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Publication Date: February 22, 2018

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CADTH RAPID RESPONSE REPORT: SUMMARY OF ABSTRACTS

Treatment of Personality Disorders in Adults with or without Comorbid Mental Health Conditions: Clinical Effectiveness and Guidelines

SUMMARY OF ABSTRACTS Treatment of Personality Disorders in Adults With or Without Comorbid Mental Health Conditions 2

Authors: Kristen Moulton, Sarah Visintini

Cite As: Treatment of personality disorders in adults with or without comorbid mental health conditions: clinical ef f ectiveness and guidelines. Ottawa: CADTH;

2018 Feb. (CADTH rapid response report: summary of abstracts).

Acknowledgments:

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Research Questions

1. What is the clinical evidence regarding the treatment and management of adults with

personality disorders who may or may not have comorbid mental health conditions?

2. What are the evidence-based guidelines associated with the treatment and

management of adults with personality disorders who may or may not have comorbid

mental health conditions?

Key Findings

Three systematic reviews and 14 randomized controlled trials were identified examining the

clinical evidence regarding the treatment and management of adults with personality

disorders using psychotherapeutic methods. Three of the RCTs included patients with

comorbid depression or post-traumatic stress disorder.

Methods

A limited literature search was conducted on key resources including PubMed, The

Cochrane Library, University of York Centre for Reviews and Dissemination (CRD)

databases, Canadian and major international health technology agencies, as well as a

focused Internet search. Methodological filters were applied to limit retrieval to health

technology assessments, systematic reviews, meta-analyses, randomized controlled trials

and guidelines. Where possible, retrieval was limited to the human population. The search

was also limited to English language documents published between January 1, 2013 and

February 13, 2018. Internet links were provided, where available.

Selection Criteria

One reviewer screened citations and selected studies based on the inclusion criteria

presented in Table 1.

Table 1: Selection Criteria

Population Adults with personality disorders, with or without comorbid post-traumatic stress disorder [PTSD] and/or depression

Intervention Psychotherapy

Comparators Q1: Psychotherapy Pharmacological therapy; Wait list Q2: No comparator

Outcomes Q1: Effectiveness of treatment (primarily interested in which condition [if any] should be treated first, the personality disorder or the comorbid mental health condition [PTSD or depression], how well the treatment or management strategies work, etc.) Q2: Guidelines

Study Designs Health technology assessment reports, systematic reviews, meta-analyses, randomized controlled trials, evidence-based guidelines


Results

Rapid Response reports are organized so that the higher quality evidence is presented first.

Therefore, health technology assessment reports, systematic reviews, and meta-analyses

are presented first. These are followed by randomized controlled trials and evidence-based

guidelines.

Three systematic reviews and 14 randomized controlled trials regarding the treatment and

management of adults with personality disorders with or without comorbid post-traumatic

stress disorder and/or depression were identified. No relevant health technology

assessment reports or evidence-based guidelines were identified.

Additional references of potential interest are provided in the appendix.

Overall Summary of Findings

Three systematic reviews (SR)1-3

and 14 randomized controlled trials (RCT)4-17

were

identified that examined the clinical evidence regarding the treatment and management of

adults with personality disorders (PD) using psychotherapeutic methods. Three of the

RCTs15-17

included patients with comorbid depression15,17

or post-traumatic stress disorder

(PTSD).16

Study details are included in Tables 2 and 3.

Psychotherapeutic interventions (type not specified) were observed to be more effective

than control interventions for the treatment of borderline personality disorder (BPD) of

differing severity in one SR.2 Although the authors of one SR

2 found that more intensive

treatment did not result in better outcomes than less intensive treatment, the authors of a

second SR3 found that self-harm was significantly reduced and social functioning was

significantly improved when patients had access to group therapy and when individual

therapy frequency was more than one time per week. A psychodynamic approach was also

observed to be effective in treating BPD symptoms in one SR.1

A dialectical behavioural therapy (DBT) approach to the treatment of BPD was found to be

effective in treating BPD symptoms in one SR1 and in two RCTs.

4,8 Specifically, DBT skills

training was observed to be effective in reducing suicidality,4 and non-suicidal self-injurious

behavior4,8

when compared with wait-list4 or with DBT without skills training.

8

Based on RCT evidence, other psychotherapeutic treatment options found to have some

effectiveness in patients with personality disorders were:

Democratic therapeutic community treatment was more effective than treatment as

usual (TAU), particularly for measures of aggression5

Manualized psychoanalytic-interactional therapy and non-manualized

psychodynamic therapy by experts were more effective than TAU and wait list for

improving levels of personality organization and psychological distress in in-

patients with cluster-B PDs6

Both cognitive rehabilitation and psychoeducational group interventions improved

daily functioning and clinical symptoms of BPD9

Schema therapy was associated with increased recovery from cluster-C PDs when

compared with TAU and clarification oriented therapy10

Emotion regulation group therapy was an effective add-on to TAU for female

patients with self-harm behaviours11


Motive-oriented therapeutic relationship add-on to manualized ‘short variant’ of

general psychiatric management may be promising for patients with BPD12

Cognitive analytic therapy was more effective than TAU for patients with PD13

Both ‘intensive’ mentalization-based psychotherapy (MBT) and less intensive

group psychotherapy had effectiveness in treating BPD after 2 year follow-up.14

Psychoeducation and problem-solving therapy was not found to be an effective add-on

therapy to treatment as usual.7

Patients with Comorbid Depression or PTSD

For patients with comorbid cluster C personality disorders and depression, the authors of

one RCT observed that depression treatment as an add-on to PD treatment may be

beneficial.15

Authors of another RCT17

found that behavioural activation therapy was more

effective than antidepressant medication in treating depression in patients with and without

cluster-C personality disorders. Further, the PD was not associated in a difference in

treatment response.17

For female in-patients with PTSD and comorbid BPD, a dialectical behavior therapy

approach was found to be more effective than treatment as usual on the wait list.16

No relevant evidence-based guidelines were identified.

Table 2: Summary of Included Studies of the Clinical Evidence Regarding the Treatment and Management of Adults with Personality Disorders

First Author, Year

Study Design Details

Patient Group Details

Intervention, Comparator

Results and Author Conclusions

Systematic Reviews

Cristea, 20171 SR and MA of RCTs

33 trials examining 2,256 participants included

Adults diagnosed with BPD

Psychotherapy interventions Control interventions Psychotherapy add-on to treatment as usual vs treatment as usual also examined and reported separately

Post-test results: For combined BPD outcomes

(symptoms, self-harm, suicide), psychotherapy interventions and add-on psychotherapy interventions were ‘moderately’ better than control interventions (g = 0.32; 95% CI, 0.14-0.51 and g = 0.40; 95% CI, 0.15-0.65)

Psychotherapy superior to control regardless of add-on status for self-harm (g = 0.32; 95% CI, 0.09-0.54), suicide (g = 0.44; 95% CI, 0.15-0.74), health service use (g = 0.40; 95% CI, 0.22-0.58), and general psychopathology (g = 0.32; 95% CI, 0.09-0.55)

BPD relevant outcomes at follow-up (N = 13 trials):

Dialectical behavior therapy (g = 0.34; 95% CI, 0.15-0.53) and psychodynamic therapy (g = 0.41; 95% CI, 0.12-0.69) were


First Author, Year





more effective than control interventions

Publication bias was identified as persistent

Authors concluded that psychotherapy treatment options (specifically dialectical and psychodynamic approaches) were effective at treating BPD symptoms.

Links, 20172

SR of 5 years of literature 16 articles included

Patients with BPD Psychotherapy interventions Comparator unclear

Psychotherapy was beneficial to patients with BPD of various severities. More ‘intensive’ therapies were not more effective than less intensive therapies. More research needed to examine outcomes for comorbid BPD and PTSD.

Omar, 20143 SR examining the

impact of treatment duration, treatment frequency, and access to group therapy 12 RCTs

Patients with BPD Psychotherapy interventions Comparator unclear

Reductions in self-harm and depression were statistically significant when the number of psychotherapy sessions were more than 1 per week and when there was access to group therapy, as were improvements in social functioning. Further research suggested regarding short vs long-term interventions.

Randomized Controlled Trials

McMain, 20174 Adjunct therapy

Assessments at 10, 20, 32 weeks

Patients with BPD at high risk for suicide 84 patients; 42 randomized to each group

Brief DBT skills training (20 weeks duration) Wait-list

32 week results: Patients in the DBT group had

more reduction in suicidal behaviours and on NSSI

* than

those in the wait list group (P < 0.0001)

Improvements in anger, distress tolerance and emotion regulation were higher in the DBT group than wait list

Authors concluded that brief DBT could be a useful intervention for patients with BPD at high risk for suicide.

Pearce, 20175 Outcome measurement

at 12 and 24 months following randomization

Patients meeting criteria for a personality disorder

DTC Treatment as usual

12 and 24 months: In-patient psychiatric use was low

in both groups (no difference)


First Author, Year





24 months: Self-directed aggression and

aggression toward others, as well as satisfaction with care significantly improved in DTC group compared to control

Authors concluded that DTC was more effective that treatment as usual; expressed need for further study.

Leichsenring, 2016

6

Occurred within an in-patient facility Two groups were randomized; a third ‘control’ group of patients either receiving treatment as usual or waiting for treatment was also examined

In-patients with cluster-B personality disorders 122 patients (n = 64 for manualized intervention; n = 58 for non-manualized) were randomized; 46 patients were further included as controls

Manualized PIT Non-manualized E-PDT Control (treatment as usual or wait list)

Control patients: No significant improvements

reported PIT and E-PDT patients: “Significant improvements” in all

outcome measures were reported and improvements were reported as being superior to those in the control group

PIT and E-PDT did not appear to be different from each other in terms of effectiveness. Unclear if the ‘all’ outcome measures included both primary (level of personality organization and overall psychological distress) and secondary (depression, anxiety and interpersonal problems) outcomes.

McMurran, 2016

7 Superiority trial; multi-site Randomization stopped after 306 people due to adverse events Social Functioning Questionnaire (SFQ) was primary outcome

Adults with personality disorders. N = 306 (n = 154 in treatment group; n = 152 in control group) Mean age: 38 67% women

Psychoeducation and problem-solving therapy (PEPS) as an add-on to usual treatment. PEPS involved 4 individual psychoeducational sessions, 12 group sessions TAU

72 week follow-up:

73% of PEPS and 65% of TAU participants completed follow-up

There were no significant differences in SFQ scores between the PEPS group and TAU group (P = 0.19)

There was more self-harm in the PEPS group than the TAU group, however, the difference was not statistically significant (adjusted incidence rate ratio 1.24, 95% CI 0.93 to 1.64)

Authors concluded that PEPS was not an effective add-on to treatment as usual.

Linehan, 20168 Single blind (assessor

blinded)

Women with BPD who had at 2 or more suicide

DBT-S DBT-I

Suicide attempts (frequency and severity), suicidal ideation, use of crisis services (due to suicidality), and


First Author, Year





1 year of treatment, 1 year of follow-up

attempts or acts of NSSI in the previous 5 years, 1 NSSI or suicide attempt in the 8 weeks prior to randomization, and 1 suicide attempt in the year prior to randomization N = 99 Mean age 30.3 years; 71% white

Standard DBT (includes skills training)

reasons for living all improved similarly in the three groups The groups with skills training had greater improvements in NSSI:

DBT-I vs. Standard DBT P < 0.001

DBT-I vs DBT-S P < 0.001 The groups with skills training had greater improvements in depression:

DBT-I vs. Standard DBT P = 0.03

DBT-I vs DBT-S P = 0.004 The groups with skills training had greater improvements in anxiety:

DBT-I vs. Standard DBT P = 0.001

DBT-I vs DBT-S P = 0.01

Drop-out rates (P = 0.04), crisis services use (P = 0.02), and psychiatric hospitalizations (P = 0.03) were lower for standard DBT vs. DBT-I. Authors concluded that a variety if DBT interventions were effective in reducing suicide attempts and NSSI and that DBT that includes skills training is likely more effective for patients with BPD than DBT without kills training.

Pascual, 20159 Multicenter, positive

controlled trial Follow-up 16 weeks and 6 months

Outpatients with BPD N = 70

Cognitive rehabilitation Psychoeducational group interventions

Psychoeducational interventions tended to enhance depressive symptoms. The groups did not seem to differ with respect to functionality following the interventions. Authors concluded that both cognitive rehabilitation and psychoeducational group interventions seemed to improve daily functioning and clinical symptoms for patients with BPD. Additionally, they are likely easy to implement.

Bamelis, 201410

Multicenter; single blind Follow-up 3 years (primary outcome was recovery from personality disorder)

Out-patients with cluster C personality disorders N = 323

Schema therapy TAU Clarification-oriented psychotherapy

The number of patients who recovered from their personality disorders was ‘significantly’ (P not reported) higher in the schema therapy group than TAU and clarification oriented therapy. TAU


First Author, Year





and clarification oriented therapy recovery rates were not significantly different from each other. Secondary outcomes (dropout rates and measures of personality disorder traits, depressive and anxiety disorders, general psychological complaints, general and social functioning, self-ideal discrepancy, and quality of life) improved for patients in all three treatment groups. Authors concluded that schema therapy was more effective than TAU and clarification oriented psychotherapy in improving recovery rates. Additionally, exercise-based schema therapy was more effective than lecture-based schema therapy.

Gratz, 201411

14 week duration plus 9 month un-controlled follow-up Outcomes measured pre-, post-treatment; 3 months, 9 months follow-up

Female out-patients with BPD and recently deliberate self-harm N = 61 (n = 30 in treatment group; n = 31 in control group)

ERGT add-on to TAU immediately; 14 weeks of treatment Waitlist for ERGT add-on to TAU (14 week wait)

ITT analysis:

ERGT had ‘significant’ effects on destructive self-harm, self-harm symptoms, emotional dysregulation, BPD symptoms, depressive symptoms, stress symptoms, and quality of life

Analysis of patients who began ERGT (at any point; n = 51):

Patients had ‘significant’ improvements in all outcomes when pre- and post- tests were compared

Deliberate self-harm, emotional dysregulation, BPD symptoms, and quality of life further improved through to the 9 month follow-up

Authors concluded that ERGT add-on therapy was effective and treatment improvements had ‘durability.’

Kramer, 201412

RCT

Patients with BPD N = 85

MOTR add-on to manualized ‘short variant’ of general psychiatric management Manualized ‘short variant’ of general psychiatric management for 10

ITT analysis:

MOTR had ‘global efficacy’ and resulted in reduction of outcomes such as symptoms, interpersonal problems and social problems (P = 0.05)

MOTR did not result in reductions in specific BPD symptoms

Authors called MOTR ‘promising’ and


First Author, Year





sessions suggested that shortening BPD treatment may have merit.

Clarke, 201313

‘Service-based’ Patients with personality disorder N = 78 (n = 38 intervention; n = 40 control)

CAT; 24 sessions TAU; 10 months

Patients in the CAT group had a reduction in symptoms and ‘experienced benefits’ compared to TAU. Those in the TAU group had significant deterioration throughout the treatment period. Authors concluded that CAT was more effective than TAU in improving personality disorder outcomes.

Jorgensen, 2013

14 2 years duration Patients with BPD

N = 85

‘Intensive’ (twice weekly) individual and group MBT Biweekly supportive group therapy

N = 58 completed 2 years of treatment Both treatment groups saw significant changes in self-reported measures of general functioning, depression, social functioning, and several BPD diagnostic symptoms. Therapist–rated global assessment of functioning was significantly higher in the MBT group than the control group. There was a trend toward BPD recovery in the MBT group. Authors concluded that both treatment options were effective when administered by ‘well-trained, experienced psychodynamic staff in a well-run clinic.’

BPD = borderline personality disorder; CAT = cognitiv e analy tic therapy ; DBT = dialectical behav ior therapy ; DBT-I = dialectical behav ior therapy indiv idual therapy plus

activ ities (no skills training); DBT-S = dialectical behav ior therapy skills training plus case management; DTC = democratic therapeutic community treatment; ERGT =

emotion regulation group therapy ; E-PDT = psy chody namic therapy by experts; ITT = intention to treat; MA = meta-analy sis; MBT = mentalization-based psy chotherapy ;

MOTR = motiv e-oriented therapeutic relationship; NSSI = non-suicidal self -injury ; PEPS = Psy choeducation and problem-solv ing therapy ; PIT = psy choanaly tic-

interactional therapy ; PTSD = post-traumatic stress disorder; RCT = randomized controlled trial; SFQ = Social Functioning Questionnaire; SR = sy stematic rev iew; TAU =

treatment as usual; v s = v ersus.


Table 3: Summary of Randomized Controlled Trials Examining the Clinical Evidence

regarding the Treatment of Adults with Comorbid Personality Disorder and Depression or Post-Traumatic Stress Disorder

First Author, Year





Renner, 201415

Same study population as Bamelis, 2014

10

Patients with cluster-C personality disorders N = 320; number of patients with depression not reported

Schema therapy TAU Clarification-oriented therapy

Patients with comorbid depression had higher baseline PD severity than those without. Depression at baseline was associated with:

reduced rates of recovery from PD at the 3 year follow-up (P = 0.01)

higher rates of psychosocial impairment (P < 0.01)

Comorbid depression did not moderate the treatment effect (with the exception of one psychosocial measure). Authors concluded that patients with cluster-C PD and comorbid depression may benefit from add-on depression treatment while receiving treatment for a PD.

Bohus, 201316

Assessor blinded Outcomes measured after treatment, 6-weeks, and 12-weeks follow-up

Female in-patients with CSA-related PTSD with and without BPD N = 74

DBT-PTSD residential program TAU waitlist

Diagnosis of BPD did not affect the efficacy of the DBT-PTSD program. Authors concluded that a DBT-PTSD program was effective for female patients with CSA-related PTSD and comorbid BPD

Moradveisi, 2013

17

Outcomes assessed at 0, 4, 13, and 49 weeks

Out-patients with major depressive disorder with and without PD N = 100 (50 in each group)

Behavioural activation therapy Antidepressant medication

Patients with cluster-C PDs had higher depression scores at baseline than those without PD. Patients with PD did not respond to treatment differently than those without, both at the short- and long-term follow-ups. Behavioural activation therapy was more effective in reducing depressive symptoms than antidepressant medication in patients with or without PD. PD was associated with higher drop-out rates. Cluster-C PDs was associated with higher depression severity but not to


First Author, Year





differences in treatment response.

BPD = borderline personality disorder; CSA = childhood sexual abuse; DBT = dialectical behav ioural therapy ; PD = personality disorder; PTSD = post-traumatic stress

disorder; RCT = randomized controlled trial; TAU = treatment as usual.

References Summarized

Health Technology Assessments

No literature identified

Systematic Reviews and Meta-analyses

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Personality Disorders with Comorbid Depression or Post-Traumatic Stress

Disorder

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Guidelines and Recommendations

No literature identified

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Appendix — Further Information

Previous CADTH Reports

18. Intensive day treatment programs for mental health treatment: a review of clinical

effectiveness, cost-effectiveness, and guidelines [Internet]. Ottawa: CADTH; 2017.

[cited 2018 Feb 22]. (CADTH Rapid response report: summary with critical appraisal).

Available from: https://www.cadth.ca/intensive-day-treatment-programs-mental-health-

treatment-review-clinical-effectiveness-cost

Qualitative Systematic Review

19. Lana F, Fernandez-San Martin MI. To what extent are specific psychotherapies for

borderline personality disorders efficacious? A systematic review of published

randomised controlled trials. Actas Esp Psiquiatr. 2013 Jul;41(4):242-52.

PubMed: PM23884616

Randomized Controlled Trials (RCTs)

Secondary Analyses of RCTs of Patients With or Without Comorbidities

20. Erkens N, Schramm E, Kriston L, Hautzinger M, Harter M, Schweiger U, et al.

Association of comorbid personality disorders with clinical characteristics and outcome

in a randomized controlled trial comparing two psychotherapies for early-onset

persistent depressive disorder. J Affect Disord. 2018 Mar 15;229:262-8.

PubMed: PM29329058

21. Berthoud L, Pascual-Leone A, Caspar F, Tissot H, Keller S, Rohde KB, et al. Leaving

distress behind: a randomized controlled study on change in emotional processing in

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better? A follow-up analysis of 10-session psychiatric treatment including the motive-

oriented therapeutic relationship for borderline personality disorder. Psychother Res.

2017 May;27(3):362-70.

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29. Antonsen BT, Klungsoyr O, Kamps A, Hummelen B, Johansen MS, Pedersen G, et al.

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treatment of military sexual trauma-related posttraumatic stress disorder with cognitive

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Meis, L. Treating veterans with PTSD and borderline personality symptoms in a 12-

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Consensus Statements, Quality Standards, or Guidelines with Unclear or Non-Rigorous Methods

32. Shining the light in dark corners of people’s lives: The consensus statement for people

with complex mental health difficulties who are diagnosed with a personality disorder.

[Internet] Cardiff (GB): Mind.org; 2018 [cited 2018 Feb 22]. Available from:

https://www.mind.org.uk/media/21163353/consensus-statement-final.pdf

33. Borderline personality disorders: psychological treatments [Internet]. Atlanta (GA):

Division 12 of the American Psychological Association; 2016 [cited 2018 Feb 22].

Available from: https://www.div12.org/psychological-treatments/disorders/borderline-

personality-disorder/

34. Personality disorders: borderline and antisocial [Internet]. London (GB): National

Institute for Health and Care Excellence; 2015 [cited 2018 Feb 22]. (Quality Standard

QS88). Available from: https://www.nice.org.uk/guidance/qs88

35. National clinical guideline for the treatment of emotionally unstable personality disorder,

borderline type [Internet]. Copenhagen (DK): Danish Health Authority; 2016 [cited 2018

Feb 22]. Available from:

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4B9E.ashx

Clinical Practice Guidelines – Rigour of Methodology Unclear

36. Clinical practice guideline for the management of borderline personality d isorder

[Internet]. Canberra (AU): Australian Government National Health and Medical

Research Council; 2013 [cited 2018 Feb 22]. Available from:

https://www.nhmrc.gov.au/guidelines-publications/mh25

Patient Care Pathways

37. Personality disorders [Internet]. London (GB): National Institute for Health and Care

Excellence; 2017 [cited 2018 Feb 22]. Available from:

https://www.nice.org.uk/guidance/conditions-and-diseases/mental-health-and-

behavioural-conditions/personality-disorders

Note: See also flowchart https://pathways.nice.org.uk/pathways/personality-disorders

38. Personality disorder service pathway [Internet]. Inverness (GB): NHS Highland; 2015

[cited 2018 Feb 22]. Available from:

http://www.nhshighland.scot.nhs.uk/Services/Pages/Personalitydisorderservice.aspx

See: PDFs embedded midway down page
https://www.mind.org.uk/media/21163353/consensus-statement-final.pdfhttps://www.div12.org/psychological-treatments/disorders/borderline-personality-disorder/https://www.div12.org/psychological-treatments/disorders/borderline-personality-disorder/https://www.nice.org.uk/guidance/qs88https://www.sst.dk/en/publications/2015/~/media/D39B3600DE4A49DC8D3FF0FC2B8C4B9E.ashxhttps://www.sst.dk/en/publications/2015/~/media/D39B3600DE4A49DC8D3FF0FC2B8C4B9E.ashxhttps://www.nhmrc.gov.au/guidelines-publications/mh25https://www.nice.org.uk/guidance/conditions-and-diseases/mental-health-and-behavioural-conditions/personality-disordershttps://www.nice.org.uk/guidance/conditions-and-diseases/mental-health-and-behavioural-conditions/personality-disordershttps://pathways.nice.org.uk/pathways/personality-disordershttp://www.nhshighland.scot.nhs.uk/Services/Pages/Personalitydisorderservice.aspx

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