Treatment of borderline personality disorder

Winston (2000) is to be congratulated on a timely and wide-ranging review. However, in the area of therapeutic community treatment and partial hospitalisation, he has omitted two recent pieces of work which are central to the field.

The first represents the best result currently available from a well-designed trial for patients with borderline personality disorder (BPD) by any treatment method. Bateman and Fonagy (1999) carried out a randomised comparison of 19 patients with BPD treated for 18 months in a psychoanalytically oriented, group-focused day service with a control group of subjects treated as usual. They found improvements in Beck Depression Inventory, Symptom Checklist-90 (global severity), Spielberger State-Trait Anxiety Inventory, Social Adjustment Scale and Inventory of Personal Problems. Self-mutilations, attempted suicides, in-patient days and episodes, and use of medication all significantly decreased. These results are superior to those found with dialectical behaviour therapy, the only other treatment for which a randomised controlled trial has been carried out.

The second piece of work is a meta-analytic review of therapeutic community effectiveness for personality disorder from the NHS Centre for Research and Dissemination in York (Reference Lees, Manning and RawlingsLees et al, 1999). This systematic review assessed 29 studies of therapeutic communities. The authors found an overall odds ratio of 0.57 (95% CI 0.52-0.61) for treatment effect on a variety of outcome measures. They conclude, “There is accumulating evidence … of the effectiveness and particular suitability of the therapeutic community model to the treatment of personality disorder, and particularly severe personality disorder”. This study provides substantially stronger evidence for the effectiveness of therapeutic community treatment than the studies cited by Winston.

The similarity of the two treatment methods investigated in the studies quoted above point to what is currently the most promising line of investigation for the treatment of BPD.