Gold Standard

Borderline personality disorder is a mental disorder characterized by a longstanding pattern of instability in one’s relationships with others, with a person’s own image of themselves, and their own emotions. It’s marked by impulsivity and, like most personality disorders, usually begins in early adulthood (early 20s) and pervades every aspect of a person’s life.

People with borderline personality disorder live tumultuous lives. Their romantic relationships rarely last more than a year, and their relationships with their own family tends to be unstable — some weeks they love them and want to spend all of their time with them, some weeks they hate them and won’t even talk to them (to extremes not usually experienced by the rest of us).

Traditionally, the treatment method most often recommended for people with borderline personality disorder has been a form of psychotherapy called dialectical behavior therapy (DBT). This form of psychotherapy has decades’ worth of research backing and is considered the “gold standard” for the treatment of borderline personality disorder. While DBT is effective, it requires an experienced and specially trained therapist, and long-term commitment on the client’s end. This can sometime limit a person’s ability to obtain this type of therapy. Many times it’s used as a group therapy process, which can also be scary to some potential clients.

And while DBT’s effectiveness is well accepted, it’s not as well known how it compares with other forms of treatment for borderline personality disorder over the long-term. A new research study (McMain et al., 2009) sheds some light on this issue.

Researchers studied 180 participants who were diagnosed with borderline personality disorder, of which 111 completed the year-long study. They were divided into two treatment groups — dialectical behavior therapy and general psychiatric management. What’s general psychiatric management?

General psychiatric management was based on the APA Practice Guideline for the Treatment of Patients With Borderline Personality Disorder and manualized for this trial. This coherent, high-standard outpatient treatment consisted of case management, dynamically informed psychotherapy, and symptom-targeted medication management. Pharmacotherapy was based on the symptom-targeted approach but prioritized treatment of mood lability, impulsivity, and aggressiveness, as presented in the APA guideline.

What did they find? Surprisingly, the researchers found that after a year’s worth of treatment for both groups, both groups significantly improved. And worse yet for DBT, there were no significant differences between the two treatment groups.

This trial demonstrated that 1 year of dialectical behavior therapy or general psychiatric management for the treatment of suicidal patients with borderline personality disorder brought about significant reductions in suicidal behavior, borderline symptoms, general distress from symptoms, depression, anger, and health care utilization, along with improvements in interpersonal functioning. Contrary to our expectations, dialectical behavior therapy was not superior to general psychiatric management with both intent-to-treat and per-protocol analyses; the two were equally effective across a range of outcomes.

One interesting data point, however, that the researchers didn’t discuss. You can see it pretty clearly in this graph:

Although this difference was reportedly not “statistically significant,” people in the general psychiatric management group had nearly 3 times the number of self-injurious episodes every month than those in the DBT group at the end of the one year treatment. That seems pretty significant, if not statistically, then at least clinically.

The other concern this article again points to is that between 38 and 39 percent of patients dropped out of treatment before the year was up. So while it’s interesting that both treatment groups benefited from the intervention, nearly 40 percent of people still aren’t helped by either (of those who returned survey about why they stopped treatment, 42 percent of subjects said that the treatment wasn’t helpful).

This is the largest trial to compare DBT against another standardized treatment and another datapoint that dispels the myth that borderline personality disorder is “untreatable.” Borderline personality disorder is treatable and this study demonstrates yet another treatment approach that appears equally effective as the “gold standard” DBT.

Reference:

McMain, S.F., Links,P.S., Gnam, W.H., Guimond, T., Cardish, R.J., Korman, L. & Streiner, D.L. (2009). A Randomized Trial of Dialectical Behavior Therapy Versus General Psychiatric Management for Borderline Personality Disorder. Am J Psychiatry.
DOI: 10.1176/appi.ajp.2009.09010039