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Effect of Psychotherapy for Borderline Personality Disorder on Quality of Life: A Systematic Review and Meta-Analysis

Published Online:https://doi.org/10.1521/pedi_2019_33_439

Whereas several meta-analyses have shown that psychotherapy is effective for reducing borderline personality disorder (BPD) pathology, the overall impact of psychotherapy for BPD on quality of life (QoL) remains as yet unclear. Because impaired QoL is associated with poor long-term outcomes after therapy for BPD, this seems a timely and relevant issue. The authors conducted a systematic review and meta-analysis of randomized controlled trials of psychotherapies for adults diagnosed with BPD that reported results of QoL at posttreatment. Fourteen trials were included (1,370 individuals with BPD). Psychotherapies for BPD relative to control conditions showed significant effect sizes for QoL (Cohen's d = 0.31; 95% CI [0.18, 0.44]), and for BPD pathology (d = 0.43; 95% CI [0.23, 0.64]). The effect on QoL was not significantly moderated by the effect on BPD pathology. Psychotherapies for BPD have a positive effect on QoL of patients with BPD. However, more studies are needed to examine the impact of psychotherapy on QoL and long-term outcome, including recovery.

REFERENCES

  • Alvarez-Tomás I., , Soler J., , Bados A., , Martín-Blanco A., , Elices M., , Carmona C., , … Pascual J. C. (2017). Long-term course of borderline personality disorder: A prospective 10-year follow-up study. Journal of Personality Disorders, 31, 590–605. LinkGoogle Scholar
  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. CrossrefGoogle Scholar
  • Bateman A., , & Fonagy P. (2009). Randomized controlled trial of outpatient mentalization-based treatment versus structured clinical management for borderline personality disorder. American Journal of Psychiatry, 166, 1355–1364. https://doi.org/10.1176/appi.ajp.2009.09040539 Crossref MedlineGoogle Scholar
  • Black D. W., , Blum N., , Pfohl B., , & Hale N. (2004). Suicidal behavior in borderline personality disorder: Prevalence, risk factors, prediction, and prevention. Journal of Personality Disorders, 18, 226–239. https://doi.org/10.1521/pedi.18.3.226.35445 LinkGoogle Scholar
  • Blum N., , St. John D., , Pfohl B., , Stuart S., , McCormick B., , Allen J., , … Black D. W. (2008). Systems Training for Emotional Predictability and Problem Solving (STEPPS) for outpatients with borderline personality disorder: A randomized controlled trial and 1-year follow-up. American Journal of Psychiatry, 165, 468–478. https://doi.org/10.1176/appi.ajp.2007.07071079 Crossref MedlineGoogle Scholar
  • Borenstein M., , Rothstein D., , & Cohen J. (2005). Comprehensive meta-analysis: A computer program for research synthesis [Computer software]. Englewood, NJ: Biostat. Google Scholar
  • Bos E. H., , van Wel E. B., , Appelo M. T., , & Verbraak M. J. (2010). A randomized controlled trial of a Dutch version of Systems Training for Emotional Predictability and Problem Solving for borderline personality disorder. Journal of Nervous and Mental Disease, 198, 299–304. https://doi.org/10.1097/NMD.0b013e3181d619cf Crossref MedlineGoogle Scholar
  • Carter G. L., , Willcox C. H., , Lewin T. J., , Conrad A. M., , & Bendit N. (2010). Hunter DBT project: Randomized controlled trial of dialectical behaviour therapy in women with borderline personality disorder. Australian and New Zealand Journal of Psychiatry, 44, 162–173. https://doi.org/10.3109/00048670903393621 Crossref MedlineGoogle Scholar
  • Chakhssi F., , Kraiss J. T., , Sommers-Spijkerman M., , & Bohlmeijer E. T. (2018). The effect of positive psychology interventions on well-being and distress in clinical samples with psychiatric or somatic disorders: A systematic review and meta-analysis. BMC Psychiatry, 18(1), 211. Crossref MedlineGoogle Scholar
  • Cohen J. (1988). Statistical power analysis for the behavioral sciences. Hillsdale, NJ: Lawrence Erlbaum Associates. Google Scholar
  • Cottraux J., , Note I. D., , Boutitie F., , Milliery M., , Genouihlac V., , Yao S. N., , … Gueyffier F. (2009). Cognitive therapy versus Rogerian supportive therapy in borderline personality disorder. Two-year follow-up of a controlled pilot study. Psychotherapy and Psychosomatics, 78, 307–316. https://doi.org/10.1159/000229769 Crossref MedlineGoogle Scholar
  • Cristea I. A., , Gentili C., , Cotet C. D., , Palomba D., , Barbui C., , & Cuijpers P. (2017). Efficacy of psychotherapies for borderline personality disorder: A systematic review and meta-analysis. JAMA Psychiatry, 74, 319–328. https://doi.org/10.1001/jamapsychiatry.2016.4287 Crossref MedlineGoogle Scholar
  • Davidson K., , Norrie J., , Tyrer P., , Gumley A., , Tata P., , Murray H., , & Palmer S. (2006). The effectiveness of cognitive behavior therapy for borderline personality disorder: Results from the Borderline Personality Disorder Study of Cognitive Therapy (BOSCOT) trial. Journal of Personality Disorders, 20, 450–465. https://doi.org/10.1521/pedi.2006.20.5.450 LinkGoogle Scholar
  • Diener E., , Emmons R. A., , Larsen R. J., , & Griffin S. (1985). The Satisfaction With Life Scale. Journal of Personality Assessment, 49, 71–75. Crossref MedlineGoogle Scholar
  • Duval S., , & Tweedie R. (2000). Trim and fill: A simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis. Biometrics, 56, 455–463. Crossref MedlineGoogle Scholar
  • Egger M., , Smith G. D., , Schneider M., , & Minder C. (1997). Bias in meta-analysis detected by a simple, graphical test. BMJ, 315(7109), 629–634. Crossref MedlineGoogle Scholar
  • Feenstra D. J., , Hutsebaut J., , Laurenssen E. M., , Verheul R., , Busschbach J. J., , & Soeteman D. I. (2012). The burden of disease among adolescents with personality pathology: Quality of life and costs. Journal of Personality Disorders, 26, 593–604. LinkGoogle Scholar
  • Franken K., , Lamers S. M., , Ten Klooster P. M., , Bohlmeijer E. T., , & Westerhof G. J. (2018). Validation of the Mental Health Continuum-Short Form and the dual continua model of well-being and psychopathology in an adult mental health setting. Journal of Clinical Psychology, 74, 2187–2202. Crossref MedlineGoogle Scholar
  • Giesen-Bloo J., , van Dyck R., , Spinhoven P., , van Tilburg W., , Dirksen C., , van Asselt T., , … Arntz A. (2006). Outpatient psychotherapy for borderline personality disorder: Randomized trial of schema-focused therapy vs transference-focused psychotherapy. Archives of General Psychiatry, 63, 649–658. https://doi.org/10.1001/archpsyc.63.6.649 Crossref MedlineGoogle Scholar
  • Gratz K., , Tull M., , & Levy R. J. P. M. (2014). Randomized controlled trial and uncontrolled 9-month follow-up of an adjunctive emotion regulation group therapy for deliberate self-harm among women with borderline personality disorder. Psychological Medicine, 44, 2099–2112. Crossref MedlineGoogle Scholar
  • Gunderson J. G., , Stout R. L., , McGlashan T. H., , Shea M. T., , Morey L. C., , Grilo C. M., , … Sanislow C. (2011). Ten-year course of borderline personality disorder: Psychopathology and function from the Collaborative Longitudinal Personality Disorders study. Archives of General Psychiatry, 68, 827–837. Crossref MedlineGoogle Scholar
  • Higgins J. P., , Altman D. G., , G⊘tzsche P. C., , Jüni P., , Moher D., , Oxman A. D., , … Sterne J. A. (2011). The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ, 343, d5928. Crossref MedlineGoogle Scholar
  • Higgins J. P., , & Thompson S. G. (2002). Quantifying heterogeneity in a meta-analysis. Statistics in Medicine, 21, 1539–1558. https://doi.org/10.1002/sim.1186 Crossref MedlineGoogle Scholar
  • IsHak W. W., , Elbau I., , Ismail A., , Delaloye S., , Ha K., , Bolotaulo N. I., , … Wang C. (2013). Quality of life in borderline personality disorder. Harvard Review of Psychiatry, 21(3), 138–150. Crossref MedlineGoogle Scholar
  • J⊘rgensen C. R., , Freund C., , B⊘ye R., , Jordet H., , Andersen D., , & Kj⊘lbye M. (2013). Outcome of mentalization-based and supportive psychotherapy in patients with borderline personality disorder: A randomized trial. Acta Psychiatrica Scandinavica, 127, 305–317. https://doi.org/10.1111/j.1600-0447.2012.01923.x Crossref MedlineGoogle Scholar
  • Keuroghlian A. S., , Frankenburg F. R., , & Zanarini M. C. (2013). The relationship of chronic medical illnesses, poor health-related lifestyle choices, and health care utilization to recovery status in borderline patients over a decade of prospective follow-up. Journal of Psychiatric Research, 47, 1499–1506. Crossref MedlineGoogle Scholar
  • Lamers S. M., , Westerhof G. J., , Bohlmeijer E. T., , ten Klooster P. M., , & Keyes C. L. (2011). Evaluating the psychometric properties of the Mental Health Continuum-Short Form (MHC-SF). Journal of Clinical Psychology, 67, 99–110. https://doi.org/10.1002/jclp.20741 Crossref MedlineGoogle Scholar
  • Laurenssen E. M. P., , Luyten P., , Kikkert M. J., , Westra D., , Peen J., , Soons M. B. J., , … Dekker J. J. M. (2018). Day hospital mentalization-based treatment v. specialist treatment as usual in patients with borderline personality disorder: Randomized controlled trial. Psychological Medicine, 48, 2522–2529. https://doi.org/10.1017/S0033291718000132 Crossref MedlineGoogle Scholar
  • Leppänen V., , Hakko H., , Sintonen H., , & Lindeman S. (2016). Comparing effectiveness of treatments for borderline personality disorder in communal mental health care: The Oulu BPD Study. Community Mental Health Journal, 52, 216–227. https://doi.org/10.1007/s10597-015-9866-4 Crossref MedlineGoogle Scholar
  • Lieb K., , Zanarini M. C., , Schmahl C., , Linehan M. M., , & Bohus M. (2004). Borderline personality disorder. The Lancet, 364(9432), 453–461. Crossref MedlineGoogle Scholar
  • Lynch T. R., , Chapman A. L., , Rosenthal M. Z., , Kuo J. R., , & Linehan M. M. (2006). Mechanisms of change in dialectical behavior therapy: Theoretical and empirical observations. Journal of Clinical Psychology, 62, 459–480. Crossref MedlineGoogle Scholar
  • McMain S. F., , Guimond T., , Barnhart R., , Habinski L., , & Streiner D. L. (2017). A randomized trial of brief dialectical behaviour therapy skills training in suicidal patients suffering from borderline disorder. Acta Psychiatrica Scandinavica, 135, 138–148. https://doi.org/10.1111/acps.12664 Crossref MedlineGoogle Scholar
  • McMain S. F., , Links P. S., , Gnam W. H., , Guimond T., , Cardish R. J., , Korman L., , & Streiner D. L. (2009). A randomized trial of dialectical behavior therapy versus general psychiatric management for borderline personality disorder. American Journal of Psychiatry, 166, 1365–1374. https://doi.org/10.1176/appi.ajp.2009.09010039 Crossref MedlineGoogle Scholar
  • Oud M., , Arntz A., , Hermens M. L., , Verhoef R., , & Kendall T. (2018). Specialized psychotherapies for adults with borderline personality disorder: A systematic review and meta-analysis. Australian and New Zealand Journal of Psychiatry, 52, 949–961. Crossref MedlineGoogle Scholar
  • Perseius K. I., , Andersson E., , Asberg M., , & Samuelsson M. (2006). Health-related quality of life in women patients with borderline personality disorder. Scandinavian Journal of Caring Sciences, 20, 302–307. https://doi.org/10.1111/j.1471-6712.2006.00408.x Crossref MedlineGoogle Scholar
  • Priebe S., , Bhatti N., , Barnicot K., , Bremner S., , Gaglia A., , Katsakou C., , … Zinkler M. (2012). Effectiveness and cost-effectiveness of dialectical behaviour therapy for self-harming patients with personality disorder: A pragmatic randomised controlled trial. Psychotherapy and Psychosomatics, 81, 356–365. https://doi.org/10.1159/000338897 Crossref MedlineGoogle Scholar
  • Schulz K. F., , Altman D. G., , & Moher D. (2010). CONSORT 2010 statement: Updated guidelines for reporting parallel group randomized trials. Annals of Internal Medicine, 152, 726–732. Crossref MedlineGoogle Scholar
  • Skodol A. E., , Pagano M. E., , Bender D. S., , Shea M. T., , Gunderson J. G., , Yen S., , … McGlashan T. H. (2005). Stability of functional impairment in patients with schizotypal, borderline, avoidant, or obsessive-compulsive personality disorder over two years. Psychological Medicine, 35, 443–451. Crossref MedlineGoogle Scholar
  • Soeteman D. I., , Verheul R., , & Busschbach J. J. (2008). The burden of disease in personality disorders: Diagnosis-specific quality of life. Journal of Personality Disorders, 22, 259–268. https://doi.org/10.1521/pedi.2008.22.3.259 LinkGoogle Scholar
  • Stoffers J. M., , Vollm B. A., , Rucker G., , Timmer A., , Huband N., , & Lieb K. (2012). Psychological therapies for people with borderline personality disorder. Cochrane Database of Systematic Reviews, 2012(8). https://doi.org/10.1002/14651858.CD005652.pub2 Google Scholar
  • Trompetter H., , Lamers S., , Westerhof G., , Fledderus M., , & Bohlmeijer E. (2017). Both positive mental health and psychopathology should be monitored in psychotherapy: Confirmation for the dual-factor model in acceptance and commitment therapy. Behaviour Research and Therapy, 91, 58–63. Crossref MedlineGoogle Scholar
  • Uliaszek A. A., , Rashid T., , Williams G. E., , & Gulamani T. (2016). Group therapy for university students: A randomized control trial of dialectical behavior therapy and positive psychotherapy. Behaviour Research and Therapy, 77, 78–85. Crossref MedlineGoogle Scholar
  • Ware J. E., , & Sherbourne C. D. (1992). The MOS 36-item Short-Form Health Survey (SF-36): I. Conceptual framework and item selection. Medical Care, 30, 473–483. Crossref MedlineGoogle Scholar
  • Westerhof G. J., , & Keyes C. L. M. (2010). Mental illness and mental health: The two continua model across the lifespan. Journal of Adult Development, 17, 110–119. https://doi.org/10.1007/s10804-009-9082-y Crossref MedlineGoogle Scholar
  • Wood A. M., , & Joseph S. (2010). The absence of positive psychological (eudemonic) wellbeing as a risk factor for depression: A ten year cohort study. Journal of Affective Disorders, 122, 213–217. Crossref MedlineGoogle Scholar
  • World Health Organization. (1995). The World Health Organization Quality of Life Assessment (WHOQOL): Position paper from the World Health Organization. Social Science and Medicine, 41, 1403–1409. Crossref MedlineGoogle Scholar
  • Zanarini M. C., , Frankenburg F. R., , Hennen J., , & Silk K. R. (2004). Mental health service utilization by borderline personality disorder patients and Axis II comparison subjects followed prospectively for 6 years. Journal of Clinical Psychiatry, 65, 28–36. Crossref MedlineGoogle Scholar
  • Zanarini M. C., , Frankenburg F. R., , Reich D. B., , & Fitzmaurice G. (2010). The 10-year course of psychosocial functioning among patients with borderline personality disorder and Axis II comparison subjects. Acta Psychiatrica Scandinavica, 122, 103–109. Crossref MedlineGoogle Scholar
  • Zanarini M. C., , Frankenburg F. R., , Reich D. B., , & Fitzmaurice G. (2012). Attainment and stability of sustained symptomatic remission and recovery among patients with borderline personality disorder and Axis II comparison subjects: A 16-year prospective follow-up study. American Journal of Psychiatry, 169, 476–483. Crossref MedlineGoogle Scholar
  • Zanarini M. C., , Jacoby R. J., , Frankenburg F. R., , Reich D. B., , & Fitzmaurice G. (2009). The 10-year course of social security disability income reported by patients with borderline personality disorder and Axis II comparison subjects. Journal of Personality Disorders, 23, 346–356. LinkGoogle Scholar
  • Zeitler M.-L., , Bohus M., , Kleindienst N., , Knies R., , Ostermann M., , Schmahl C., , & Lyssenko L. (2018). How to assess recovery in borderline personality disorder: Psychosocial functioning and satisfaction with life in a sample of former DBT study patients. Journal of Personality Disorders. Advance online publication. Google Scholar