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.

Download full-text


Available from: David L Streiner
  • Source
    • "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. "
    [Show abstract] [Hide abstract]
    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.
    Full-text · Article · Jan 2016 · Journal of Personality Disorders
    • "We observed that after 10 sessions, patients reached a clinically significant decrease in psychological distress which was maintained over the following 6 months, irrespective of the treatment condition. This is an important finding, as maintenance of gains from month 3 until 9 after intake, after an initial treatment phase of 3 months, was observed in treatments based on the good psychiatric management model (McMain et al., 2009). By examining change in borderline symptoms over one year of treatment, the latter study observed a greater rate of change for the first 3 months (i.e., corresponding to roughly 10 sessions), when compared to the rates of change during the following 3 and 6 months. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Objective: There is little research on short-term treatments for borderline personality disorder (BPD). While the core changes may occur only in long-term treatments, short-term treatments may enable the study of early generic processes of engagement in therapy and thus inform about effective treatment components. It was shown that a 10-session version of a psychiatric treatment was effective in reducing borderline symptoms at the end of this treatment [Kramer, U., Kolly, S., Berthoud, L., Keller, S., Preisig, M., Caspar, F., … Despland, J.-N. (2014). Effects of motive-oriented therapeutic relationship in a ten-session general psychiatric treatment for borderline personality disorder: A randomized controlled trial. Psychotherapy and Psychosomatics, 83, 176-186.]. Also, it was demonstrated in a randomized design that adding the motive-oriented therapeutic relationship (MOTR), following an individualized case formulation based on Plan Analysis, further increased general outcome after session 10 and had a positive effect on the early changes in self-esteem and alliance. Method: The present study focuses on the follow-up period after this initial treatment, examining treatment density and outcomes after 6 months and service utilization after 12 months. Outcome was measured using the OQ-45. Results: Results on a sub-sample of N = 40 patients with available OQ-45 data at follow-up (n = 21 for MOTR-treatment, n = 19 for comparison treatment) showed maintenance of gains over the follow-up period, which did not differ between both conditions. It appeared for this sample that MOTR treatments, while using the same number of sessions, lasted more weeks (i.e., lower treatment density, defined as the number of sessions per week), when compared to the treatments without MOTR. Density marginally predicted symptom reduction at follow-up. Patients in MOTR treatments had a greater likelihood of entering structured psychotherapy after the initial sessions than patients in the comparison group. Conclusions: These results are overall consistent with earlier studies on short-term treatments for BPD and underline the importance of individualizing interventions, by using case formulations that rely on idiographic methods and integrative concepts.
    No preview · Article · Dec 2015 · Psychotherapy Research
  • Source
    • "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. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Cognitive behavior therapy (CBT) has come to be a widely practiced psychotherapy throughout the world. The present article reviews theory, history, and evidence for CBT. It is meant as an effort to summarize the forms and scope of CBT to date for the uninitiated. Elements of CBT such as cognitive therapy, behavior therapy, and so-called "third wave" CBT, such as dialectical behavior therapy (DBT) and acceptance and commitment therapy (ACT) are covered. The evidence for the efficacy of CBT for various disorders is reviewed, including depression, anxiety disorders, personality disorders, eating disorders, substance abuse, schizophrenia, chronic pain, insomnia, and child/adolescent disorders. The relative efficacy of medication and CBT, or their combination, is also briefly considered. Future directions for research and treatment development are proposed.
    Full-text · Article · Aug 2015 · Psychodynamic Psychiatry
Show more