A meta-analysis of psychodynamic treatments for borderline and cluster C personality disorders.

Abstract

Personality disorders (PD) carry high psychosocial dysfunction and are associated with treatment resistance in nonspecialized care. Psychodynamic therapies (PDT) are often used to treat PDs, but there has never been a systematic meta-analysis of PDT trials for PD. To evaluate the evidence base for PDTs for PDs across multiple outcome domain, a systematic search for PDT for PD trials was conducted through PubMed and PsycINFO. Sixteen trials were identified, comprising 19 dynamic, 8 active, and 9 control groups predominantly reflecting treatment of borderline and mixed Cluster C PDs, and a random effects meta-analysis was undertaken. PDTs were superior to controls in improving core PD symptoms (g = −0.63; 95% confidence interval [CI; −0.87, −0.41]), suicidality (g = −0.79, p = .02; 95% CI [−1.38, −0.20]), general psychiatric symptoms (g = −0.47; 95% CI [−0.69, −0.25]), and functioning (g = −0.66; 95% CI [−1.01, −0.32]), but not for interpersonal problems due to heterogeneity (g = −1.25; 95% CI [−3.22, 0.71]). Outcomes for PDTs were not different from other active treatments in core PD (g = 0.05; 95% CI [−0.25, 0.35]) or other symptoms. This pattern continued into posttreatment follow-up (average 14 months). Study quality was generally rated as adequate and was unrelated to outcomes. Compared with other treatments, PDTs do not have different acute effects and are superior to controls, although only trials treating BPD employed active controls and non-BPD trials were of lower quality. Underresearched areas include narcissistic PD, specific Cluster C disorders, and personality pathology as a continuous construct.

Treatment selection in borderline personality disorder between dialectical behavior therapy and psychodynamic psychiatric management

“…Overall, our results suggest that a ‘one-size fits all’ or uniform approach to the treatment of BPD may leave some patients with an inadequate recovery from symptoms, as their baseline characteristics imply a need for or enhanced response to one treatment over another. Clinical trials comparing two active treatments for BPD are uncommon (Cristea et al, 2017; Keefe et al, 2019), but may be useful to conduct to provide clinicians with more precise information as to optimal therapies for their patients. Research distinguishing and capitalizing on heterogeneity among patients meeting for BPD may lead to better targeted, patient-personalized treatments.…”

“…Most head-to-head comparison of specialized treatments for BPD has found cognitive-behavioral and psychodynamic therapies to have similar outcomes (Cristea et al, 2017; Keefe et al, 2019). While some therapies have demonstrated potentially unique benefits, such as transference-focused psychotherapy (TFP) improving attachment and mentalization (Keefe & DeRubeis, 2019; Levy et al, 2006) and dialectical behavior therapy (DBT; Linehan, 1993) improving coping behaviors that help prevent suicide attempts (Neacsiu, Rizvi, & Linehan, 2010), generally there are few data recommending any particular approach over another.…”

Dynamic deconstructive psychotherapy in Iran: A randomized controlled trial with follow-up for borderline personality disorder.

“…A meta-analysis of effectiveness of long-term psychodynamic therapies relative to controls across conditions reported a larger overall effect size for DDP than for any of the other treatments, with the exception of an 18 month psychoanalytic day hospital (Woll & Schönbrodt, 2019). In a meta-analysis of psychodynamic therapies for personality disorders, DDP compared very favorably with other treatments for core symptoms of BPD (Keefe et al, 2020).…”

How are expert therapists similar, different, and integrative in the treatment of borderline personality disorder?

“…Borderline personality disorder (BPD) is a complex disorder to treat; however, recent research has enhanced the understanding and treatment of BPD (Barnicot et al, 2011; Cristea et al, 2017; Finch et al, 2019; Keefe et al, 2020; Storebø et al, 2020). The criteria for BPD in the Diagnostic Statistical Manual of Mental Disorders, Fifth Edition (American Psychiatric Association, 2013) includes frantic efforts to avoid real or imagined abandonment, unstable self-image, impulsivity (potentially self-damaging), recurrent suicidal behavior or threats, affective instability, feelings of emptiness, intense anger, stress-related paranoid ideation, and a pattern of unstable and intense interpersonal relationships that alternate between idealization and devaluation.…”

“…This leads to strong emotional reactions in both the patient and the therapist (Stolorow, 1995), and thus a dynamic therapist is attuned to the patient–therapist relationship. Related to this clinical model, psychodynamic therapy has demonstrated both efficacy and effectiveness with BPD patients (Cristea et al, 2017; Keefe et al, 2020).…”