOTR group). Most were women (79% in the GPM and 58% in the GPM plus MOTR group), and most had a comorbid psychiatric condition, primarily depression (68% in the GPM and 83% in the GPM plus MOTR group). Attrition analysis yielded between-group equivalence.

The primary analysis used the Outcome Questionnaire–45.2 (OQ-45), a self-report questionnaire with 45 items, looking at a global score and scores for 3 subscales: symptomatic level, interpersonal relationships, and social role. The ITT analysis showed a between-group effect on the total OQ-45 score (P ˂ .02), significant effects favoring MOTR for all subscales, and a nearly significant effect favoring MOTR on the 3 subscales taken together (P = .06).

Symptom Reduction

There were no between-group differences on 2 secondary self-reported outcomes in the ITT analyses: the Inventory of Interpersonal Problems (IIP), which assesses interpersonal function, and the Borderline Symptoms List (BSL), which measures specific borderline symptomatology.

However, noted Dr. Kramer, there were significant reductions on both scales in both groups, and for the completers, MOTR did better than GPM alone in reducing interpersonal problems.

"The general symptoms like depressive mood, anxiety, and emotion dyscontrol and some interpersonal and social aspects were better after 10 sessions in patients who got MOTR," said Dr. Kramer. "For borderline symptoms, we actually saw quite a steep decrease in symptoms in both groups ― there might not have been room for more improvement in this short time frame."

The results suggest that this short version of the GPM model is adequate for reducing rapidly borderline symptoms, but that adding the individualized element of plan analysis and MOTR is appropriate to tackle more general distress, such as lack of interpersonal skills, anxiety, and mood problems, said Dr. Kramer.

At the end of each session, both patients and therapists completed the short version of the Working Alliance Inventory, a self-report questionnaire that assesses the bond between patient and therapist and their agreement on therapy collaboration (goals and tasks).

There were no differences in how patients in the 2 groups rated the sessions. "This was contrary to expectations," commented Dr. Kramer. "We thought that the individualized way of working would engage patients more in the relationship, but there was an equal increase in collaboration."

It was a different story for MOTR therapists, who gave an increasingly positive assessment of their clients' engagement and their ability to work with the therapist toward a common goal.

"This is important given the potential difficulty of working with these clients: if the therapist is feeling positive and hopeful for the bond he or she is experiencing with the patient, this will go a long way," said Dr. Kramer. Such therapist engagement in therapy may ultimately facilitate patient engagement and symptom alleviation.

At the end of the sessions, about 70% of each group required additional treatment, most receiving intensive psychotherapy, said Dr. Kramer.

Outpatient Treatment

Outpatient treatment for BPD typically continues for up to 3 years, at least in European countries. There are no effective drug treatments for this psychiatric disorder except for some specific symptom groups, such as impulsivity or cognitive impairments, so more of this kind of research into refining already effective psychological treatments is very much in order.

Researchers are now analyzing 6-month follow-up data to see whether the benefits of MOTR are long-lasting. They also plan to assess use of mental health services with an eye to possibly documenting the cost-effectiveness of this intervention.

In addition to being limited by its short duration (10 sessions), the study had few exclusion criteria, so the influence of comorbid disorders and of cointerventions, such as use of medications and alcohol counseling, cannot be ruled out. Also, the primary outcome was self-reported, so is subject to responder bias, and insufficient power prevented the researchers from testing hypotheses in subgroups.

Overall, the good news is that there are a number of effective treatments for BPD on the market now, commented Dr. Kramer.

"At a time when there is a debate in the media whether or not Marilyn Monroe was suffering from borderline personality disorder, clinicians treating patients with BPD feel more and more supported by such research evidence that their work may potentially impact their patients' lives.

"And for the patients, with their families, there is hope to not end like a 'candle in the wind,' but that life is there for them, too, and they may progressively reclaim and affirm strong identities and move towards healthier, caring, and more satisfying relationships."

The study was funded by the Swiss National Science Foundation. The authors have disclosed no relevant financial relationships.

Psychother Psychosom. 2014;83:176-186. Abstract

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