Borderline personality disorder is characterized by a consistent pattern of instability in controlling feelings, deficiency in controlling impulses, problems with relationships, and poor self-esteem. In a clinical context, the disorder is expressed as difficulties in managing ones feelings, impulsive actions and aggressiveness, repeated episodes of self-inflicted injury, and suicide attempts. Patients with borderline personality disorder often have other personality disorders or diseases, eg, depression, eating disorders, drug abuse, or anxiety problems. Dialectical behavioral therapy (DBT) is an extensive and advanced form of cognitive behavioral therapy (CBT) that was developed specifically for chronically suicide-prone patients with borderline personality disorder. The DBT method includes several components, eg, behavior-changing techniques and methods for learning to accept feelings. Treatment is carried out in several steps, but self-injury and therapy-disrupting behaviors are prioritized when treatment commences. A distinctive characteristic of DBT is the extensive contact between the therapy team and the patient, eg, through individual therapy, group therapy, and telephone support. Furthermore, staff members working with this group of patients also receive guidance and support. One estimate showed that between 70 000 and 140 000 people in Sweden could possibly meet the diagnostic criteria for borderline personality disorder. The number in this group who would be likely candidates for DBT has not been determined.
Can DBT reduce self-injurious behavior and drug abuse among people with borderline personality disorder?
Six randomized controlled trials compared DBT to other psychiatric treatment. A large percentage of women were included in these trials. The duration of treatment was usually 1 year, and the outcomes varied by study, partly because different subgroups were studied. The results show that DBT leads to a reduction in self-injurious behavior and fewer dropouts from treatment. The effects were found to remain in followup for up to 2 years. Treatment also appeared to reduce the need for hospitalization and reduce drug use among substance abusers. There is no evidence to show that treatment outcomes would be influenced in patients who are also diagnosed with substance abuse. Likewise, there are no confirmed results concerning the impact of different treatment components on the outcome.
A Swedish study investigated the cost of dialectical behavioral therapy. The total annual cost, per patient, for care decreased from 320 000 Swedish kronor (SEK) in the year before treatment commenced to 210 000 SEK when treatment was given. Health economic studies are needed to investigate the cost effectiveness of the method.
There is limited scientific evidence showing that DBT reduces self-injurious behavior and that the effect remains at 2-year followup (Evidence grade 3)*. Treatment also appears to reduce the need for hospitalization and reduce drug use among people with addictions. Hence, DBT appears to be a promising form of treatment for patients with borderline personality disorder. However, it needs to be tested under Swedish conditions, and it is essential to conduct studies addressing the cost effectiveness of the method.
*Grading of the level of scientific evidence for conclusions. The grading scale includes three levels;Evidence grade 1 = strong scientific evidence,Evidence grade 2 = moderately strong scientific evidence,Evidence grade 3 = limited scientific evidence.
This summary is based on a report prepared at SBU in collaboration with Prof. Gerhard Andersson (expert), Linköping University, Assoc. Prof. Margda Wærn (reviewer), Göteborg University, and Prof. Lars-Göran Öst (reviewer), Stockholm University.
The complete report is available only in Swedish.
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