Advances in Psychotherapy of Personality Disorders: A ... - Springer Link

Advances in Psychotherapy of Personality Disorders: A Research Update Shelley McMain, PhD, and Alberta E. Pos, PhD

Corresponding author Shelley McMain, PhD Centre for Addiction and Mental Health, 33 Russell Street, Toronto, Ontario M5S 2S1, Canada. E-mail: [email protected] Current Psychiatry Reports 2007, 9:46–52 Current Medicine Group LLC ISSN 1523-3812 Copyright © 2007 by Current Medicine Group LLC

This article reviews psychotherapy studies published between 2003 and 2006 directed at psychotherapy for personality disorders (PDs). Over the past 3 years, there has been a substantial increase in these studies compared with previous decades. Psychodynamic therapy, cognitive-behavioral therapy, and variants of these approaches have been evaluated and shown to have positive results. Borderline personality disorder continues to garner the most attention and has been shown to respond favorably to several types of therapeutic interventions on a range of outcomes. Avoidant personality disorder and obsessive-compulsive personality disorder also respond positively to psychotherapy. Although growing attention to the treatment of PDs is encouraging, further research is indicated. A summary of recent empirical ﬁndings and their implications for clinical practice are discussed.

Introduction Personality disorders (PDs) are associated with high prevalence rates, serious morbidity, and significant personal and social costs. Programs designed to treat them are scarce and difficult to access, and health professionals often lack adequate training in the treatment of these disorders. Reasons for this neglect include the following: 1) the clinical challenges associated with this population; 2) a prevailing belief that people with PDs derive little benefit from treatment; and 3) until recently, the lack of evidence-based treatment data. Fortunately, our understanding of the treatment of PDs is improving, based on two promising lines of research: the growing number of well-controlled trials demonstrating the effectiveness of various treatments and longitudinal studies that reveal

higher rates of remission than previously assumed [1]. Subsequent to studies discussed in previous reviews [2–10], this article highlights recent well-controlled studies (eg, randomized controlled trials [RCTs] or quasi-experimental trials) with a primary focus on the treatment of Axis II disorders and published in English between January 2003 and October 2006. We review new evidence and comment on its implications for treatment and future research.

Evidence from Recent Psychotherapy Studies of PDs Although the overall number of RCTs of psychotherapy of PDs is small, there has been considerable growth in the field. Over this 3-year review period, twice as many RCTs on the effectiveness of psychotherapeutic interventions for PDs have been published than during the preceding 2 decades. Most studies have focused on dynamic therapy (DT), cognitive-behavioral therapy (CBT), or their variants. We begin by highlighting a recent meta-analysis and follow with a review of research on specific and then general PDs.

Evidence from a Meta-analytic Study Leichsenring and Leibing [11] conducted a meta-analysis of the effectiveness of psychotherapy of PDs. They identified 26 studies published between 1974 and 2001, of which five were RCTs. Psychotherapy produced medium to large effect sizes. Both DT and CBT resulted in improvements in symptom and personality measures; however, several limitations of the research were noted. Meaningful comparisons of treatment approaches could not be made due to different outcome measures, treatment lengths, and follow-up periods; variability in treatment protocols; and heterogeneity between and within study samples. Furthermore, twice as many subjects received DT as CBT treatment, which biased results in favor of DT. The authors caution that their findings are preliminary and that more well-controlled trials are needed.

Advances in Psychotherapy of Personality Disorders

Borderline Personality Disorder (BPD) Binks et al. [12•], in a meta-analysis of the effectiveness of psychosocial treatments of BPD, identified seven RCTs or quasi-randomized trials, all published prior to 2003, involving 262 individuals. Results supported the effectiveness of dialectical behavior therapy (DBT) and psychodynamically oriented day treatment. Again, the authors caution that the studies are too few and small to allow for confidence in findings. We identified 13 recent psychotherapy outcome trials of BPD, of which six were RCTs [13••–16••,17–20], all focusing on variants of CBT. Many studies included treatment-as-usual (TAU) comparison groups. Two involved comparisons of an experimental treatment with an active comparator treatment [13••,14••], and two examined the costs of treatment [21,22]. There is continued interest in the evaluation of DBT. DBT is distinguished from traditional CBT by its emphasis on balancing change and acceptance strategies. Two RCTs contribute additional support for the effectiveness of this approach. Linehan et al. [13••] randomized 101 women diagnosed with BPD and recent suicidal or selfinjurious behaviors to either DBT or treatment by experts (TBE). Compared with TBE, the DBT group was half as likely to attempt suicide and had fewer hospitalizations and emergency room visits, decreased medical risk associated with self-harm behaviors, and better treatment retention. However, at discharge, measures of depression and suicidal ideation remained elevated. In the first independent replication of DBT, conducted in the Netherlands [18], 58 women diagnosed with BPD, some with substance use disorders, were randomized to standard DBT or to a TAU control. DBT was associated with better treatment retention and decreases in self-mutilating and self-damaging impulsive behaviors. No between-group differences were found on substance abuse. Two German studies evaluated the efficacy of DBT adapted to inpatient settings. In a nonrandomized controlled trial, Bohus et al. [23] compared 3 months of inpatient DBT to a wait-list control in 50 women who had at least one suicide attempt or two nonsuicidal self-injurious acts within 2 years prior to treatment. Compared with the control group, the DBT group showed greater reductions in self-mutilating behaviors, suicide risk, depression, anxiety, interpersonal functioning, and global psychopathology. In a similar study, Kroger et al. [24] reported on 50 patients with BPD admitted to a 3-month DBT inpatient treatment. At 15-month follow-up, improvements were observed on measures of psychopathology (general symptoms and depression) and global functioning. In an uncontrolled trial that provided preliminary support for a brief intensive adaptation of DBT [25], 87 BPD patients were treated in a 3-week outpatient program. In contrast to standard DBT, sessions were held 4 days per week, with each lasting 2 to 4 hours. Patients showed

McMain and Pos

47

significant improvement in levels of depression, hopelessness, and hospitalization rates. CBT has been the focus of a few recent studies. In the first published trial of CBT for BPD [26], 32 individuals treated for a year in weekly sessions made moderate gains on levels of depression, suicidal ideation, hopelessness, and borderline symptoms. BPD diagnostic criteria were met by 48% of the sample at termination and by just 16% at 18-month follow-up. In the BOSCOT study, a multisite trial of CBT for BPD conducted in the United Kingdom [15••,16••,17], 106 individuals were randomly assigned to 1 year of either CBT plus TAU or TAU alone. At the end of treatment and at 1-year follow-up, patients receiving CBT plus TAU were less likely to have attempted suicide and showed more improvement in dysfunctional beliefs, state anxiety, and symptom distress. No between-group differences were evidenced on levels of depression, social functioning, quality of life, psychiatric symptoms, and interpersonal functioning or the level of distress. Dysfunction remained relatively high for all patients at the end of treatment. An economic analysis indicated that CBT did not result in cost benefits [16••]. Finally, several brief CBT skills-based approaches for BPD have been examined. One of these approaches, STEPPS, is a 20-week, skills-based group involving BPD awareness, skills training in emotional management and behavioral control, and education of patients’ support system [27–29]. It was developed to complement existing treatments. Blum et al. [27], in a sample of 53 individuals meeting criteria for BPD, found that STEPPS resulted in reductions in BPD symptoms, negative affect, and negative behaviors. In the Netherlands, Freije et al. [30] studied 85 individuals with BPD and found that STEPPS improved borderline symptoms, global functioning, depression, anxiety, and interpersonal sensitivity. Other brief interventions have been tested and provide preliminary support for the effectiveness of brief, skillsbased interventions for the treatment of BPD. Weinberg et al. [19] randomly assigned 30 patients with BPD to either manual-assisted cognitive therapy (MACT) plus TAU or TAU alone. MACT consists of bibliotherapy and up to six CBT sessions based on DBT strategies [31,32]. Compared with TAU, patients receiving MACT plus TAU had greater reductions in the frequency and severity of deliberate selfharm behavior at post-treatment and at 6-month follow-up. Further, MACT contributed more to these outcomes than did the concurrent treatments. Gratz et al. [20] examined the efficacy of a 14-week emotion regulation group designed to improve emotion regulation skills and reduce self-harm behaviors. Based on a small sample of 22 subjects who were randomized to receive this group intervention in addition to standard care or to continue with their standard care, results indicated that the group intervention produced significant improvements in self-harm behavior, BPD symptoms, and emotion dysregulation. In the first controlled trial of schema-focused therapy (SFT), an integrative approach that combines CBT, expe-

48

Personality Disorders

riential therapy, attachment theory, and psychodynamic theory [33], 88 patients with BPD were randomized to 3 years of either twice-weekly SFT or transference-focused therapy (TFP). Although both groups improved on personality constructs, patients receiving SFT showed superiority on all outcome measures, including BPD severity, general psychopathologic dysfunction, and quality of life. In addition, the SFT group had a lower attrition rate. Stevenson et al. [34] reported follow-up data on 30 of 48 subjects from their uncontrolled trial of 1-year, twiceweekly conversational model therapy (manualized as psychodynamic–interpersonal). At 4 years postdischarge, gains on self-harm behaviors, violent episodes, use of drugs, medical visits, and length of hospital admissions were maintained. Bateman and Fonagy [21] reported on cost outcomes from their RCT comparing 18 months of psychoanalytically informed partial hospitalization with standard psychiatric care. Overall costs were comparable; however, partial hospitalization showed greater annual cost reductions following discharge than did the TAU group. Preliminary evidence supports the effectiveness of other previously untested treatments. Cognitive analytic therapy [35], an integration of object relations therapy and cognitive therapy, has shown promise in naturalistic studies [22,36]. A 20-week psychoeducational group based on psychodynamic treatment of BPD [37] also was shown to be effective for treating 20 patients with BPD. Reductions were seen in suicidal ideation, interpersonal sensitivity, hostility, and urges to act on impulsive anger. Other controlled trials of psychotherapy of BPD are in progress or under review. Clarkin et al. [38] completed an RCT comparing TFP with DBT or supportive psychotherapy, but results have not yet been published. McMain et al. [39] recently reported on a Canadian RCT that is currently underway and involves the comparison of 180 patients with BPD who have been randomized to DBT or general psychiatric management, a control group developed from the American Psychiatric Association practice guidelines for the treatment of BPD.

Antisocial Personality Disorder (ASPD) One study supports the effectiveness of psychosocial treatments for ASPD. Messina et al. [40] compared methadone-maintained patients with and without a diagnosis of ASPD being treated for cocaine dependence. Participants were randomized to CBT, contingency management (CM), CBT plus CM, or methadone maintenance. Patients with ASPD had a strong positive response to CM that involved vouchers for drug-free urine samples.

Avoidant Personality Disorder (AVPD) Psychotherapy for AVPD remains relatively unexamined. A recent Dutch study [41] randomized 62 subjects to 20 weeks

of individual brief DT, individual CBT, or a no-treatment wait-list control condition. Both active treatments reduced avoidance and social phobia; however, CBT was superior to brief DT in improving avoidance, social phobia, and obsessive symptoms. In a controlled trial in Switzerland, Beretta et al. [42] treated 70 individuals with or without a Cluster C diagnosis with a four-session psychodynamic intervention. Although one third of the patients demonstrated clinically significant change, poorer outcome was specifically associated with AVPD. In a Norwegian multisite study [43] of day treatment that included 1244 patients with various PDs, those with AVPD were more likely to relapse in general symptomatology and interpersonal problems from discharge to follow-up.

Heterogeneous Cluster C Disorders Some evidence concerning the effectiveness of psychotherapy is emerging from studies of patients with mixed samples of Cluster C disorders. In one trial [44•], 51 patients were randomly assigned to receive 40 weeks of either short-term DT or CBT. There were no differences between treatments, with both resulting in significant reductions of general symptoms and interpersonal problems, as well as increased general functioning. Strauss et al. [45] examined treatment outcomes after 52 weeks of CBT in patients diagnosed with either AVPD or obsessive-compulsive personality disorder (OCPD). There were significant reductions in depression and personality symptoms at the end of treatment. AVPD and OCPD patients did not differ in their response to CBT. The authors also examined therapy process and found that stronger alliances early in therapy that were followed later in therapy by a repaired alliance rupture predicted better outcomes. Muran et al. [46] compared three treatments in 128 patients diagnosed with either Cluster C (34%) or a “nototherwise-specified” PD diagnosis. Patients received either 30 sessions of short-term DT, CBT, or brief relational therapy (BRT), an integration of dynamic and experiential approaches. All treatments were equally effective in reducing targeted complaints, general symptoms, interpersonal problems, and personality pathology. However, BRT had significantly fewer dropouts, and both BRT and CBT fared significantly better than short-term DT in producing clinically significant changes in interpersonal problems at 6-month follow-up. The authors concluded that all three treatments may be efficacious for treating Cluster C PDs. Hoffart et al. [47] offered a two-stage inpatient treatment for 35 clients with agoraphobia/panic disorder; a total of 60% met criteria for a Cluster C PD diagnosis. Their schema-focused CBT involved 5 weeks of daily standard CBT group treatment focusing on Axis I problems, followed by 6 weeks of group and individual sessions in schema-focused CBT. Patients showed significant reductions in Cluster C symptoms and endorsed significantly fewer maladaptive schemas post-treatment.


Heterogeneous Samples of PDs Three RCTs have evaluated the effectiveness of psychotherapeutic interventions in general PD samples. In the POPMACT study, a large, multisite RCT conducted in the United Kingdom [32,48], 480 patients (42.3% with personality disturbance) recruited following a deliberate self-harm were randomly assigned to either MACT or TAU. Although there were no between-group differences in the proportion of self-harm acts, the MACT treatment was associated with fewer self-harm episodes and lower costs. Patients with more severe personality disturbances, in particular BPD, had poorer treatment outcomes and were more expensive to treat. In a Swedish controlled trial, Vinnars et al. [49•] randomized 156 patients, all with a PD diagnosis, to either 1 year of manualized, supportive, expressive DT or to nonmanualized psychodynamic therapy in the community. Both treatments were effective, and no differences between groups were found. At termination, 33.6% of patients no longer met criteria for a PD diagnosis. This increased to 58% at 1-year follow-up. Patients showed significant improvement in symptoms and general functioning. However, at follow-up, they continued to function on average below a community comparison sample. Cluster C patients improved the least. Treatment outcome and 6-year follow-up data have been reported from a controlled trial in the United Kingdom [50–52]. A total of 143 patients with PD diagnoses (85% Cluster B) were assigned to one of three approximately year-long treatments: a specialized inpatient treatment (IP), a two-phase “step-down” treatment of day hospital followed by twice-weekly group therapy and access to an outreach nurse (SD), or community TAU. At termination, the SD group was superior to both the IP and TAU groups in self-reported symptoms, clinicianrated social adjustment, and global functioning, as well as self-harm and suicide attempts. At 72 months follow-up, 61% of SD patients had clinically significant change in symptoms, versus 26% and 13% for IP and TAU patients, respectively. SD resulted in significantly lower rates of suicide, self-harm, and readmissions than either IP or TAU. Results from several uncontrolled trials also have been recently reported. Prepost and follow-up data have been reported for more than 1200 patients in a large, multisite, Norwegian study of day hospital treatment [43]. The program offered 8 to 16 hours weekly (total of 18 months on average) of nonmanualized standard care. At termination, patients showed significant improvements on general symptomatology, interpersonal problems, general functioning, and quality of life. At 1-year follow-up, general functioning showed further improvement, and other measured outcomes were maintained. In another Norwegian study, Wilberg et al. [53] followed 187 clients who, after having taken part in a day treatment program for PDs, were offered 1.5 hours of weekly nonmanualized psychodynamic group therapy for a maximum of 3.5

McMain and Pos

49

years. Although patients generally improved on all outcome measures, more Cluster C criteria (when A or B criteria were controlled for) predicted poorer general functioning and interpersonal problems at termination. Bond and Perry [54,55] reported a study of 53 patients with mixed Axis I (depressive and anxiety disorders) and Axis II diagnoses (75% PDs) who were treated with longterm (3 to 5 years) group psychodynamic psychotherapy with or without medication. Patients with PDs improved significantly in general symptomatology. Whereas patients on medications improved on general functioning, those on no medications showed improvement on depressive symptoms. The higher the number of PD criteria met at pretreatment predicted poorer general functioning at follow-up. Another small, uncontrolled study [56] examined data on 56 patients (68% PDs) treated in private practice with 1.5 hours of weekly psychodynamic group therapy for a maximum of 2.5 years. PD diagnosis was not associated with poorer outcomes, but longer treatment duration predicted greater improvement in general functioning and symptomatology. Narud et al. [57] reported data from a Norwegian study that examined the effect of individual treatment in the community for 110 outpatients, 72% of whom had a PD diagnosis. Patients had 17 months of unspecified individual therapy on average. Whereas Cluster A and B patients improved in general functioning and personality pathology and met significantly fewer Cluster criteria at follow-up, patients with Cluster C PDs improved in general functioning only.

Discussion and Conclusions Research on PDs is evolving rapidly and, as Paris [58] observes, the field is coming of age. In the past 3 years, more controlled psychotherapy trials of PDs have been published than in previous decades. Continued evidence that psychotherapy is effective increases optimism about the prognoses of these disorders. Before summarizing the findings, some comments about the methodological quality of the studies reviewed are warranted. Several factors limit our ability to draw strong conclusions from this research. Overall, the number of well-designed controlled trials is limited. Moreover, the majority of RCTs are underpowered, lack rigorous comparator controls, and include inadequate follow-up periods to evaluate the maintenance of gains. Also problematic is the confounding of concurrent treatments during active treatment and follow-up phases. An additional concern is substantial heterogeneity among studies included in meta-analytic research. For example, trials differ with respect to therapy format and length, the use of treatment manuals, patient samples, and length of follow-up periods. Therefore, at this stage, meta-analytic studies do not permit conclusions about the relative effectiveness of different psychotherapy approaches. The relative continued

50


neglect of specific PDs other than BPD also is troubling. Finally, current psychotherapy research on PDs is almost entirely restricted to a two-horse race between psychodynamic and CBT, with few other approaches tested. Despite the previously mentioned limitations, findings from recent studies make an important contribution to our understanding of the role of psychotherapy of PDs. Recent data strengthen confidence that psychotherapy should be considered a key element of effective treatment of PDs. Findings support the effectiveness of psychotherapy for BPD, AVPD, ASPD, and personality disturbance in general. Indirect evidence for the efficacy of psychotherapeutic interventions for other specific PDs can be inferred from studies of large, mixed PD samples. Recent studies of BPD reveal an increased focus on the evaluation of CBT approaches. A consistent finding is that DBT produces positive change not only on behavioral outcomes (eg, suicidal behavior, hospitalization) but also on measures of symptom distress and general psychopathology. Multimodal comprehensive treatments may be more appropriate for addressing the multiple problems associated with individuals with severe BPD. Further, there is evidence that specialized comprehensive treatments for BPD may be more cost effective than standard care. Still, in view of shrinking health care resources and pressures to identify economical treatments, it is encouraging that brief, CBT skills-based interventions (eg, MACT, STEPPS) also have been shown to be effective in reducing self-harm and BPD symptoms. A further positive observation is the preliminary support for the effectiveness of previously untested treatments such as SFT for BPD. With respect to PDs other than BPD, one recent study suggests that contingency management may be more effective than CBT in the treatment of ASPD. New studies of AVPD support the limited findings from previous research. CBT and DT have been shown to be effective in the treatment of AVPD. Also, OCPD appears to benefit from CBT and DT. Finally, research on severe PDs suggests that brief hospitalizations followed by community aftercare are more effective than extended periods of hospitalization. Several areas should be given priority in future research on psychotherapy of PDs. Additional clinical and cost effectiveness data based on rigorous trials are essential. There is a need for more PD-specific research. In addition to BPD, other PDs that occur frequently in clinical populations, such as AVPD and ASPD, require more attention, especially in light of evidence that these disorders predict poorer treatment outcomes. The longterm effects of treatment interventions also require more attention, especially because PDs are chronic disorders associated with significant functional impairment. Finally, other approaches to psychotherapy of PDs existing in the clinical literature require evaluation. Research also must be directed toward understanding the active mechanisms of change within psychotherapy. A recent special issue of the Journal of

Clinical Psychology (volume 62, number 4) devoted to this issue in the treatment of BPD provides welcome direction. Some psychotherapy process research in the field of PDs is already taking place [59,60]. Finally, many researchers note that PD symptom heterogeneity impedes basic research. There is a need to identify subgroups within PDs in order to determine the optimal matching of patients to effective treatment.

Acknowledgment Neither of the authors has a possible conflict of interest, financial or otherwise.

References and Recommended Reading Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance 1.

Fonagy P, Bateman A: Progress in the treatment of borderline personality disorder. Br J Psychiatry 2006, 188:1–3. 2. Roth A, Fonagy P: What Works for Whom?: A Critical Review of Psychotherapy Research, edn 2. New York: Guilford Publications; 2005. 3. Crits-Christoph P, Barber J: Psychological treatments for personality disorders. In A Guide to Treatments That Work. Edited by Nathan P, Gorman JM. New York: Oxford University Press, 2002:611–623. 4. Crits-Christoph P, Barber J: Empirical research on the treatment of personality disorders. In Handbook of Personality Disorders: Theory and Practice. Edited by Magnavita JJ. Hoboken, NJ: John Wiley & Sons; 2004:513–527. 5. Alden LE, Laposa JM, Taylor CT, Ryder AG: Avoidant personality disorder: current status and future directions. J Personal Disord 2002, 16:1–29. 6. Piper W, Joyce S, Anthony S: Psychosocial treatment outcome. In Handbook of Personality Disorders: Theory, Research, and Treatment. Edited by Livesley WJ. New York: Guilford Press; 2001:323–343. 7. Mancebo MC, Eisen J, Grant JE, Rasmussen S: Obsessive compulsive personality disorder and obsessive compulsive disorder: clinical characteristics, diagnostic difficulties, and treatment. Ann Clin Psychiatry 2005, 17:197–204. 8. Sanislow CA, McGlashan TH: Treatment outcome of personality disorders. Can J Psychiatry 1998, 43:237–250. 9. Perry JC: Dependent personality disorder. In Oxford Textbook of Psychotherapy. Edited by Gabbard GO, Beck JS, Holmes J. New York: Oxford University Press; 2005:321–328. 10. Gabbard GO, Newman CF: Psychotherapy of obsessivecompulsive personality disorder. In Oxford Textbook of Psychotherapy. Edited by Gabbard GO, Beck JS, Holmes J. New York: Oxford University Press; 2005:329–337. 11. Leichsenring F, Leibing E: The effectiveness of psychodynamic therapy and cognitive behavior therapy in the treatment of personality disorders: a meta-analysis. Am J Psychiatry 2003, 160:1223–1232. 12.• Binks CA, Fenton M, McCarthy L, et al.: Psychological therapies for people with borderline personality disorder. Cochrane Database Syst Rev 2006, 1:CD005652 A recent meta-analysis of the efficacy of psychotherapy for BPD. 13.•• Linehan MM, Comtois KA, Murray AM, et al.: Two-year randomized trial + follow-up of dialectical behavior therapy vs. therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry 2006, 63:757–766.


The most well-powered RCT of the effectiveness of DBT compared with a strong comparator treatment. 14.•• Giesen-Bloo J, van Dyck R, Spinhoven P, et al.: Outpatient psychotherapy for borderline personality disorder: randomized trial of schema-focused therapy vs transference-focused psychotherapy. Arch Gen Psychiatry 2006, 63:649–658. The first RCT to examine the efficacy of SFT compared with TFP for BPD. 15.•• Davidson K, Norrie J, Tyrer P, et al.: The effectiveness of cognitive behavior therapy for borderline personality disorder: results from the borderline personality disorder study of cognitive therapy (BOSCOT) trial. J Personal Disord 2006, 20:450–465. The first RCT to examine the clinical efficacy of cognitive therapy for BPD. 16.•• Palmer S, Davidson K, Tyrer P, et al.: The cost-effectiveness of cognitive behavior therapy for borderline personality disorder: results from the BOSCOT trial. J Personal Disord 2006, 20:466–481. The first RCT to examine the cost efficacy of cognitive therapy for BPD. 17. Davidson K, Tyrer P, Gumley A, et al.: A randomized controlled trial of cognitive behavior therapy for borderline personality disorder: rationale for trial method, and description of sample. J Personal Disord 2006, 20:431–449. 18. Verheul R, Van Den Bosch LM, Koeter MW, et al.: Dialectical behaviour therapy for women with borderline personality disorder: 12-month, randomised clinical trial in The Netherlands. Br J Psychiatry 2003, 182:135–140. 19. Weinberg I, Gunderson JG, Hennen J, Cutter CJ: Manual assisted cognitive treatment for deliberate self-harm in borderline personality disorder patients. J Personal Disord 2006, 20:482–492. 20. Gratz KL, Lacroce DM, Gunderson JG: Measuring changes in symptoms relevant to borderline personality disorder following short-term treatment across partial hospital and intensive outpatient levels of care. J Psychiatr Pract 2006, 12:153–159. 21. Bateman A, Fonagy P: Health service utilization costs for borderline personality disorder patients treated with psychoanalytically oriented partial hospitalization versus general psychiatric care. Am J Psychiatry 2003, 160:169–171. 22. Ryle A, Golynkina K: Effectiveness of time-limited cognitive analytic therapy of borderline personality disorder: factors associated with outcome. Br J Med Psychol 2000, 73:197–210. 23. Bohus M, Haaf B, Simms T, et al.: Effectiveness of inpatient dialectical behavioral therapy for borderline personality disorder: a controlled trial. Behav Res Ther 2004, 42:487–499. 24. Kroger C, Schweiger U, Sipos V, et al.: Effectiveness of dialectical behaviour therapy for borderline personality disorder in an inpatient setting. Behav Res Ther 2006, 44:1211–1217. 25. McQuillan A, Nicastro R, Guenot F, et al.: Intensive dialectical behavior therapy for outpatients with borderline personality disorder who are in crisis. Psychiatr Serv 2005, 56:193–197. 26. Brown GK, Newman CF, Charlesworth SE, et al.: An open clinical trial of cognitive therapy for borderline personality disorder. J Personal Disord 2004, 18:257–271. 27. Blum N, Pfohl B, John DS, et al.: STEPPS: a cognitivebehavioral systems-based group treatment for outpatients with borderline personality disorder—a preliminary report. Compr Psychiatry 2002, 43:301–310. 28. Black DW, Blum N, Pfohl B, John DS: The STEPPS group treatment program for outpatients with borderline personality disorder. J Contemp Psychother 2004, 34:193–210. 29. van Wel B, Blum N, Heesterman W: STEPPS group treatment for borderline personality disorder in The Netherlands. Ann Clin Psychiatry 2006, 18:63–67.

30.

McMain and Pos

51

Freije H, Dietz B, Appelo M: Behandling van de borderline persoonlijk heidsstoornis met de VERS: de Vaardigheidstraining emotionele regulatiestoornis. Directive Ther 2002, 4:367–378. 31. Evans K, Tyrer P, Catalan J, et al.: Manual-assisted cognitive-behaviour therapy (MACT): a randomized controlled trial of a brief intervention with bibliotherapy in the treatment of recurrent deliberate self-harm. Psychol Med 1999, 29:19–25. 32. Tyrer P, Thompson S, Schmidt U, et al.: Randomized controlled trial of brief cognitive behaviour therapy versus treatment as usual in recurrent deliberate self-harm: the POPMACT study. Psychol Med 2003, 33:969–976. 33. Kellogg SH, Young JE: Schema therapy for borderline personality disorder. J Clin Psychol 2006, 62:445–458. 34. Stevenson J, Meares R, D’Angelo R: Five-year outcome of outpatient psychotherapy with borderline patients. Psychol Med 2005, 35:79–87. 35. Ryle A: The contribution of cognitive analytic therapy to the treatment of borderline personality disorder. J Personal Disord 2004, 18:3–35. 36. Wildgoose A, Clarke S, Waller G: Treating personality fragmentation and dissociation in borderline personality disorder: a pilot study of the impact of cognitive analytic therapy. Br J Med Psychol 2001, 74:47–55. 37. Whewell P, Lingam R, Chilton R: Reflective borderline group therapy: the patients’ experience of being borderline. Psychoanalytic Psychotherapy 2004, 18:324–345. 38. Clarkin JF, Levy KN, Lenzenweger MF, Kernberg OF: The Personality Disorders Institute/Borderline Personality Disorder Research Foundation randomized control trial for borderline personality disorder: rationale, methods, and patient characteristics. J Personal Disord 2004, 18:52–72. 39. McMain S, Links P, Gnam W, et al.: Randomized controlled effectiveness trial of dialectical behavior therapy for chronically suicidal patients with borderline personality disorder: rationale, design, and patient characteristics. Paper presented at the Society for Psychotherapy Research Conference. Edinburgh, Scotland; June 1, 2006. 40. Messina N, Farabee D, Rawson R: Treatment responsivity of cocaine-dependent patients with antisocial personality disorder to cognitive-behavioral and contingency management interventions. J Consult Clin Psychol 2003, 71:320–329. 41. Emmelkamp PM, Benner A, Kuipers A, et al.: Comparison of brief dynamic and cognitive-behavioural therapies in avoidant personality disorder. Br J Psychiatry 2006, 189:60–64. 42. Beretta V, de Roten Y, Drapeau M, et al.: Clinical significance and patients’ perceived change in four sessions of brief psychodynamic intervention: characteristics of early responders. Psychol Psychother 2005, 78:347–362. 43. Karterud S, Pedersen G, Bjordal E, et al.: Day treatment of patients with personality disorders: experiences from a Norwegian treatment research network. J Personal Disord 2003, 17:243–262. 44.• Svartberg M, Stiles TC, Seltzer MH: Randomised, controlled trial of the effectiveness of short-term dynamic psychotherapy and cognitive therapy for cluster C personality disorders. Am J Psychiatry 2004, 161:810–817. A well-designed RCT to evaluate the effectiveness of dynamic and CBT approaches for the treatment of Cluster C PDs. 45. Strauss JL, Hayes AM, Johnson SL, et al.: Early alliance, alliance ruptures, and symptom change in a nonrandomized trial of cognitive therapy for avoidant and obsessive-compulsive personality disorders. J Consult Clin Psychol 2006, 74:337–345. 46. Muran JC, Safran JD, Samstag LW, Winston A: Evaluating an alliance-focused treatment for personality disorders. Psychother Theory Res Pract Train 2005, 42:532–545.

52 47.


Hoffart A, Sexton H, Nordahl HM, Stiles TC: Connection between patient and therapist and therapist’s competence in schema-focused therapy of personality problems. Psychother Res 2005, 15:409–419. 48. Tyrer P, Tom B, Byford S, et al.: Differential effects of manual assisted cognitive behavior therapy in the treatment of recurrent deliberate self-harm and personality disturbance: the POPMACT study. J Personal Disord 2004, 18:102–116. 49.• Vinnars B, Barber JP, Noren K, et al.: Manualized supportive-expressive psychotherapy versus nonmanualized community-delivered psychodynamic therapy for patients with personality disorders: bridging efficacy and effectiveness. Am J Psychiatry 2005, 162:1933–1940. An important controlled trial that examined the effectiveness of manualized versus nonmanualized, community-delivered psychodynamic therapy for patients with PDs. 50. Chiesa M, Fonagy P, Holmes J, Drahorad C: Residential versus community treatment of personality disorders: a comparative study of three treatment programs. Am J Psychiatry 2004, 161:1463–1470. 51. Chiesa M, Fonagy P: Cassel Personality Disorder Study. Methodology and treatment effects. Br J Psychiatry 2000, 176:485–491. 52. Chiesa M, Fonagy P, Holmes J: Six-year follow-up of three treatment programs to personality disorder. J Personal Disord 2006, 20:493–509. 53. Wilberg T, Karterud S, Pedersen G, et al.: Outpatient group psychotherapy following day treatment for patients with personality disorders. J Personal Disord 2003, 17:510–521.

54. 55. 56. 57.

58. 59.

60.

Bond M, Perry JC: Long-term changes in defense styles with psychodynamic psychotherapy for depressive, anxiety, and personality disorders. Am J Psychiatry 2004, 161:1665–1671. Bond M, Perry JC: Psychotropic medication use, personality disorder and improvement in long-term dynamic psychotherapy. J Nerv Ment Dis 2006, 194:21–26. Lorentzen S, Hoglend P: Predictors of change after longterm analytic group psychotherapy. J Clin Psychol 2005, 61:1541–1553. Narud K, Mykletun A, Dahl AA: A comparison of gains after treatment at a psychiatric outpatient clinic in patients with cluster A + B, or cluster C personality disorders, and non-psychotic axis I disorders. Nord J Psychiatry 2005, 59:331–338. Paris J: Personality disorders: Psychiatry’s stepchildren come of age. Psychiatr News 2006, 41:33. Schut AJ, Barber JP, Castonguay LG, et al.: Therapist interpretation, patient-therapist interpersonal process, and outcome in psychodynamic psychotherapy for avoidant personality disorder. Psychother Theory Res Pract Train 2005, 42:494–511. Kolden GG, Klein MH, Strauman TJ, et al.: Early psychotherapy process and cluster B and C personality pathology: similarities and differences in interactions with symptomatic and interpersonal distress. Psychother Res 2005, 15:165–177.