A Randomized Trial of Dialectical Behavior Therapy Versus General Psychiatric Management for Borderline Personality Disorder

Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
American Journal of Psychiatry (Impact Factor: 12.3). 09/2009; 166(12):1365-74. DOI: 10.1176/appi.ajp.2009.09010039
Source: PubMed


The authors sought to evaluate the clinical efficacy of dialectical behavior therapy compared with general psychiatric management, including a combination of psychodynamically informed therapy and symptom-targeted medication management derived from specific recommendations in APA guidelines for borderline personality disorder.
This was a single-blind trial in which 180 patients diagnosed with borderline personality disorder who had at least two suicidal or nonsuicidal self-injurious episodes in the past 5 years were randomly assigned to receive 1 year of dialectical behavior therapy or general psychiatric management. The primary outcome measures, assessed at baseline and every 4 months over the treatment period, were frequency and severity of suicidal and nonsuicidal self-harm episodes.
Both groups showed improvement on the majority of clinical outcome measures after 1 year of treatment, including significant reductions in the frequency and severity of suicidal and nonsuicidal self-injurious episodes and significant improvements in most secondary clinical outcomes. Both groups had a reduction in general health care utilization, including emergency visits and psychiatric hospital days, as well as significant improvements in borderline personality disorder symptoms, symptom distress, depression, anger, and interpersonal functioning. No significant differences across any outcomes were found between groups.
These results suggest that individuals with borderline personality disorder benefited equally from dialectical behavior therapy and a well-specified treatment delivered by psychiatrists with expertise in the treatment of borderline personality disorder.

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    • "The participants were 180 individuals enrolled in a randomized controlled trial (RCT) designed to evaluate the clinical effectiveness and cost-effectiveness of one year of either DBT or GPM for the treatment of BPD (McMain et al., 2009; McMain, Guimond, Streiner, Cardish, & Links, 2012). The results of the original outcome study by McMain and colleagues (2009) showed that participants in both treatment conditions evidenced comparable and statistically significant improvements on the majority of clinical outcomes; there were no between-group differences on outcomes at the end of the one year of treatment or at the end of the two-year follow-up. "
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    ABSTRACT: The aim of this study was to determine the influence of posttraumatic stress disorder (PTSD) on treatment outcomes in patients with borderline personality disorder (BPD). Participants were 180 individuals diagnosed with BPD enrolled in a randomized controlled trial that compared the clinical and cost effectiveness of dialectical behavior therapy (DBT) and general psychiatric management (GPM). Multilevel linear models and generalized linear models were used to compare clinical outcomes of BPD patients with and without PTSD. BPD patients with comorbid PTSD reported significantly higher levels of global psychological distress at baseline and end of treatment compared to their non-PTSD counterparts. Both groups evidenced comparable rates of change on suicide attempts and non-suicidal self-injury (NSSI), global psychological distress, and BPD symptoms over the course of treatment and post-treatment follow-up. DBT and GPM were effective for BPD patients with and without PTSD across a broad range of outcomes.
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    • "None of the experts were CBT-oriented , and all identified either as psychodynamic or eclectic. Thus, while other treatments (e.g., TFP and the approach employed by McMain et al., 2009) are promising and deserve further attention, one advantage DBT currently has is that of offering a BDP-specific treatment that has been codified in terms of both implementation and in training of therapists . As a result, it now has widespread availability in the community. "
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    • "The strict exclusion criteria that often characterize RCTs have produced client samples that in many cases are not representative of the populations seen in routine settings (Westen, Novotny, & Thompson- Brenner, 2004), and many clinicians have expressed concerns that the findings from efficacy trials are not clinically relevant and do not transfer easily to routine practice. Awareness of this problem has prompted a rise in the number of CBT trials that include participants who are more typical of those in routine practice, such as individuals with significant comorbidities and/or who are receiving concurrent medication (e.g., DeRubeis et al., 2005; McMain et al., 2009). Confidence in a treatment is stronger if the effects observed in RCTs are replicated in effectiveness trials. "
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