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GREAT NEWS New Treatments, BPD Redefined ( Borderline Personality Disorder Literature Review)

Uploaded 10/3/2022, approx. 40 minute read

Some good upheaval in the world of borderline personality disorder.

Many things we thought we knew were disproven lately, and others have emerged.

All in all, more optimistic news.

If I had to choose between borderline personality disorder and narcissistic personality disorder as a diagnosis, I would choose borderline.

There is spontaneous remission after age 40 or 45. There is DBT, which is a very effective treatment strategy. And there is growing hope day in and day out. The more we believe or the more we convince ourselves that borderline personality disorder is actually a form of hereditary brain abnormality, the more treatment horizons and medical interventions open.

But even in the classical field of psychotherapy, there are mega developments.

Stay with me for this ride, a literature review of the most recent studies in the world of borderline personality disorder.

My name is Stan Wagner, I'm the author of Malignant Self-Love, Narcissism Revisited, and a professor of psychology. And let's delve right in and review a new study.

This study upends our perception of borderline personality disorder.

Before I go there, there is enormous ignorance, enormous ignorance, even among people who are supposed to know better. I just returned from a trip in July to Vienna, where I've met 13 psychologists and psychiatrists, 12 of whom had insisted that borderline personality disorder is actually bipolar disorder, not borderline personality disorder, as the name implies, is a personality disorder. Bipolar disorder has absolutely nothing to do with it. It's a mood disorder.

And yet these top-notch professionals didn't know the difference.

In another country, Hungary, I've heard of the most credentialed, prestigious diagnostician there, misdiagnosing borderline personality disorder, or actually the absence or lack thereof, egregiously. He hands down diagnosis to people telling them they do not have borderline personality disorders because they don't self-mutilate or self-harm.

This is a level of profound ignorance in every civilized country. This man would have lost his license.

Let me elucidate a bit.

The absence of self-harm does not preclude a diagnosis of borderline personality disorder.

There are new findings and they have enormous implications when it comes to the diagnostic criteria for this disorder.

And so there's a study, recently published study, and it's titled The Hidden Borderline Patient, Patients with Borderline Personality Disorder Who Do Not Engage in Recurrent Suicidal or Self-Injurious Behavior. It was published by Cambridge University Press in July 2022, and the authors are Mark Zimmerman and Lena Becker.

I will summarize the study for you, and then as is my habit, I will read to you the abstract.

And so what these people are saying, what these investigators or scholars are saying, is that you don't need to self-harm or self-mutilate or cut in order to gain the diagnosis of borderline or qualify for the diagnosis of borderline personality disorder.

They selected 400 psychiatric outpatients diagnosed with borderline personality disorder. About half the participants were suicidal and they engaged in recurrent self-injury, self-mutilation and self-harm. The other half didn't.

Then they studied these two populations and the results showed no difference between the two groups in the degree of impairment in occupational functioning, social functioning, comorbidity of psychiatric disorders, history of childhood trauma, severity of depression, presence of anxiety, anger, emptiness, etc.

In other words, these two populations were identical, diagnostically and psychodynamically.

The only single difference between them is that people in the first group, self-injured, self-harm and self-mutilated intended to have suicidal ideation and people in the second group didn't.

And yet clearly, members of both groups qualified abundantly for a diagnosis of borderline personality disorder.

Mark Zimmerman, who is an MD and a professor of psychiatry and human behaviour at Brown University in Providence, Rhode Island, said that just because a person doesn't engage in self-harm or suicidal behaviour doesn't mean that the person is free of borderline personality disorder.

Clinicians need to screen for borderline personality disorder in patients with other suggestive symptoms, even if these patients do not self-harm.

Just as they would for similar patients who do self-harm.

Zimmerman is also the director of the outpatient division at the partial hospital programme in Rhode Island Hospital.

Anyhow, he published his findings in the journal Psychological Medicine.

The problem with borderline personality disorder and with all other personality disorders is that they are polythetic, at least in the Diagnostic and Statistical Manual 4, 3 and 2.

This approach of making a list of diagnostic criteria prevailed over the alternative approach, which is descriptive and dimensional.

So we ended up having lists. Each diagnosis had its own list of criteria.

Again, in the case of borderline personality disorder and narcissistic personality disorder, it was sufficient to meet five of the nine criteria in order to be diagnosed with a disorder.

But this created a major problem because, for example, you could be diagnosed with criteria 1, 2, 3, 4 and 5 and then I could be diagnosed with criteria 5, 6, 7, 8 and 9 and both of us would qualify to receive the diagnosis of borderline personality disorder.

Yet we have almost nothing in common.

Your borderline personality disorder relies on diagnostic criteria 1, 2, 5. My borderline personality disorder relies on diagnostic criteria 5, 6 and 9. We have extremely little in common and this is called the polythetic problem.

So there were scholars and researchers and experimenters and psychologists all over the world who have spent the past two decades trying to find the single criterion which would apply to all patients with borderline personality disorder, regardless of which other criteria they had met.

And they found that the only criterion which applies to 90% that's 90% of all patients with borderline personality disorder is affective instability also known as emotional dysregulation.

Zimmerman says that affective instability had a very high negative predictive value meaning that if you didn't have affective instability you didn't have the disorder.

Given the clinical and public health significance of suicidal and self-harm behavior in patients with BPD, an important question is whether the absence of these criteria which might attenuate the likelihood of recognising and diagnosing this disorder and they identify the subgroup of patients with borderline personality disorder who are less borderline than patients with BPD who do not manifest these criteria.

In short, the issue is this.

We know that 90% of patients with borderline personality disorder have emotional dysregulation aka affective instability.

These scholars wanted to find out whether self-harm, self-injury, self-mutilation occupies the same hallowed space, in other words whether it was also present in the vast majority of borderline cases.

What they found is no, the answer is no.

You could definitely be borderline without any hint or trace of suicidal ideation, self-harm, self-injurious behavior or self-mutilation.

Similarly, there was no difference between any specific axis 1 or personality disorder and borderline personality disorder.

In other words, the comorbidity of borderline personality disorder with other mental health disorders did not have a predictive diagnostic value.

You couldn't say if this person doesn't have depression, if this person doesn't have, I don't know, some other issue, for example, grandiosity, if this person doesn't self-harm and self-mutilate and doesn't have suicidal ideation, this person is not borderline.

You can't say this. It's wrong.

The only two comorbidities which have some predictive value when it comes to borderline personality disorder are generalized anxiety disorder in patients under age 45, especially very young patients, and histrionic personality disorder. Both were more frequent in the patients who did not meet the suicidal self-injury criteria.

So it seems that there are two groups of borderline.

Borderlines who are suicidal and self-injurious, these borderlines would tend to have anxiety and histrionic personality disorder, and borderlines who are self-destructing, self-harming and these borderlines would not have usually or normally or would have less lower frequency of histrionic personality disorder.

The patients who met the suicidality self-injury criterion were significantly more likely to have been hospitalized and reported more suicidal ideation at the time of the evaluation, wrote the researchers.

There were no between-group differences on severity of depression, anxiety or anger at the initial evaluation. There were no differences in social functioning, adolescent social functioning, likelihood of persistent unemployment or receiving disability benefits, childhood trauma or neglect. All these parameters were identical in the group of patients who were suicidal and self-harming and in the group of patients who were not suicidal and were not self-injurious. All these parameters, I repeat them, social functioning, adolescent social functioning, likelihood of persistent unemployment or receiving disability benefits, childhood trauma or neglect.

Zimmerman says, I suspect that there are a number of individuals whose BPD is not recognized because they don't have the more overt feature of self-injury or suicidal behavior. He calls this hidden BPD, hidden borderline personality disorder.

Repeated self-injurious and suicidal behavior, he says, is not synonymous with borderline personality disorder and clinicians should be aware that the absence of these behaviors does not rule out a diagnosis of borderline personality disorder.

Monica Karski is the assistant professor of psychology in psychiatry and a senior fellow of the Personality Disorders Institute in Weill Cornell Medical College, New York City. She has a very long list of credentials. She is also a manager of the post doctoral program in psychoanalysis, psychotherapy, etc.

Karski suggested to stop using the diagnostic and statistical manual edition four text revision model. In other words, she says, don't use the list of nine diagnostic criteria. This list is very misleading. It's very misleading. It's also culture bound. It includes gender bias and it's polythetic. It leads equally to comorbidity with other disorders. It's a mess.

The diagnostic and statistical manual edition four, including the text revision, are a bloody mess and they are a mess because they rely on lists and categories whereas the human psyche and the human mind are not categorical. They are dimensional and they are on a spectrum.

So Karski suggests to use the alternative model or the alternate model for personality disorder in the diagnostic and statistical manual fifth edition text revision.

In the alternative model or alternate model of borderline personality disorder, first you rate the severity level of personality. You assess identity, relationship problems, intimacy issues, self-regulation, you note specific traits of personality disorders. And she says, this will help clinicians who dread telling patients that they are borderline.

I concur wholeheartedly.

The alternative model in the DSM five is vastly superior to anything DSM four has to offer.

It is regrettable that the insurance industry and the pharmaceutical industry have both intimidated the diagnostic and statistical manual committee into including the outdated and defunct language of the diagnostic and statistical manual edition four in the fifth edition and in the text revision.

Summary of this part, you don't have to self-harm, you don't have to self-mutilate, you don't have to be suicidal to qualify for a diagnostic diagnosis of borderline personality disorder. If you are emotionally dysregulated and your affect is unstable, you probably have borderline features and in all likelihood a borderline personality disorder.

So this is the article, go to the description for a bibliography. I'm going to read to you what the authors said in the article itself.

Background, despite the significant psychosocial morbidity associated with borderline personality disorder, it's under recognition is a significant clinical problem.

BPD is likely underdiagnosed in part because patients with BPD usually present with chief complaints associated with mood, anxiety and substance abuse disorders. When patients with BPD do not exhibit self-harm behavior, we suspect that BPD is less likely to be recognized.

An important question is whether the absence of these criteria, which might attenuate the likelihood of recognizing and diagnosing the disorder, identifies a subgroup of patients with BPD who are less borderline than patients with BPD who do not manifest these criteria.

The results are this.

Approximately half of the patients with BPD did not meet the suicidality self-injury diagnostic criteria for the disorder. There were no differences between the patients who did and did not meet this criteria in terms of occupational impairment, likelihood of receiving disability payments, impairment in social functioning, level of educational achievement, comorbid psychiatric disorders, history of childhood trauma or severity of depression, anxiety or anger upon presentation for treatment.

I'm just correcting one thing. The only exceptions are generalized anxiety disorder in patients under age 40 and histrionic personality disorder throughout the lifespan.

These two are correlated with borderline personality disorder. The comorbidity is significant, statistically speaking.

The conclusions of the study, repeated self-injurious and suicidal behavior is not synonymous with borderline personality disorder.

It is critical for clinicians to be aware that the absence of repeated self-injury and suicide threats or gestures or attempts does not rule out the diagnosis of borderline personality disorder.


Onward to the next article.

It identified a new treatment modality for borderline personality disorder.

Hereto, we have had mostly dialectical behavioral therapy, DBT. DBT has been extremely efficacious, while over 50% of patients lost the diagnosis within one year.

A DBT involved a group element and an individual therapy element.

To this very day, DBT, dialectical behavioral therapy, is the gold standard for treating borderline personality disorder.

And here comes another possibility, another possibility.

I'm referring to an article titled The Effectiveness of Predominantly Group Schema Therapy and Combined Individual and Group Schema Therapy for Borderline Personality Disorder: A randomized Clinical Trial.

The lead author is Anvert Anz, A-R-N-Z. And I will read to you the key points and findings from the study itself, but I want to discuss it a bit beforehand.

What the study shows is that if you were to combine individual schema therapy with group schema therapy, you would accomplish a reduction of symptoms, a substantial reduction of symptoms in patients with borderline personality disorder.

That's a new tool in our arsenal.

Schema is a form of psychotherapy that focuses on the experience, on experiential approach.

It's not so focused on behavior change. It teaches you how to manage your experience in ways which render you more functional and definitely more self-aware.

This study, again, the lead author was Dr. Anvert Anz. This study was an international randomized control trial.

And what the study found was that it's not enough to offer individual schema therapy. You need to couple it with group schema therapy.

And so what Dr. Anz says is, in the Netherlands, there's a big push from mental health institutes to deliver treatments in group therapy only because people think it's more cost-effective.

But these findings question this idea.

The findings were published in a very prestigious academic journal, Journal of American Medical Association Psychiatry.

The study characterizes borderline personality disorder a bit idiosyncratically, I must say.

Many scholars would disagree with some of the characteristics of borderline personality disorder as incorporated in this study.

The study says that patients with borderline personality disorder exhibit extreme sensitivity to interpersonal threat. This kind of hypervigilance is actually much more typical in narcissistic personality disorder, not in borderline personality disorder.

The study says that patients with BPD have intense and volatile emotions, which is true, as we've seen in the previous study. Impulsive behaviors, also true. Many of them abuse drugs, self-harm, or attempt suicide. Wrong, it seems. About half of them do, not many of them.

At any rate, borderline personality disorder is by and large captured appropriately in the study. We can't disqualify the study as having explored other mental health disorders.

Patients in the study were clearly borderline.

When we look at evidence-based recommendations by various psychiatric and psychological associations around the world, the usual first venue or first resort is psychotherapy.

Psychotherapy is a primary treatment for people presenting with what appears to be borderline personality disorder, and so we need many more therapies.

Classical therapies such as psychoanalysis or cognitive, even cognitive behavior therapy, have proven to be inefficacious with borderline, hence the modification of DBT.

Schematherapy uses techniques from traditional psychotherapy, but it focuses, as I said, on an experiential strategy. It delves into early childhood experiences, and in the case of borderline personality disorder, this is very relevant, because in the vast majority of patients with borderline personality disorder, we do find adverse childhood experiences, trauma, abuse, and neglect in early life.

That is not to say that borderline personality disorder is not a brain abnormality. It's not to say that there is no genetic or hereditary component in borderline.

It seems that people who go on to develop borderline personality disorder as early as childhood, in childhood or adolescence, are people who have a propensity, a predilection, to develop borderline personality disorder genetically or cerebrally in the brain.

In other words, these people are somehow predisposed to develop borderline personality disorder because they have defective genes or brain abnormalities, but the trigger is environmental.

Nurture, not nature. In the absence of abuse, trauma, and neglect in early childhood, you're very unlikely to develop borderline personality disorder, even if you have all the genes and all the brain abnormalities.

So, schema therapy seems to be very relevant.

With this approach, therapists take on a kind of parenting role, and they try to meet the needs of these patients that were not met in early childhood.

The patient is perceived as a frustrated child, and the role of the therapist is to help the patient grow up and mature by acting the parent.

Previous research had suggested that both individual and group schema therapy help to reduce BPD symptoms, but what this study shows is that if you were to combine individual and group schema therapy, the benefit becomes exponential.

Treatment retention is also higher when you combine the therapy. It's the improvement in multiple secondary outcomes, happiness, quality of life, patient reports, and enhanced sense of well-being.

Still, just to put things in perspective, outcomes in society or in work are more improved in DBT than they are in this combined approach.

I want to be clear. Combining individual schema therapy and group schema therapy does improve societal and work-functioning patterns and outcomes, but not as much as DBT.

So, Arndt says that group therapy seems to offer something that is important for learning to cooperate with other people.

At work, you often have to collaborate with people who are not necessarily your friends. It's the same approach in DBT, by the way. There's a very strong dominant group element there.

The number of suicide attempts among patients exposed to combined schema therapy, the number of suicide attempts declined over time. The combination proved to be significantly superior to treatment as usual.

During the study period, three patients died of suicide, one in each treatment arm. Another third one was not, it wasn't clear that it was suicide. So, these are three out of hundreds. It's a major improvement in the statistics of suicide in typical borderline groups.

Overall, the results suggest that group and individual sessions address different needs of patients, said the investigators, while patients may learn to get along with others in a group setting, they may be more comfortable discussing severe trauma or suicidal ideation or thoughts in one-on-one sessions with a therapist.


So, let me read to you from the study. And again, go to the description, the zobibliography, with the list of all these studies and where to find them.

Let me read to you the key points of the study.

The question was, is group schema therapy for borderline personality disorder more effective than optimal treatment as usual? And is predominantly group schema therapy or combined individual and group schema therapy more effective?

The findings.

In this randomized clinical trial, which included 495 adult participants with borderline personality disorder in five countries, combined individual and group schema therapy was significantly more effective than optimal treatment as usual and predominantly group schema therapy.

So, the combination was much more effective in reducing BPD severity.

The findings add to the evidence for the effectiveness of schema therapy for borderline personality disorder and indicated the combination of individual and group schema therapy is the more effective schema therapy format.


Okay, let's go on to the next study. And the next study kind of challenges the common orthodox wisdom in all the treatment guidelines that I'm aware of all over the world.

If this study is replicated and supported by other studies, we have been doing things wrong for decades.

According to this study, and in a minute I'll read you the title of this study. Give me a minute.

Effect of three forms of early intervention for young people with borderline personality disorder.

The MOBI, M-O-B-Y, randomized clinical trial.

The lead author is Andrew Channon, CHANEEN. And as usual, I'll first analyze the study and then read to you from the study.

What the study says is that early interventions that focus on clinical case management and psychiatric care and not on individual psychotherapy are more effective for young patients with borderline personality disorder.

You remember that we can diagnose and do diagnose borderline personality disorder as early as 12 years old.

It's not the case with narcissistic and antisocial personality disorder, which are diagnosed only after age 18 or sometimes 21.

Borderline can be diagnosed very early, only in life.

And so we have patients, they're underage, and we need to treat them somehow.

And hitherto, all the treatment guidelines all over the world said that what you do with such a young patient is give him or her psychotherapy.

And what this study says, it's a wrong approach.

You should focus on clinical case management. You should focus on psychiatric care, including medication.

And there is this trial, big trial, called Monitoring Outcomes of Borderline Personality Disorder in Youth, the MOBI trial, a M-O-B-Y trial. It showed improved psychosocial functioning and reduced suicidal ideation with early psychiatric intervention and case management.

So the results of this study suggest that psychotherapy is not the only or even first effective approach for early BPD.

Dr. Chainen is the Director of Clinical Programs and Services and Head of Personality Disorder Research at Origin, Melbourne, Australia. And he said, we can say that early diagnosis and early treatment is effective, and the treatment doesn't need to involve individual psychotherapy, but does need to involve clinical case management and psychiatric care.

Patients with BPD have extreme sensitivity to interpersonal slides and exhibit all kinds of volatile emotions and impulsive behavior.

As we said, many self-harm, abuse drugs, attempt suicide. The suicide rate among patients with Borderline Personality Disorder, to remind you, is anywhere between 8 and 11%, depending on the country.

The condition is diagnosed in puberty or early adulthood, and it affects about 3% of young people.

Luckily for humanity, many of these young people grow out of their Borderline Personality Disorder.

There are two ways where you can lose the diagnosis, between ages 12 and 21, and then after age 45. Only one third of young adults or adolescents diagnosed with Borderline Personality Disorder go on to become adults with the diagnosis of Borderline Personality Disorder.

But these patients, young patients, they are volatile, they are labile, they are dysregulated, they are aggressive, they have enormous interpersonal difficulties, and they are discriminated against by health professionals. They don't get treated. Those that are treated are often shunted off to some therapists, once a month or something. They receive individual psychotherapy. A very small percentage of them end up in the Dialectical Behavioral Therapy program.

Let me be clear, individual psychotherapy is a good thing. These therapies, especially DBT, teach you healthy ways to cope with stress and to regulate emotions. And so these therapies are highly effective.

But the MOBI trial examined three treatment approaches, not only one.

The first treatment approach is called the Help Young People Early model, Hype.

The second is Hype, combined with weekly befriending. And the third was a general youth mental health service, YMHS model, combined with befriending.

So a key element of Hype is cognitive analytic therapy. It's a psychotherapy program focused on understanding problematic self-management and interpersonal relationship patterns.

The model also includes clinical case management, for example, housing, vocational and educational issues, other mental health needs, comorbidities like depression and anxiety, medication, physical health needs.

In the second model, psychotherapy of the Hype program is replaced. You have all the elements of clinical case management, but instead of psychotherapy, you have befriending. Befriending means chatting with the patients, with the patients. The chats are about neutral topics. I don't know, sports. Avoiding emotionally loaded topics, avoiding actually not discussing interpersonal problems.

And the third approach was YMHS plus befriending. It's when the experts trained young people. They were trained in the they gave the young people therapy. They managed the patients, but these therapists were not specialists in BPD.

So the third approach is what we call as usual treatment or treatment as usual approach. Therapists, psychologists who are not experts and scholars of BPD, but treat BPD as well. All patients across all three groups had marked and sustained improvements in ways you wouldn't expect for borderline personalities or interventions have a true effect, especially in childhood and puberty.

The results suggest that early diagnosis and not very complicated treatment or even just chatting to someone drastically improves the lives of these young people. The results also imply that there are effective alternatives to near treatment as usual psychotherapy.

The insistence of the field by many scholars and many institutions and many treatment guidelines, the insistence that only therapy works in BPD is wrong.

Cheyenne says this study turns things upside down and says actually that psychotherapy is not the single modality. It's the basics of treatment that are important, not which treatment.

When a patient presents at an emergency department following, for example, severe overdose, clinicians reflexively refer that person to a psychotherapy program.

But the problem is these programs are not built to service the needs of suicidal borderline personality disorder patients. They are canvassing programs and most of the workers in these programs, albeit with academic degrees in psychology, are not experts in the extremely convoluted and complicated dynamic of borderline personality disorder.

The skills for clinical case management and psychiatric care are very specialized. So this is the study.

John Oldham, who is a distinguished emeritus professor in the Menninger Department of Psychiatry and Behavioral Sciences in Baylor College of Medicine, Houston, Texas.

Oldham says the general standard approach in psychiatry in the diagnostic world has been to not even consider anything until after somebody is 18 years of age, which is a mistake because these kids can become quite impaired much earlier than that, he says incorrectly.

Oldham was not involved in this study. Ironically, he was one of the main contributors and authors of the very treatment guidelines, which are undermined by this study.

And yet, amazingly at his age, and with his renomé and track record, Oldham is an example of a good scientist, a scientist who is open to new information, scientist who is capable of modifying his views very substantially when exposed to new findings.

Oldham says there is an emerging trend towards good psychiatric management that focuses on level of functioning rather than on a specific strategy requiring a certificate of training that not many people out there have.

Oldham says. You're not going to make much headway, he concludes with his keys. You're not going to make much headway with these keys.

If you are going to be searching around for a DBT certified therapist, what you need is to bring them in, get them to trust you, and in a sense, to be a kind of overall behavioral medicine navigator for them.


Let me read to you from the study, as I usually do. By the way, the study comes with a beautiful graphic.

And so the study, the key points are, question, what combination of treatment components is sufficient for early intervention for young people with borderline personality disorder? And the findings in this randomized clinical trial with 139 youth with borderline personality disorder, a dedicated BPD service model and a specialized BPD psychotherapy were associated with superior retention in care, but not a superior rate of change in psychological functioning by 12 months. And this is compared with general youth mental health care in a psychotherapy controlled condition.

Effective early intervention for BPD is not reliant on availability of BPD psychotherapy.

This is a major change in orientation. It means that when we are confronted with a young BPD patient, we should immediately take care of all the aspects of his functioning and his life. We should befriend him, in which we should offer a complete or total solution, not focus on psychotherapy, which often doesn't work or works less effectively.

And there are very few people qualified to administer it.


And so now I want to review six studies of psychosocial interventions.

It is an article titled, borderline personality disorder, six studies of psychosocial interventions by Sai Atizaz Sayed and Angela Kallis, published in the Journal of Current Psychiatry in 2002.

So the first study is by Zanarini, Konki and Temis.

But before we go there, a reminder of what is borderline personality disorder.

Borderline personality disorder is a serious impairment on multiple levels and in multiple areas of life, starting with emotional dysregulation and affect instability.

But psychosocial functioning is severely affected. There's an ongoing pattern of mood instability or mood lability, cognitive distortions, problems with self-image, impulsive behavior that often results in problems in the workplace and in relationships.

Patients with BPD tend to utilize more mental health services than patients with any other mental health disorder or even with major depressive disorder. Many clinicians believe that BPD is very difficult to treat. This is no longer true. This hasn't been true for decades.

But the stigma lingers on. Historically, there's been little consensus on the best treatments for these disorders. And currently, we use pharmacologic and psychological interventions in combination.

And so I want to review six studies very briefly.

So again, the first one is titled Randomized Control Trial of Web-based Psychoeducation for Women with Borderline Personality Disorder. It was published in the Journal of Clinical Psychiatry in 2018.

The authors are the authors of Zandarini, Konki and Temis. I'm reading the abstract.

Research has shown that BPD is a treatable illness with a more favorable prognosis than previously believed. Despite these, patients often experience difficulty accessing the most up-to-date information on BPD, which can impede their treatment.

A 2008 study by Zandarini and allies of younger female patients with BPD demonstrated that immediate in-person psychoeducation improved impulsivity and relationships. Widespread implementation of this program proved problematic, however, due to cost and personnel constraints.

To resolve this issue, researchers developed an internet-based version of the program.

In a 2018 follow-up study, Zandarini and his collaborators examined the effect of this internet-based psychoeducation program on symptoms of BPD. And the outcomes were pretty astonishing.

In the acute phase, treatment group participants experienced statistically significant improvements in all 10 endpoints and outcomes.

It seems that in patients with BPD, internet-based psychoeducation reduced symptom severity and improved psychosocial functioning, with effects lasting up to one year.

Treatment group participants experienced clinically significant improvements in all outcomes measured during the acute phase of the study. Most improvements were maintained over one year.

So this is a pretty interesting study.


The next study is a randomized trial of brief dialectical behavioral therapy skills training in suicidal patients suffering from borderline disorder. It was published in Acta Psychiatrica Scandinavia, Scandinavia 2017. The authors were McCain and Guillemot and Barnhart.

So they said, standard dialectical behavioral therapy, DBT, is an effective treatment for BPD. However, access is often limited by shortages of clinicians and resources.

Therefore, it has become increasingly common for clinical settings to offer patients only the skills training component of DPD, which requires fewer resources.

While several clinical trials examining brief DBT, DBT skills, only treatment for BPD, several clinical trials examining this shortened or condensed version of DPD for BPD, these studies have shown promising results, it is unclear how effective this kind of intervention is introducing suicidal or non-suicidal self-injury episodes.

So the study explored the effectiveness of brief DPD DBT skills, only adjunctive treatment on the race of suicide and NSSI episodes in patients with BPD.

I'll summarize this for you.

DPD is expensive. DPD is costly. DPD DBT requires training. DBT is not available everywhere to everyone.

So there's a sort of zipped, a sort of zipped or condensed version of DBT, which offers only skills training.

The authors try to find out if BPD patients subjected to abridged DBT, the skills training component of DBT, if these patients responded favorably to the treatment by reducing rates of suicide and self-injury, which was not suicidal.

And so the outcomes were that the DBT group showed statistically significant greater reductions in the frequency of suicidal and NSSI episodes.

So the DBT group experienced statistically significant improvements in distress tolerance and emotion regulations, but no difference on mindfulness.

The DBT group achieved greater reductions in anger over time.

So it seems that yes, there are impacts.

Even if we use only a single component of DBT, it already has massive effects on multiple, very crucial dimensions of BPD.

The DBT group showed significant improvements in social adjustment, symptom distress, borderline symptoms, but no significant change in impulsivity.

Clinical improvements were the statistics, the statistical measures are very significant, so it's pretty safe to say that these outcomes are real.

The conclusions are brief DBT skills training, reduced suicidal and NSSI self-injury episodes in patients with BPD.

Participants in the DBT group also demonstrated greater improvements in anger, distress tolerance and emotion regulation compared to the control group.

These results were evident three months after treatment.

However, any gains in healthcare utilization, social adjustment, symptom distress, and borderline symptoms diminished or did not differ from the other participants at week 32.

At that time, participants in the DBT group demonstrated a similar level of symptomatology as the control group.

So this was the second study.


The next study is titled Combined therapy with interpersonal psychotherapy adapted for borderline personality disorder. A two-year follow-up was published in 2016. The authors are Vozatello and Bellino.

Ah, I love Italian, how musical.

The study was interesting. It says that psychotherapeutic options for treating BPD, including DBT, mentalization-based treatment, schema-focused therapy, transference-based psychotherapy, and systems training for emotional predictability and problem solving. All these are psychotherapeutic options, but they're not widely available.

More recently, interpersonal therapy also has been adopted for BPD. It is known as IPT BPD.

However, thus far, say the authors, no trials have investigated the long-term effects of this particular therapy on BPD.

In 2010, Bellino and allies published a 32-week study examining the effect of IPT BPD on BPD. They concluded that IPT BPD, in other words, interpersonal therapy, adapted for BPD. They concluded that IPT BPD plus Prozac was superior to Prozac alone in improving symptoms and quality of life.

The present study by Vozatello and allies examined whether the benefits of IPT BPD plus Prozac demonstrated in the 2010 study persisted over a 24-month follow-up.

And so the outcomes were, while the original study demonstrated that combined therapy had a clinically significant effect over Prozac alone on BPD, this advantage was maintained only at the six-month assessment.

The improvement of the combined therapy provided over Prozac monotherapy and with regards to impulsivity and interpersonal relationships, as well as factors of social and psychological functioning at 32 weeks were preserved at 24 months.

No additional improvements have been seen.

The conclusions of the study are that the improvements in impulsivity, interpersonal functioning, social functioning and psychological functioning at 32 weeks were seen with IPT BPD plus Prozac, compared with Prozac alone, persisted for two years after completing therapy.

But no further improvements were seen.

The improvements to anxiety and affective instability that combined therapy demonstrated over Prozac monotherapy at 32 weeks when not maintained after 24 months.

So the next study is favorable outcome of long-term combined psychotherapy for patients with borderline personality disorder, six-year follow-up with a randomized study.

Again in psychotherapy research, 2017, the authors were Antonesen, Kvarshstein, and Ernest.

While many studies have demonstrated the benefits of psychotherapy for treating personality disorders, say the authors, there is limited research of how different levels of psychotherapy may impact treatment outcomes.

There is something called the Uleval Personality Project. It compared an intensive combined treatment program with outpatient individual psychotherapy in patients with personality disorders. The combined treatment program consisted of short-term day hospital treatment followed by outpatient combined group and individual psychotherapy.

The outcomes evaluated included suicide attempts, suicidal thoughts, self-injury, psychosocial functioning, symptom distress and interpersonal personality problems.

A six-year follow-up concluded that there were no differences in outcomes between the two treatment groups.

However, the authors examined whether combined therapy, the combined psychotherapy, produced statistically significant benefits over the outpatient therapy in a subset of patients with borderline personality disorder.

So you remember that the group included many types of personality disorders.

So these authors wanted to home in to focus on patients with borderline personality disorder and to see whether combined therapy was superior to outpatient therapy in the case of BPD only.

So they discovered that when it comes to BPD, borderline personality disorder, compared to the outpatient group, the combined psychotherapy group demonstrated statistically significant reductions in symptom distress.

At year six, in between years three and six, the combined psychotherapy group continued to show improvements in psychosocial functioning. So the outpatient psychotherapy group worsened during this time.

The scores of this group worsened during this time compared to the outpatient group.

Participants in the composite group also had significantly better outcomes on multiple domains of self-control and identity integration. There were no significant differences between groups on the proportion of participants who engaged in self-harm or experienced suicidal thoughts or attempts. There were no significant differences in outcomes between the treatment groups in all these domains.

Participants in the composite group tended to use fewer psychotropic medications than those in the outpatient groups over time. But this difference was not statistically significant. The two groups did not differ in the use of health care services over the last year.

Avoidant personality disorder did not have a significant moderate effect in this case.

Comorbid avoidant personality disorder was actually a negative predictor, independent of the group. Both groups experienced a remission rate of 90% at six-year follow-up.

Compared with the outpatient group, participants in the composite group experienced significantly greater reductions in symptom distress and improvements in self-control and identity integration at six years.

So this is the study.

The next study is eight-year prospective follow-up of mentalization-based treatment versus structured clinical management for people with borderline personality disorder. It was published in the Journal of Personality Disorders, 2021, and the authors of Bateman, Constantino, and Phonology.

They say the efficacy of various psychotherapies for symptoms of BPD has been well-established. However, there is limited evidence that these effects persist over time.

In 2009, Bateman and others conducted an 18-month study comparing the effectiveness of outpatient mentalization-based treatment, MBT, against structured clinical management for patients with BPD. Both groups experienced substantial improvements, but patients assigned to mentalization-based treatment demonstrated greater improvement in clinically significant problems, including suicide attempts and hospitalization.

In a 2021 follow-up to this study, Bateman and allies investigated whether the MBT group, the mentalization group, the gains in this group in the primary outcomes, absence of severe self-harm, suicide attempts, and inpatient admissions in the previous 12 months, the gains in social functioning, the gains in vocational engagement, mental health service usage, whether these gains were maintained throughout an eight-year follow-up period.

So the outcomes were that the number of participants who met diagnostic criteria for BPD at the one-year follow-up was significantly lower at the mentalization-based group compared with the other group.

To improve participant retention, this outcome was not evaluated at later visits. The number of participants who achieved the primary recovery criteria of the original trial, to remind you, absence of self-harm, suicide attempts, and inpatient admissions, the number of patients who achieved these primary recovery criteria and remained well throughout the entire follow-up period was significantly higher in the mentalization group compared with the other group.

The average number of years through during which participants failed to meet recovery criteria was significantly greater in the other group compared to the mentalization group.

When controlling for age, treatment group was a significant predictor of recovery during the follow-up period.

Overall, significantly fewer participants in the mentalization group experienced critical incidents during the follow-up period, which was a very long follow-up period.

The other group, the non-mentalization group, used mental health services for a significantly greater number of follow-up years than the mentalization group.

The likelihood of using crisis services did not statistically differ between the groups, but the first group, the non-mentalization group, used these services much more.

MBT group participants spent more time in education, were less likely to be unemployed, were less likely to use social care interventions than the other group.

People in the MBT group spent more months engaged in purposeful activity, etc. They had fewer months of psychotherapeutic medication compared to the other group and so on.

The study demonstrated that patients with BPD significantly benefited from specialized therapies such as mentalization-based therapy.

At the one-year follow-up, the number of participants who made diagnostic criteria for BPD was significantly lower in the mentalization group.

The number of participants who achieved the primary recovery criteria and remained well during the eight-year follow-up period was also significantly higher in the mentalization group.

Mentalization is a third option after DBT and schema therapy.

Finally, a sigh of relief. Finally, an article titled, Effectiveness and Safety of the Adjunctiviews of an Internet-based Self-Management Intervention for Borderline Personality Disorder, in addition to care as usual, results from a randomized controlled trial. It was published in the BMJ Open Access, BMJ 2021. The authors are Klein, Hauer, and Bergen.

They say fewer than one in four patients with BPD have access to effective psychotherapies.

The use of Internet-based self-management interventions developed from evidence-based psychotherapies can help close this treatment gap.

Although the efficacy of Internet for several mental health disorders has been demonstrated in multiple mental analyses, results for BPD are mixed.

In this study, Klein and allies examined the effectiveness and safety of the adjunctiviews of an Internet-based self-management intervention based on schema therapy in addition to care as usual in patients with BPD.

So the outcomes were there were large reductions in the severity of BPD symptoms as measured in various ways.

In people who used an Internet-based intervention method, this difference was statistically significant.

There was no statistically significant difference in the number of serious adverse events between the two groups.

So the conclusion was that treatment with an Internet-based intervention module did not result in improved outcomes over care as usual.

Although the average reduction was greater in this group compared to the reduction in symptoms was greater in this group compared to the control group, this difference was not statistically significant.

The authors believe that because many of the patients were receiving psychotherapy, the study should be taken with a grain of salt.

But it's interesting. It's interesting because many people resort to the Internet as a first option. You know, support groups, forums, even Internet-based psychotherapy.

This study seems to indicate that it's not working.

Many groundbreaking and earth-shattering discoveries. I thought I'd bring them to your attention. Thank you for surviving and see you next time.

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