Clinical severity as a moderator of outcome in psychodynamic and dialectical behavior therapies for borderline personality disorder.

Abstract

The aim of the present study was to assess the effect of initial level of psychiatric severity on treatment outcome in psychodynamic therapy and dialectical behavior therapy (DBT) for borderline personality disorder (BPD). It was hypothesized that DBT would lead to better outcome for patients with high psychiatric severity, whereas dynamic treatment would lead to better outcome for patients with lower psychiatric severity. Data from the 5th-year follow-up of the Stockholm City Council's and the Karolinska Institute's Psychotherapy Project were used in the present study. A total of 106 female patients diagnosed with BPD with at least 2 past suicide attempts were randomized into object-relational psychotherapy (ORP; based on transference-focused psychotherapy), DBT, and treatment as usual. Patients' baseline global severity index was used as a moderator. Global Assessment of Functioning (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition [American Psychiatric Association, 1994]) was used to examine outcome. There was a significant 3-way interaction of Time × Treatment × Severity. Post hoc analyses suggested that patients with lower levels of severity had significantly better outcomes in object-relational psychotherapy. For patients with higher severity, the 3 treatments resulted in similar outcomes in terms of level of functioning. Outcome of treatment for BPD might differ significantly for patients depending on their initial levels of overall psychiatric severity. If our findings are replicated for patients with low severity and supported for a high-severity sample, psychiatric severity can be used as a low-cost and effective tool to match patients with BPD to optimal treatments. (PsycINFO Database Record

A proposed severity classification of borderline symptoms using the borderline symptom list (BSL-23)

“…For instance, it is unclear whether the currently recommended evidence based psychosocial treatments [2] should be applied in all BPD patients, or whether a differential indication based on symptom severity might reveal better treatment results. In particular, the studies by Bateman & Fonagy [3] and by Sahin et al [4] indicate that the relative efficacy of treatments might be moderated by the severity of the disorder. Accordingly, most clinicians and researchers agree, that in addition to the categorical diagnostic, the severity of the disorder should be defined.…”

Dialectical behavioral therapy for the treatment of adolescent eating disorders: a review of existing work and proposed future directions

“…Following the initial determination of efficacy and effectiveness of DBT for adolescent eating disorders, it will be important to determine for whom DBT may be best suited. We recommend that researchers and clinicians use existing moderator research in DBT for other presenting problems (e.g., Sahin et al, 2018) as a starting point for determining for whom DBT is most effective. We also recommend that researchers and clinicians consider a range of clinical characteristics-diagnostic, demographic, developmental, or psychological-that may indicate or contraindicate the use of DBT or influence outcome.…”

Long-term clinical and functional course of borderline personality disorder: A meta-analysis of prospective studies

“…In addition to naturalistic research, clinical trials of psychotherapeutic interventions for BPD have recently shown greater interest in their long-term outcomes, reporting follow-up data for five years or more [19, 20, 21, 22, 23]. This longitudinal perspective on efficacy studies underlines the relevance of treatment as a potential factor of change over time.…”