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Treatment selection in borderline personality disorder between dialectical behavior therapy and psychodynamic psychiatric management

Published online by Cambridge University Press:  24 March 2020

John R. Keefe Open the ORCID record for John R. Keefe [Opens in a new window] ,
Thomas T. Kim ,
Robert J. DeRubeis ,
David L. Streiner ,
Paul S. Links  and
Shelley F. McMain Open the ORCID record for Shelley F. McMain [Opens in a new window]
John R. Keefe*
Affiliation:
Department of Psychiatry, Weill Medical College of Cornell University, New York, NY, USA
Thomas T. Kim
Affiliation:
Department of Psychology, University of Pennsylvania, Philadelphia, PA, USA
Robert J. DeRubeis
Affiliation:
Department of Psychology, University of Pennsylvania, Philadelphia, PA, USA
David L. Streiner
Affiliation:
Department of Psychiatry & Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
Paul S. Links
Affiliation:
Department of Psychiatry & Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada
Shelley F. McMain
Affiliation:
Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada Borderline Personality Disorder Clinic, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
*
Author for correspondence: John R. Keefe, E-mail: jack.keefe@gmail.com, jok9134@med.cornell.edu
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Abstract

Background

No evidence-based therapy for borderline personality disorder (BPD) exhibits a clear superiority. However, BPD is highly heterogeneous, and different patients may specifically benefit from the interventions of a particular treatment.

Methods

From a randomized trial comparing a year of dialectical behavior therapy (DBT) to general psychiatric management (GPM) for BPD, long-term (2-year-post) outcome data and patient baseline variables (n = 156) were used to examine individual and combined patient-level moderators of differential treatment response. A two-step bootstrapped and partially cross-validated moderator identification process was employed for 20 baseline variables. For identified moderators, 10-fold bootstrapped cross-validated models estimated response to each therapy, and long-term outcomes were compared for patients randomized to their model-predicted optimal v. non-optimal treatment.

Results

Significant moderators surviving the two-step process included psychiatric symptom severity, BPD impulsivity symptoms (both GPM > DBT), dependent personality traits, childhood emotional abuse, and social adjustment (all DBT > GPM). Patients randomized to their model-predicted optimal treatment had significantly better long-term outcomes (d = 0.36, p = 0.028), especially if the model had a relatively stronger (top 60%) prediction for that patient (d = 0.61, p = 0.004). Among patients with a stronger prediction, this advantage held even when applying a conservative statistical check (d = 0.46, p = 0.043).

Conclusions

Patient characteristics influence the degree to which they respond to two treatments for BPD. Combining information from multiple moderators may help inform providers and patients as to which treatment is the most likely to lead to long-term symptom relief. Further research on personalized medicine in BPD is needed.

Keywords

BPDDBTmoderationpsychodynamic therapy
Type
Original Article
Information
Psychological Medicine , Volume 51 , Issue 11 , August 2021 , pp. 1829 - 1837
Copyright
Copyright © The Author(s), 2020. Published by Cambridge University Press

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