Personality and Mental Health 9: 173–194 (2015) Published online 7 June 2015 in Wiley Online Library (wileyonlinelibrary.com) DOI 10.1002/pmh.1296
Change in interpersonal functioning during psychological interventions for borderline personality disorder—a systematic review of measures and efficacy
ROLAND SINNAEVE1, LOUISA M. C. VAN DEN BOSCH1,2,3 AND KIRSTEN M. VAN STEENBERGEN-WEIJENBURG3, 1University Psychiatric Center K.U. Leuven, Leuven, Belgium; 2 Psychiatric Hospital Pro Persona, Arnhem, The Netherlands; 3Pro Persona Centre for Education and Science, Nijmegen, The Netherlands ABSTRACT Objective – To provide a systematic review of measures of interpersonal functioning used in treatments for people diagnosed with borderline personality disorder (BPD) and to report the effectiveness of treatments on these measures of interpersonal functioning. Method – Literature was reviewed using the online databases and reference lists of previous systematic reviews. Selected studies were randomized controlled trials (RCTs) that examined psychotherapeutic interventions for people with BPD and contained quantitative outcomes on various aspects of interpersonal functioning and reported their results in peer-reviewed journals. Reliability and validity of the results were evaluated. Results – Nineteen RCTs met our inclusion criteria. We found 16 different (sub)scales that measured some aspect of interpersonal functioning. Only four instruments were used by more than one research team. There is some evidence that psychotherapeutic interventions have beneficial effects on some aspects of interpersonal functioning in people diagnosed with BPD, both after individual and group therapy. Generalizability of these findings is limited. Conclusion – There is preliminary evidence that psychotherapeutic interventions have beneficial effects on various aspects of interpersonal reactivity that characterize people diagnosed with BPD. However, none of these effects have a robust evidence base. There are serious concerns about the lack of agreed-upon concepts and instruments. Copyright © 2015 John Wiley & Sons, Ltd. Background Borderline personality disorder (BPD) is a serious and prevalent psychiatric condition, characterized by a pervasive pattern of instability in interpersonal relationships, self-image, affects and marked
Copyright © 2015 John Wiley & Sons, Ltd.
impulsivity that begins by early adulthood. It is a complex disorder associated with substantial morbidity, mortality and public health costs (American Psychiatric Association [APA], 2013; Black, Blum, Pfohl, & Hale, 2004; Soeterman, Hakkaart-van Roijen, Verheul, & Bussbach, 2008).
9: 173–194 (2015) DOI: 10.1002/pmh
174
Sinnaeve et al.
According to the diagnostic criteria in Section 2 of the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5; APA, 2013), personality disorders, and thus BPD, are defined by an enduring pattern of experience and behaviour that deviates from the expectations of the individual’s culture. This pattern is pervasive and leads to significant impairment. Interpersonal functioning is one of the four areas in which personality psychopathology manifests itself. The significance of disturbances in this area is stressed in the alternative model for personality disorders, published in Section 3: ‘Disturbances in self and interpersonal functioning constitute the core of personality psychopathology.’ In BPD, three main symptom clusters have been identified: behavioural deregulation, affect deregulation and disturbances in interpersonal relatedness. The latter dimension comprises frantic efforts to avoid real or imagined abandonment and includes a pattern of unstable and intense interpersonal relationships characterized by alternating between the extremes of idealization and devaluation (Sanislow et al., 2002). Individuals diagnosed with BPD are very sensitive to environmental circumstances. They experience intense fear and anger even when faced with a realistic time-limited separation or change in plans. Frantic efforts to avoid abandonment include self-mutilating or suicidal behaviours. Individuals with this disorder tend to idealize potential caregivers or lovers in the beginning. However, they may switch quickly to devaluating the other person, feeling that he or she is not ‘there‘ enough or is behaving cruelly punitive (DSM, 5th Edition). This remarkable level of interpersonal reactivity has been central to characterizations of people with this disorder since its earliest descriptions in the psychiatric literature (Kernberg, 1967; Stern, 1938). There appears to be a growing consensus that this reactivity originates from a complex interaction of dysfunctional emotion processing and aversive interpersonal experiences. This results in a tendency to experience more negative affect
Copyright © 2015 John Wiley & Sons, Ltd.
towards others, misinterpret neutral situations, feel socially rejected during normative inclusion conditions, have difficulties in repairing cooperation and demonstrate impairments in social problem-solving skills. Dysfunctions of the frontolimbic circuitry and dysregulations of the dopaminergic and the serotonin system in response to interpersonal stressors have been reported (Gunderson & Lyons-Ruth, 2008; Lazarus, Cheavens, Festa, & Rosenthal, 2014; Lis & Bohus, 2013; Schmahl, 2014; Stanley & Siever, 2013 for an overview). Empirical evidence suggests that relationships of patients with BPD are less stable. Higher levels of violence in romantic relationships have been reported (see Lazarus et al., 2014; Lis & Bohus, 2013; Schmahl, 2014 for an overview). In turn, loneliness, perceived rejection, failure and disruptions in relationships precipitate suicide attempts, non-suicidal self-injury and substance use (Brodsky, Groves, Oquendo, Mann, & Stanley, 2006; Gunderson & Lyons-Ruth, 2008; Levy, Meehan, Weber, Reynoso, & Clarkin, 2005; Welch & Linehan, 2002). Hill et al. (2008) discovered that intimate, social and vocational competence for BPD patients is difficult to achieve and to maintain over time. Though psychosocial functioning improves over the course of 10 years, these patients still report significantly worse relationships with partners and parents than individuals with other personality disorders. Vocational functioning remains substantially compromised (Zanarini, Frankenburg, Reich, & Fitzmaurice, 2010). Interpersonal features slowest to remit are affective responses to being alone, active caretaking, discomfort with care and dependency (Choi-Kain, Zanarini, Frankenburg, Fitzmaurice, & Reich, 2010). It is clear that a high level of interpersonal reactivity characterizes BPD. This reactivity seems to be related to suicidal and parasuicidal behaviours and severe impairments in psychosocial functioning. Accordingly, all evidence-based treatments for BPD include treatment strategies and modules aimed at improving interpersonal functioning. Indeed, the American Psychiatric
9: 173–194 (2015) DOI: 10.1002/pmh
Changing interpersonal functioning in BPD
Association (APA) states that ‘clinical experience suggests that most patients with borderline personality disorder will need some form of extended psychotherapy in order to resolve interpersonal problems and attain and maintain lasting improvements in their personality and overall functioning’ (APA, 2001, p.18). However, it is not clear whether these treatments are effective at changing interpersonal functioning of people with BPD. The latest Cochrane review included ‘interpersonal cluster symptoms’ as a primary outcome, referring to ‘general interpersonal symptoms’ and ‘avoidance of abandonment’ (Stoffers et al., 2012, p. 12). It provides some information about changes in interpersonal functioning during psychological interventions for BPD. However, if we consider interpersonal functioning to be functioning ‘being, relating to, or involving relations between persons’ (Merriam-Webster’s online dictionary, n.d.), then the definition in Stoffers et al. (2012) is incomplete. Changes in adaptive interpersonal behaviour, interaction with the therapist and psychological processes/skills specifically related to interpersonal functioning were not included. Moreover, interpersonal behaviour patterns elicit effects in daily life, affecting quality of life and feelings of (in)adequacy in specific social roles. In this review, we will evaluate these effects as well. By using a more comprehensive definition, we hope to learn more about how interpersonal functioning during psychological interventions for BPD is operationalized and about the effectiveness of psychological interventions in changing interpersonal functioning of people diagnosed with BPD.
Objective To provide a systematic review of measures of interpersonal functioning used in treatments for people diagnosed with BPD and to report the effectiveness of treatments on these measures of interpersonal functioning.
Copyright © 2015 John Wiley & Sons, Ltd.
Method Criteria for considering studies for this review Type of studies. Only randomized studies (with or without blinding) that examined psychotherapeutic interventions for people with BPD were included. Participants. All participants in the studies were adults diagnosed with BPD according to a validated, semi-structured interview administered by a trained clinician. The operational criteria were based on the DSM-III (APA, 1980), DSMIV (APA, 2000) or DSM V (APA, 2013). Studies in which at least 70% of the participants had a diagnosis of BPD were included. Experimental interventions. Experimental interventions comprised any well-defined, theorydriven psychotherapeutic treatment, regardless of theoretical orientation or setting (hospitalization, partial hospitalisation and outpatient). We decided to arrange the interventions in the same categories as Stoffers et al. (2012). Comprehensive psychotherapies include individual psychotherapy as a substantial part of the intervention; duration of at least 3 months. Non-comprehensive psychotherapeutic interventions do not include individual psychotherapy as a substantial part of the intervention, duration of less than 3 months. Comparator interventions. Because only RCTs were considered, all experiments compared the results of the experimental intervention with a control group. Control interventions could be ‘non-active’ (e.g. no treatment, standard care, waiting list, treatment as usual and clinical management) or ‘active’ (e.g. another well-defined psychotherapeutic treatment). Outcome measures. Included studies contained quantitative data on ‘interpersonal functioning’. Outcomes were either self-rated or interviewerassessed. Studies were only included if they
9: 173–194 (2015) DOI: 10.1002/pmh
175
176
Sinnaeve et al.
provided information for at least one of outcomes defined as follows: (I)
Changes in behaviour patterns when interacting with others (not therapist), including the following: (a) changes in maladaptive interpersonal behaviour considered characteristic for BPD (such as avoiding real or imagined abandonment, unstable and intense interpersonal relationships, idealization and devaluation); (b) changes in other maladaptive interpersonal behaviour patterns, such as hostility; and (c) changes in social affiliation and cooperation. (II) Changes in cooperation with therapist and therapeutic alliance (not drop-out). (III) Changes in psychological processing and skills targeted during psychotherapy, including quality of mentalization in attachment relationships and level of interpersonal effectiveness skills. (IV) Changes in effects of interpersonal behaviour, including the following: (a) feelings of uneasiness and distress associated with interpersonal problems; (b) impaired quality of life and satisfaction associated with interpersonal problems; and (c) friction and inadequacy in specific role areas, including work, social and leisure activities, friendships, family life, marriage and intimate relationships. Peer review. All studies reported their results in peer-reviewed journals. Search method and selection of studies Literature was reviewed using the online databases MEDLINE/PubMed and PsycINFO. Combinations of keywords were used referring to participants (BPD); interventions (psychological treatment, psychodynamic/ cognitive behavio(u)r(al)/ dialectical behavio(u)r/mentalization/schema/ dynamic deconstructive/emotion regulation/ transference focussed/group (psycho)therapy, Systems training for Emotional Predictability and Problem Solving (STEPPS), standard psychiatric
Copyright © 2015 John Wiley & Sons, Ltd.
care, psychoanalysis, dialectical behaviour therapy (DBT), mentalization based treatment (MBT), emotion regulation treatment; outcome (interpersonal functioning/problems, social adjustment/ functioning and relationships) and study design (randomized controlled trial, RCT). Reference lists of systematic reviews (Barnicot, Katsakou, Marougka, & Priebe, 2011; Brazier et al., 2006; Zanarini, 2009) were hand searched for additional relevant trials of psychotherapeutic treatment for BPD, alongside the Cochrane reviews (Binks et al., 2006; Stoffers et al., 2012). The search covered the literature from 1970 to December 2013. Search results were divided to examine eligibility using title and abstract, in such a way that two authors independently assessed every abstract. In the next stage, references were made available in full text. Reports of the same study were linked together. Two authors assessed full texts independently. Conflicting decisions were reconsidered with all authors until agreement was reached. Measures of treatment effect To evaluate the effect of a psychological intervention on interpersonal functioning, we used the p-value of this treatment effect reported by the authors and estimates of the post-treatment effect size. Estimates of effect sizes were calculated on basis of post-treatment group results. Hedges’ g was used, applying procedures and formulas discussed by Lipsey and Wilson (2001). The pooled standard deviation was used as an estimate of the population variance. Following Cohen (1988), effect sizes around 0.20 were regarded small, scores of 0.50 as moderate and scores of 0.80 or more as large. Separate comparisons were performed by type of intervention (comprehensive or not), therapeutic orientation (psychodynamic, humanistic, cognitive behavioural, systems therapy, integrative approach), type of controls (active or passive), duration (number of months) and treatment setting (hospitalized, partially hospitalized or outpatient). If studies were judged to be homogeneous, then meta-analytic pooling was considered.
9: 173–194 (2015) DOI: 10.1002/pmh
Changing interpersonal functioning in BPD
Assesment of the reliability and validity of the effect size estimates Measurements in the selected studies that yield quantitative data on interpersonal functioning were assorted according to four domains of outcome, listed previously (‘Criteria for considering studies for this review’). Reliability and validity of these (sub)scales were evaluated (van den Bosch, Sinnaeve, & van Steenbergen-Weijenburg, 2014). Like Stoffers et al. (2012), we also assessed risk of bias using The Cochrane Collaboration’s tool (Higgins, Altman, & Sterne, 2011). This evaluation included ratings of selection bias (random sequence generation and concealment of allocation), detection bias (blinding of outcome assessors), reporting bias (selective reporting), performance bias (treatment adherence), bias due to allegiance effects and attention bias. Two of the review authors independently rated the studies. Discrepancies between these authors or conclusions that deviated from the conclusions of Stoffers et al. (2012) were discussed in order to arrive at a consensus. Potential sources of bias were listed in Table 1. Results Results of the search A diagram of paper selection can be found in Figure 1. In total, 275 potentially relevant abstracts were collected. One hundred sixty-nine abstracts were excluded because they did not meet the inclusion criteria. Subsequently, 106 full texts were screened. Thirty-five RCTs met the inclusion criteria for population, intervention, research design and peer review. Nineteen studies were identified as providing data on change in interpersonal behaviour and eligible for inclusion in this review (Table 1). Characteristics of included studies Studies included are described in Table 1. Results of the trials were published between 1991 and 2011.
Copyright © 2015 John Wiley & Sons, Ltd.
Participants. Four studies consisted of female participants only (Farrell, Shaw, & Webber, 2009; Linehan, Tutek, Heard, & Armstrong, 1994; Linehan et al., 1999, 2002). Remaining studies were predominantly female. All participants were diagnosed with BPD according to the DSM criteria (edition III, III-R, IV, IV-TR). Bellino (2006) and Bellino, Zizza, Rinaldi, and Bogetto (2007) focused also on the comorbid major depressive episode. Linehan et al. (1999, 2002) concentrated on patients with concomitant substance abuse disorder. All studies excluded patients suffering from chronic psychotic disorders. Most studies excluded patients with comorbid bipolar disorder (13/19), substance misuse problems (15/19) and cognitive or neurological impairments (11/19). All studies except Bateman and Fonagy (1999) were located in an outpatient setting. Experimental interventions. The duration of the interventions ranged from 10 weeks to 18 months (Table 1). Nine experimental interventions were based on cognitive behaviour therapy, predominantly DBT (Blum et al., 2008; Bos, van Wel, Appelo, & Verbraak, 2010; Cottraux et al., 2009; Davidson et al., 2006; Linehan et al., 1994, 1999, 2002; McMain et al., 2009; Soler et al., 2009). Seven studies were psychodynamically oriented (Amianto et al., 2011; Bateman & Fonagy, 1999, 2009; Bellino, 2006; Bellino, Rinaldi, & Bogetto, 2010; Bellino et al., 2007; Clarkin, Levy, Lenzenweger, & Kernberg, 2007). One study examined the efficacy of an interpersonal approach in group (Munroe-Blum & Marziali, 1995). Farrell et al. (2009) studied the effects of schema therapy, an integration of cognitive therapy, behaviour therapy, object relations and gestalt therapy. Kramer et al. (2011) used an integrative approach to improve therapist responsiveness to patients’ in-session behaviour in early-phase treatment. Controls. Treatment as usual (TAU) was the most commonly used control condition (Amianto et al., 2011; Bateman & Fonagy, 1999, 2009;
9: 173–194 (2015) DOI: 10.1002/pmh
177
Participants
Experimental intervention
Amianto et al., (2011)
Intervention: Sequential N: 17 + 18 Sex: resp 53 and 44% female Brief Adlerian Psychodynamic Psychotherapy (SBAPP): 40 Age: resp 40.1 and 39.2 on weekly sessions, sequential average and repeatable modules Setting: outpatient (Italy) Duration: 10–11 months Exclusion: heavy use of MHS prior year, acute comorbid Axis I disorder requiring hospitalization, substance dependence, mental retardation, previous psychotherapy Diagnosis: DSM-IV, SCID Intervention: Bateman & N: 19 + 19 psychoanalytically oriented Fonagy (1999, Sex: 57.9% female 2001, 2008) Age: 16–65, 31.8 on average partial hospitalization Duration: 18 months Setting: partial hosp + outpatient (UK) Exclusion: schizophrenia, bipolar disorder, substance misuse, mental impairment, organic brain disorder Diagnosis: DSM-III-R, SCID and DIB-R Intervention: MBT Bateman & N: 71 + 63 outpatient: weekly individual Fonagy (2009) Sex: 79.9% female and group psychotherapy Age: resp 31.3 and Duration: 18 months 30.9 on average Setting: outpatient (UK) Exclusion: psychotic disorder, bipolar I disorder, opiate dependence requiring specialist treatment, mental impairment, organic brain disorder, being in long-term psychotherapeutic treatment Diagnosis: DSM-IV, SCID-II
Study
Table 1: Description of studies included
Copyright © 2015 John Wiley & Sons, Ltd.
Change in interpersonal functioning during psychological interventions for borderline personality disorder—a systematic review of measures and efficacy
ROLAND SINNAEVE1, LOUISA M. C. VAN DEN BOSCH1,2,3 AND KIRSTEN M. VAN STEENBERGEN-WEIJENBURG3, 1University Psychiatric Center K.U. Leuven, Leuven, Belgium; 2 Psychiatric Hospital Pro Persona, Arnhem, The Netherlands; 3Pro Persona Centre for Education and Science, Nijmegen, The Netherlands ABSTRACT Objective – To provide a systematic review of measures of interpersonal functioning used in treatments for people diagnosed with borderline personality disorder (BPD) and to report the effectiveness of treatments on these measures of interpersonal functioning. Method – Literature was reviewed using the online databases and reference lists of previous systematic reviews. Selected studies were randomized controlled trials (RCTs) that examined psychotherapeutic interventions for people with BPD and contained quantitative outcomes on various aspects of interpersonal functioning and reported their results in peer-reviewed journals. Reliability and validity of the results were evaluated. Results – Nineteen RCTs met our inclusion criteria. We found 16 different (sub)scales that measured some aspect of interpersonal functioning. Only four instruments were used by more than one research team. There is some evidence that psychotherapeutic interventions have beneficial effects on some aspects of interpersonal functioning in people diagnosed with BPD, both after individual and group therapy. Generalizability of these findings is limited. Conclusion – There is preliminary evidence that psychotherapeutic interventions have beneficial effects on various aspects of interpersonal reactivity that characterize people diagnosed with BPD. However, none of these effects have a robust evidence base. There are serious concerns about the lack of agreed-upon concepts and instruments. Copyright © 2015 John Wiley & Sons, Ltd. Background Borderline personality disorder (BPD) is a serious and prevalent psychiatric condition, characterized by a pervasive pattern of instability in interpersonal relationships, self-image, affects and marked
Copyright © 2015 John Wiley & Sons, Ltd.
impulsivity that begins by early adulthood. It is a complex disorder associated with substantial morbidity, mortality and public health costs (American Psychiatric Association [APA], 2013; Black, Blum, Pfohl, & Hale, 2004; Soeterman, Hakkaart-van Roijen, Verheul, & Bussbach, 2008).
9: 173–194 (2015) DOI: 10.1002/pmh
174
Sinnaeve et al.
According to the diagnostic criteria in Section 2 of the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5; APA, 2013), personality disorders, and thus BPD, are defined by an enduring pattern of experience and behaviour that deviates from the expectations of the individual’s culture. This pattern is pervasive and leads to significant impairment. Interpersonal functioning is one of the four areas in which personality psychopathology manifests itself. The significance of disturbances in this area is stressed in the alternative model for personality disorders, published in Section 3: ‘Disturbances in self and interpersonal functioning constitute the core of personality psychopathology.’ In BPD, three main symptom clusters have been identified: behavioural deregulation, affect deregulation and disturbances in interpersonal relatedness. The latter dimension comprises frantic efforts to avoid real or imagined abandonment and includes a pattern of unstable and intense interpersonal relationships characterized by alternating between the extremes of idealization and devaluation (Sanislow et al., 2002). Individuals diagnosed with BPD are very sensitive to environmental circumstances. They experience intense fear and anger even when faced with a realistic time-limited separation or change in plans. Frantic efforts to avoid abandonment include self-mutilating or suicidal behaviours. Individuals with this disorder tend to idealize potential caregivers or lovers in the beginning. However, they may switch quickly to devaluating the other person, feeling that he or she is not ‘there‘ enough or is behaving cruelly punitive (DSM, 5th Edition). This remarkable level of interpersonal reactivity has been central to characterizations of people with this disorder since its earliest descriptions in the psychiatric literature (Kernberg, 1967; Stern, 1938). There appears to be a growing consensus that this reactivity originates from a complex interaction of dysfunctional emotion processing and aversive interpersonal experiences. This results in a tendency to experience more negative affect
Copyright © 2015 John Wiley & Sons, Ltd.
towards others, misinterpret neutral situations, feel socially rejected during normative inclusion conditions, have difficulties in repairing cooperation and demonstrate impairments in social problem-solving skills. Dysfunctions of the frontolimbic circuitry and dysregulations of the dopaminergic and the serotonin system in response to interpersonal stressors have been reported (Gunderson & Lyons-Ruth, 2008; Lazarus, Cheavens, Festa, & Rosenthal, 2014; Lis & Bohus, 2013; Schmahl, 2014; Stanley & Siever, 2013 for an overview). Empirical evidence suggests that relationships of patients with BPD are less stable. Higher levels of violence in romantic relationships have been reported (see Lazarus et al., 2014; Lis & Bohus, 2013; Schmahl, 2014 for an overview). In turn, loneliness, perceived rejection, failure and disruptions in relationships precipitate suicide attempts, non-suicidal self-injury and substance use (Brodsky, Groves, Oquendo, Mann, & Stanley, 2006; Gunderson & Lyons-Ruth, 2008; Levy, Meehan, Weber, Reynoso, & Clarkin, 2005; Welch & Linehan, 2002). Hill et al. (2008) discovered that intimate, social and vocational competence for BPD patients is difficult to achieve and to maintain over time. Though psychosocial functioning improves over the course of 10 years, these patients still report significantly worse relationships with partners and parents than individuals with other personality disorders. Vocational functioning remains substantially compromised (Zanarini, Frankenburg, Reich, & Fitzmaurice, 2010). Interpersonal features slowest to remit are affective responses to being alone, active caretaking, discomfort with care and dependency (Choi-Kain, Zanarini, Frankenburg, Fitzmaurice, & Reich, 2010). It is clear that a high level of interpersonal reactivity characterizes BPD. This reactivity seems to be related to suicidal and parasuicidal behaviours and severe impairments in psychosocial functioning. Accordingly, all evidence-based treatments for BPD include treatment strategies and modules aimed at improving interpersonal functioning. Indeed, the American Psychiatric
9: 173–194 (2015) DOI: 10.1002/pmh
Changing interpersonal functioning in BPD
Association (APA) states that ‘clinical experience suggests that most patients with borderline personality disorder will need some form of extended psychotherapy in order to resolve interpersonal problems and attain and maintain lasting improvements in their personality and overall functioning’ (APA, 2001, p.18). However, it is not clear whether these treatments are effective at changing interpersonal functioning of people with BPD. The latest Cochrane review included ‘interpersonal cluster symptoms’ as a primary outcome, referring to ‘general interpersonal symptoms’ and ‘avoidance of abandonment’ (Stoffers et al., 2012, p. 12). It provides some information about changes in interpersonal functioning during psychological interventions for BPD. However, if we consider interpersonal functioning to be functioning ‘being, relating to, or involving relations between persons’ (Merriam-Webster’s online dictionary, n.d.), then the definition in Stoffers et al. (2012) is incomplete. Changes in adaptive interpersonal behaviour, interaction with the therapist and psychological processes/skills specifically related to interpersonal functioning were not included. Moreover, interpersonal behaviour patterns elicit effects in daily life, affecting quality of life and feelings of (in)adequacy in specific social roles. In this review, we will evaluate these effects as well. By using a more comprehensive definition, we hope to learn more about how interpersonal functioning during psychological interventions for BPD is operationalized and about the effectiveness of psychological interventions in changing interpersonal functioning of people diagnosed with BPD.
Objective To provide a systematic review of measures of interpersonal functioning used in treatments for people diagnosed with BPD and to report the effectiveness of treatments on these measures of interpersonal functioning.
Copyright © 2015 John Wiley & Sons, Ltd.
Method Criteria for considering studies for this review Type of studies. Only randomized studies (with or without blinding) that examined psychotherapeutic interventions for people with BPD were included. Participants. All participants in the studies were adults diagnosed with BPD according to a validated, semi-structured interview administered by a trained clinician. The operational criteria were based on the DSM-III (APA, 1980), DSMIV (APA, 2000) or DSM V (APA, 2013). Studies in which at least 70% of the participants had a diagnosis of BPD were included. Experimental interventions. Experimental interventions comprised any well-defined, theorydriven psychotherapeutic treatment, regardless of theoretical orientation or setting (hospitalization, partial hospitalisation and outpatient). We decided to arrange the interventions in the same categories as Stoffers et al. (2012). Comprehensive psychotherapies include individual psychotherapy as a substantial part of the intervention; duration of at least 3 months. Non-comprehensive psychotherapeutic interventions do not include individual psychotherapy as a substantial part of the intervention, duration of less than 3 months. Comparator interventions. Because only RCTs were considered, all experiments compared the results of the experimental intervention with a control group. Control interventions could be ‘non-active’ (e.g. no treatment, standard care, waiting list, treatment as usual and clinical management) or ‘active’ (e.g. another well-defined psychotherapeutic treatment). Outcome measures. Included studies contained quantitative data on ‘interpersonal functioning’. Outcomes were either self-rated or interviewerassessed. Studies were only included if they
9: 173–194 (2015) DOI: 10.1002/pmh
175
176
Sinnaeve et al.
provided information for at least one of outcomes defined as follows: (I)
Changes in behaviour patterns when interacting with others (not therapist), including the following: (a) changes in maladaptive interpersonal behaviour considered characteristic for BPD (such as avoiding real or imagined abandonment, unstable and intense interpersonal relationships, idealization and devaluation); (b) changes in other maladaptive interpersonal behaviour patterns, such as hostility; and (c) changes in social affiliation and cooperation. (II) Changes in cooperation with therapist and therapeutic alliance (not drop-out). (III) Changes in psychological processing and skills targeted during psychotherapy, including quality of mentalization in attachment relationships and level of interpersonal effectiveness skills. (IV) Changes in effects of interpersonal behaviour, including the following: (a) feelings of uneasiness and distress associated with interpersonal problems; (b) impaired quality of life and satisfaction associated with interpersonal problems; and (c) friction and inadequacy in specific role areas, including work, social and leisure activities, friendships, family life, marriage and intimate relationships. Peer review. All studies reported their results in peer-reviewed journals. Search method and selection of studies Literature was reviewed using the online databases MEDLINE/PubMed and PsycINFO. Combinations of keywords were used referring to participants (BPD); interventions (psychological treatment, psychodynamic/ cognitive behavio(u)r(al)/ dialectical behavio(u)r/mentalization/schema/ dynamic deconstructive/emotion regulation/ transference focussed/group (psycho)therapy, Systems training for Emotional Predictability and Problem Solving (STEPPS), standard psychiatric
Copyright © 2015 John Wiley & Sons, Ltd.
care, psychoanalysis, dialectical behaviour therapy (DBT), mentalization based treatment (MBT), emotion regulation treatment; outcome (interpersonal functioning/problems, social adjustment/ functioning and relationships) and study design (randomized controlled trial, RCT). Reference lists of systematic reviews (Barnicot, Katsakou, Marougka, & Priebe, 2011; Brazier et al., 2006; Zanarini, 2009) were hand searched for additional relevant trials of psychotherapeutic treatment for BPD, alongside the Cochrane reviews (Binks et al., 2006; Stoffers et al., 2012). The search covered the literature from 1970 to December 2013. Search results were divided to examine eligibility using title and abstract, in such a way that two authors independently assessed every abstract. In the next stage, references were made available in full text. Reports of the same study were linked together. Two authors assessed full texts independently. Conflicting decisions were reconsidered with all authors until agreement was reached. Measures of treatment effect To evaluate the effect of a psychological intervention on interpersonal functioning, we used the p-value of this treatment effect reported by the authors and estimates of the post-treatment effect size. Estimates of effect sizes were calculated on basis of post-treatment group results. Hedges’ g was used, applying procedures and formulas discussed by Lipsey and Wilson (2001). The pooled standard deviation was used as an estimate of the population variance. Following Cohen (1988), effect sizes around 0.20 were regarded small, scores of 0.50 as moderate and scores of 0.80 or more as large. Separate comparisons were performed by type of intervention (comprehensive or not), therapeutic orientation (psychodynamic, humanistic, cognitive behavioural, systems therapy, integrative approach), type of controls (active or passive), duration (number of months) and treatment setting (hospitalized, partially hospitalized or outpatient). If studies were judged to be homogeneous, then meta-analytic pooling was considered.
9: 173–194 (2015) DOI: 10.1002/pmh
Changing interpersonal functioning in BPD
Assesment of the reliability and validity of the effect size estimates Measurements in the selected studies that yield quantitative data on interpersonal functioning were assorted according to four domains of outcome, listed previously (‘Criteria for considering studies for this review’). Reliability and validity of these (sub)scales were evaluated (van den Bosch, Sinnaeve, & van Steenbergen-Weijenburg, 2014). Like Stoffers et al. (2012), we also assessed risk of bias using The Cochrane Collaboration’s tool (Higgins, Altman, & Sterne, 2011). This evaluation included ratings of selection bias (random sequence generation and concealment of allocation), detection bias (blinding of outcome assessors), reporting bias (selective reporting), performance bias (treatment adherence), bias due to allegiance effects and attention bias. Two of the review authors independently rated the studies. Discrepancies between these authors or conclusions that deviated from the conclusions of Stoffers et al. (2012) were discussed in order to arrive at a consensus. Potential sources of bias were listed in Table 1. Results Results of the search A diagram of paper selection can be found in Figure 1. In total, 275 potentially relevant abstracts were collected. One hundred sixty-nine abstracts were excluded because they did not meet the inclusion criteria. Subsequently, 106 full texts were screened. Thirty-five RCTs met the inclusion criteria for population, intervention, research design and peer review. Nineteen studies were identified as providing data on change in interpersonal behaviour and eligible for inclusion in this review (Table 1). Characteristics of included studies Studies included are described in Table 1. Results of the trials were published between 1991 and 2011.
Copyright © 2015 John Wiley & Sons, Ltd.
Participants. Four studies consisted of female participants only (Farrell, Shaw, & Webber, 2009; Linehan, Tutek, Heard, & Armstrong, 1994; Linehan et al., 1999, 2002). Remaining studies were predominantly female. All participants were diagnosed with BPD according to the DSM criteria (edition III, III-R, IV, IV-TR). Bellino (2006) and Bellino, Zizza, Rinaldi, and Bogetto (2007) focused also on the comorbid major depressive episode. Linehan et al. (1999, 2002) concentrated on patients with concomitant substance abuse disorder. All studies excluded patients suffering from chronic psychotic disorders. Most studies excluded patients with comorbid bipolar disorder (13/19), substance misuse problems (15/19) and cognitive or neurological impairments (11/19). All studies except Bateman and Fonagy (1999) were located in an outpatient setting. Experimental interventions. The duration of the interventions ranged from 10 weeks to 18 months (Table 1). Nine experimental interventions were based on cognitive behaviour therapy, predominantly DBT (Blum et al., 2008; Bos, van Wel, Appelo, & Verbraak, 2010; Cottraux et al., 2009; Davidson et al., 2006; Linehan et al., 1994, 1999, 2002; McMain et al., 2009; Soler et al., 2009). Seven studies were psychodynamically oriented (Amianto et al., 2011; Bateman & Fonagy, 1999, 2009; Bellino, 2006; Bellino, Rinaldi, & Bogetto, 2010; Bellino et al., 2007; Clarkin, Levy, Lenzenweger, & Kernberg, 2007). One study examined the efficacy of an interpersonal approach in group (Munroe-Blum & Marziali, 1995). Farrell et al. (2009) studied the effects of schema therapy, an integration of cognitive therapy, behaviour therapy, object relations and gestalt therapy. Kramer et al. (2011) used an integrative approach to improve therapist responsiveness to patients’ in-session behaviour in early-phase treatment. Controls. Treatment as usual (TAU) was the most commonly used control condition (Amianto et al., 2011; Bateman & Fonagy, 1999, 2009;
9: 173–194 (2015) DOI: 10.1002/pmh
177
Participants
Experimental intervention
Amianto et al., (2011)
Intervention: Sequential N: 17 + 18 Sex: resp 53 and 44% female Brief Adlerian Psychodynamic Psychotherapy (SBAPP): 40 Age: resp 40.1 and 39.2 on weekly sessions, sequential average and repeatable modules Setting: outpatient (Italy) Duration: 10–11 months Exclusion: heavy use of MHS prior year, acute comorbid Axis I disorder requiring hospitalization, substance dependence, mental retardation, previous psychotherapy Diagnosis: DSM-IV, SCID Intervention: Bateman & N: 19 + 19 psychoanalytically oriented Fonagy (1999, Sex: 57.9% female 2001, 2008) Age: 16–65, 31.8 on average partial hospitalization Duration: 18 months Setting: partial hosp + outpatient (UK) Exclusion: schizophrenia, bipolar disorder, substance misuse, mental impairment, organic brain disorder Diagnosis: DSM-III-R, SCID and DIB-R Intervention: MBT Bateman & N: 71 + 63 outpatient: weekly individual Fonagy (2009) Sex: 79.9% female and group psychotherapy Age: resp 31.3 and Duration: 18 months 30.9 on average Setting: outpatient (UK) Exclusion: psychotic disorder, bipolar I disorder, opiate dependence requiring specialist treatment, mental impairment, organic brain disorder, being in long-term psychotherapeutic treatment Diagnosis: DSM-IV, SCID-II
Study
Table 1: Description of studies included
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