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Am Fam Physician. 2022;106(4):381-382

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial relationships.

Clinical Question

Is psychotherapy beneficial for patients with borderline personality disorder (BPD)?

Evidence-Based Answer

In patients with BPD, psychotherapy in the form of dialectical behavior therapy (DBT) or mentalization-based treatment (MBT) reduces the severity of symptoms, improves psychosocial functioning, and reduces depression scores compared with no treatment. (Strength of Recommendation [SOR]: B, inconsistent or limited-quality patient-oriented evidence.) In addition, DBT and MBT reduce the severity of BPD symptoms compared with usual treatment, including other types of psychotherapies.1 (SOR: B, inconsistent or limited-quality patient-oriented evidence.)

Practice Pointers

BPD is defined by a pervasive pattern of instability in affect regulation, impulse control, interpersonal relationships, and self-image. 2 The prevalence in the primary care setting is approximately 6%, but the disorder is frequently underdiagnosed and undertreated. 3,4 BPD is often characterized by comorbid psychiatric disorders and difficulties in patient-physician relationships, highlighting the importance of effective therapies.3,4

This updated Cochrane review included 75 randomized controlled trials and 4,507 participants to assess psychological therapies for patients with BPD.1 Participants had a mean age of 15 to 46 years and were primarily located in the United States and Europe, but also in Australia, Canada, Iran, and Taiwan. The trials incorporated more than 16 kinds of psychotherapy compared with usual treatment, waiting list placement, or other active treatments. Therapy was predominantly conducted in outpatient settings, lasted one to 36 months, and included major psychotherapeutic interventions used for BPD (e.g., DBT, MBT, schema-focused therapy, transference-based therapy). However, the number of trials for each intervention varied. DBT was used in 24 trials, MBT was used in seven trials, and a limited number of studies used schema-focused and transference-based therapies.

All outcomes, which were self-reported or clinician rated, were analyzed posttreatment and at six months of follow-up or later. BPD symptom severity was quantified using scales such as the Zanarini Rating Scale for Borderline Personality Disorder. Other primary outcomes were evaluated using the Deliberate Self-Harm Inventory, Suicide Attempt Self-Injury Interview, and Global Assessment of Functioning scale. Secondary outcomes included abandonment, affective instability, anger, chronic feelings of emptiness, depression, dissociation and psychotic-like symptoms, identity disturbance, impulsivity, and interpersonal problems.

Compared with patients on waiting list placement or no treatment, those receiving psychotherapy had improvements in BPD symptom severity (standardized mean difference [SMD] = −0.49; 95% CI, −0.93 to −0.05; three trials; n = 161), psychosocial functioning (SMD = −0.56; 95% CI, −1.01 to −0.11; five trials; n = 219), and depression (SMD = −1.28; 95% CI, −2.21 to −0.34; six trials; n = 239). There was no evidence that psychotherapy changes the risk of self-harm or suicide- related outcomes.

Compared with usual treatment, psychotherapy led to a clinically relevant improvement in symptom severity (SMD = −0.52; 95% CI, −0.70 to −0.33; 22 trials; n = 1,244), corresponding to a mean difference of −3.6 (95% CI, −4.4 to −2.08) on the Zanarini Rating Scale for Borderline Personality Disorder, which ranges from 0 to 36. Psychotherapy may be slightly more effective than usual treatment for self-harm, suicide- related outcomes, and psychosocial functioning, but it did not show clinically meaningful benefit.

Subgroup analyses demonstrated that, compared with usual treatment, DBT decreased BPD symptom severity (SMD = −0.60; 95% CI, −1.05 to −0.14; three trials; n = 149), reduced incidence of self-harm (SMD = −0.28; 95% CI, −0.48 to −0.07; seven trials; n = 376), and improved psychosocial functioning (SMD = −0.36; 95% CI, −0.69 to −0.03; six trials; n = 225). MBT appeared to be better than usual treatment at reducing self- harm (relative risk [RR] = 0.62; 95% CI, 0.49 to 0.80; three trials; n = 252), suicidality (RR = 0.10; 95% CI, 0.04 to 0.30; three trials; n = 218), and depression (SMD = −0.58; 95% CI, −1.22 to 0.05; four trials; n = 333). No significant adverse effects were identified with these therapies.

Current guidelines recommend psychotherapy as first-line treatment for BPD but do not single out one therapy over the others.5,6 Further studies are needed to better clarify the treatment effects of various psychotherapies. Another systematic review, which included some of the same studies as this Cochrane review, had a similar conclusion and found that DBT can be helpful in treating BPD.7 This Cochrane review provides low-quality evidence that DBT and MBT may reduce morbidity associated with BPD. These low-risk interventions may be worth considering when caring for these patients.

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These are summaries of reviews from the Cochrane Library.

This series is coordinated by Corey D. Fogleman, MD, assistant medical editor.

A collection of Cochrane for Clinicians published in AFP is available at

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