SAN FRANCISCO – Seven forms of psychotherapy have been proven in randomized clinical trials to be effective in treating borderline personality disorder.
No one knows why so many approaches work, but there are some common elements among them, Dr. Glen O. Gabbard said at the annual meeting of the American College of Psychiatrists. Researchers and clinicians are trying to figure out which psychotherapy might be best for any subset of patients with borderline personality disorder.
Dr. Glen O. Gabbard
Within each individual patient, too, there are aspects of the disorder that might respond to one form of therapy, while another aspect of the disorder requires a different therapeutic approach, said Dr. Gabbard, professor of psychiatry and chair of psychoanalysis at Baylor College of Medicine, Houston.
Psychotherapies that are effective in treating borderline personality disorder include dialectical behavior therapy, mentalization-based therapy, transference-focused psychotherapy, schema-focused therapy, supportive psychotherapy, systems training for emotional predictability and problem solving, and general psychiatric management with dynamically oriented therapy.
All provide a systematic conceptual framework of pathogenesis and treatment that helps patients organize their internal chaos and make sense of it. Research shows that the therapeutic alliance is the key factor, while the technique gets credited with only 12%-15% of therapeutic change across different kinds of therapy.
In each of the psychotherapies, change happens through similar underlying neurophysiologic processes: increased activity of the prefrontal cortex modifies amygdala hyperactivity, and the therapeutic relationship is used to sharpen patients’ ability to reappraise their assumptions, perceptions, and "knee-jerk" beliefs, he said. "All seven models have somebody sitting with patients and helping them sharpen self-observation."
Within individual patients, some aspects of the disorder respond to insight, while others require internalization of the therapeutic relationship over time.
The therapeutic relationship by itself is not enough, however. "We might overvalue that," Dr. Gabbard said. The therapeutic frame is an envelope within which the therapist helps the patient impose a way of thinking to manage unbearable affect states, "those that can’t be borne by one person alone. You need somebody else to help you through that," he said. The aim is to help patients develop their own capacity for thinking and feeling their experience.
Building "procedural memories" requires multiple repetitions to develop new neural networks of self and other, which don’t replace old maladaptive neural networks but gradually supersede them over time. "It’s interesting that all of those seven therapies are long-term therapies. There’s no quick fix with borderline" personality disorder, he said.
Efforts aimed at tailoring the therapeutic approach to patients’ individual characteristics all have the common goal of activating the prefrontal cortex and the anterior cingulate cortex to modulate limbic-based negative feelings and promote thinking in the service of regulating intolerable affect states.
A recent study suggesting that there are two subtypes of post-traumatic stress disorder (PTSD) – including a dissociative subtype – might hold lessons for treating borderline personality disorder, he said (Am. J. Psychiatry 2010;167:640-7).
In a study by other investigators that will be published in the Journal of Personality Disorders, a high level of dissociation was an important predictor of negative outcomes in 57 females treated with dialectical behavior therapy for borderline personality disorder, he said. A phase-oriented approach that focuses on building better functioning in multiple domains might be a better than exposure-based treatment for patients with a dissociative subtype of borderline personality disorder.
People with borderline personality disorder seem to be hard-wired for opioid deficits, which might be one reason for high rates of self-cutting in this disorder – cutting might be a form of self-medicating to release endogenous opioids. Opioids are involved in both emotional regulation and social behavior.
"I don’t think this gets enough attention," Dr. Gabbard said.
Separate studies in the last 3 years report high rates of opiate abuse in patients with borderline personality disorder, and high rates of the disorder in patients seeking buprenorphine treatment (44%). Insufficient endogenous opioids might be a reason that patients with borderline personality disorder have difficulty feeling the satisfaction that usually accompanies intimacy, posing a barrier to the therapeutic alliance.
"I don’t think we’ve fully appreciated how that may be relevant to psychotherapy" for this disorder, he said.
On the other hand, knowing that the opiate deficit might contribute to a feeling that the patient’s pain is not bearable can help prevent the therapist from "blaming" the patient, he said.
Dr. Gabbard said he has no relevant conflicts of interest.