Borderline Personality Disorder Recent Psychodynamic therapy Trials

BATEMAN AND FONAGY PARTIAL HOSPITILISATION STUDIES 1999, 2001, 2003, 2008 (1) 38 BPD patients Random Allocation 18/12 partial Hospitalisation General Psychiatric Care Individual and group Psychotherapy (Rx as Usual) PH Stat sign - suicide attempts - self harming - number and duration I/P stays - self reports – depression, anxiety general symptom distress, interpersonal functioning and social adjustment Began after 6/12 Continued to end. TAU group limited change or deterioration

BATEMAN AND FONAGY – PH STUDIES (2) Follow up of original group. 3/12ly for 18/12 of 44 patients Maintained gains and continued to improve (stat. sign.) on most measures for PH group. Limited change in TAU group Rehabilitative change

BATEMAN AND FONAGY – PH STUDIES COSTS – Psychiatric, Pharmacological, A&E Pre Rx and during Rx – No differences in service utilisation cost of day care in PH group balanced by less I/P care and less A&E Trend for costs in PH group during F/U no trend for costs in TAU group

8 yr follow up-5yrs after Rx 2008 Rxed group-13% vs 87% TAU group still meet criteria for BPD Stat sig decrease in suicidality, service and medication use in Rx Gp Stat sig increase in global and vocational functioning in Rx Gp But still appreciable social and functional impairment- quality of life. Bateman and Fonagy Am J Psych 165 631-638

Transference Focused Therapy (TFP) Clarkin et al 2007-Am J Psych 164:6 922-928- RCT Levy et al 2006-J Cons and Clin Psychol 74(6) 1027-1040.RCT Structured Outpatient treatment-twice weekly, modified psychodynamic Rx based on Kernberg’s theoretical model

TFP /DBT/SPT Clarkin et al-1yr figs All broadly equivalent overall but individual domains differ-?different routes to symptom change TFP and DBT reduce suicidality TFT and SPT reduce anger and impulsivity All reduce depression, anxiety All improve global functioning All improve social adjustment Only TFT sign predictive of changes in irritability, verbal and physical assault

TFP /DBT/SPT Clarkin et al-1yr figs All broadly equivalent overall but individual domains differ-?different routes to symptom change TFP and DBT reduce suicidality TFT and SPT reduce anger and impulsivity All reduce depression, anxiety All improve global functioning All improve social adjustment Only TFT sign predictive of changes in irritability, verbal and physical assault

Attachment changes in Levy 2006 Same trial as Clarkin Sign inc in attachment security on AAI in TFP not others Sign inc in reflective functioning, and attachment coherence in TFT not others

Borderline Personality Disorders Are Common Frequently exist as co-morbid disorders Arouse powerful feelings in staff and teams Can test professional boundaries Can be understood Can be treated-often need combined psychotherapy and pharmacotherapy MBT,DBT TFP all effective Treatment teams need to communicate