Borderline Personality Disorder is an illness that frustrates patients, disturbs their loved ones, and vexes clinicians who try to treat it.  Long-term prognostic studies confirm that most patients improve eventually, many even without formal, consistent treatment.  Still, there has been vigorous work looking for treatment approaches which more effectively treat these individuals in pain. 

     Since no medications are specifically indicated for BPD, psychotherapy has been the primary treatment of choice, and several structured, manualized programs have been proposed as preferred treatments.  Dialectical Behavioral Therapy (DBT), Transference-Focused Therapy (TFP), Cognitive Based Therapy (CBT), Mentalization Based Therapy (MBT), Schema-Focused Therapy (SFT), and others have been offered as treatment approaches directed for BPD.  Studies have been conducted comparing these specific approaches to non-specific, less intensive "control" treatments.  A rigorous, recent analysis of these comparative studies (JAMA Psychiatry, April, 2017) revealed both encouraging and surprising information.

     Most studies involved DBT and psychodynamic treatments, such as TFP and MBT.  Most treatment groups, including "controls" improved.  DBT and psychodynamic treatments exhibited slightly superior outcome, especially regarding self-harming behavior and use of health services.  There were no differences in drop-out rates.  Overall efficacy rates were small despite the greater intensity of treatment with specialized therapy. 

     The good news is that supportive, general psychotherapy is effective.  This may reflect that greater understanding of BPD has enhanced clinican skills.  The surprising news is that more intensive, specialized approaches do not produce markedly better results.  It appears that no one treatment approach is the most effective for all borderline patients.  A trusting therapeutic alliance with a skilled therapist is most predictive of a positive outcome.

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