Online Education Improves Borderline Personality Symptoms

Pauline Anderson

June 02, 2015

TORONTO ― Contrary to popular belief, informing patients that they have borderline personality disorder (BPD) does not have negative consequences.

In fact, new research suggests that educating patients about this diagnosis leads to an improvement of symptoms and to better psychosocial outcomes.

Mary C. Zanarini, EdD, Maclean Hospital, Belmont, Massachusetts, discussed the benefits of an Internet-based psychoeducational intervention for BPD here at the American Psychiatric Association (APA) 2015 Annual Meeting.

A common psychiatric disorder, BPD is marked by symptoms in four areas: feelings, thoughts, behaviors, and interpersonal patterns. Several forms of therapy have been found to be effective in treating BPD.

However, health professionals are reluctant to diagnose patients with BPD, which often leaves these patients thinking that they are "bad" people or the only ones suffering their debilitating symptoms, according to Dr Zanarini.

There are several reasons why psychiatrists and others are reluctant to use the BPD label, she said. For example, they may be uncertain about how to diagnose the condition. Or they may lean toward a diagnosis they think is more treatable and has a better prognosis, such as bipolar disorder, or one that they consider less "pejorative," such as post-traumatic stress disorder or major depression, she said.

And if patients are told they have BPD, they are often not given the most up-to-date information on the condition, said Dr Zanarini. "Because of this, they are deprived of the information they need to be informed consumers of mental health services and to plan for their future in a reasonable manner."

During her presentation, Dr Zanarini described a pilot study of a psychoeducational intervention involving 50 patients from 2003 to 2004. The intervention included providing information on the signs and symptoms of BPD, its etiology, comorbid disorders, treatment options, and course of the disorder. The curriculum was taught by two clinically experienced research assistants.

Thirty patients were randomly assigned to participate in the psychoeducational workshop, and 20 were assigned a wait list. The study design included a baseline visit and 11 weeks of follow- up.

One outcome measure was the validated, clinician-rated Zanarini Rating Score for PPD (ZAN-BPD). The 9-item scale assesses the severity of DSM-IV-based BPD symptoms.

The four-point rating scale also measures meaningful changes in symptoms over time, from 0, indicating an absence of symptoms, to 4, indicating severe symptoms. Ratings are applied to the following categories:

  • Affective (inappropriate anger or frequent angry acts; chronic feelings of emptiness; mood instability)

  • Cognitive (stress-related paranoia/dissociation; severe identity disturbance based on false personal beliefs)

  • Impulsive (self-mutilation and/or suicidal efforts; two other forms of impulsivity)

  • Interpersonal (unstable interpersonal relationships; frantic efforts to avoid abandonment)

Another outcome measure was the Borderline Evaluation of Severity Over Time (BEST) scale, a 15-item measure developed as a self-report questionnaire. It assesses the severity of and change in borderline personality symptoms during the course of treatment.

The investigators found that for the active intervention group, scores declined significantly more than the wait list group on general impulsivity, such as binge eating, spending sprees, and reckless driving, and on unstable relationships. There were no significant differences in areas of work or school, social relationships, and family relationships.

One patient (2% of the sample) required emergency psychiatric care. This, said Dr Zanarini, involved a telephone call to an old therapist.

None of the patients dropped out of the study.

To address the inability of treatment facilities to offer this early treatment intervention because of cost constraints, Dr. Zanarini and her colleagues have introduced an Internet-based program and a self-report version of the ZAN-BPD.

The curriculum includes information on the history of the diagnosis, the stigma associated with it, demographic information surrounding it, symptoms that make up BPD, comorbidities, and available treatments.

Dr Zanarini described a recent study of 80 female BPD patients aged 18 to 30 years, half of whom were randomly assigned to receive the Internet-based psychoeducational intervention for 12 weeks. Follow-up evaluations were conducted at 6, 9, and 12 months.

Of the 80 patients, 78 completed the study, and 77 completed 12 months of follow-up.

The study found significant between-group differences on several ZAN-BPD measures, including moodiness, identity disturbance, self-harm/suicide attempts, and overall impulsivity, as well as on the BEST scale for anger, temper outbursts, general impulsivity, and overall behavior.

Overall psychosocial functioning improved significantly more for those who received the intervention compared with those who did not.

Dr Zanarini stressed that patients who were told of their diagnosis did not experience an upsurge in their symptoms. "In fact, those in the treatment group experienced a significantly greater decline in five of the nine DSM criteria for BPD than those in the control group," she said.

The study was funded by the National Institute of Mental Health.

American Psychiatric Association (APA) 2015 Annual Meeting. Abstract SCR-1. Presented May 18, 2015.

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