Borderline personality disorder (BPD) is characterized by affective instability, angry outbursts, frequent suicidality and parasuicidality, as well as marked deficits in the capacity to work and to maintain meaningful relationships. BPD has prevalence rates of nearly 1-4% in the general population, 10% in psychiatric outpatient samples, and up to 20% in psychiatric inpatient samples (e.g., Paris, 1999; Torgersen, Kringlen, & Cramer, 2001; Weissman, 1993; Widiger & Frances, 1989; Widiger & Weissman, 1991). In addition, BPD is frequently comorbid with depression, anxiety disorders, eating disorders, posttraumatic stress disorder, and substance abuse, often with detrimental effects on the treatment of these disorders (for a review, see Skodol, Gunderson, Pfohl, Widiger, Livesley, & Siever, 2002). Furthermore, patients with BPD typically experience profound impairment in general functioning and have an estimated suicide completion rate of 8-10% (Oldham et al., 2001). Thus, BPD is a debilitating and life-threatening disorder that represents a serious clinical and public health concern.
Although patients with BPD are often deemed difficult to treat, there is some evidence that BPD may be a treatable disorder (Perry, Banon, & Ianni, 1999)
and that psychotherapy is the recommended primary technique for its treatment (Oldham et al., 2001). Evidence for the efficacy of specific treatments for BPD now exists (Bateman & Fonagy, 1999; Giesen-Bloo et al., 2006; Koons et al., 2001; Linehan, Armstrong, Suarez, Allmon, & Heard, 1991; Linehan et al., 1999; Linehan et al., 2002; Turner, 2000; Verheul et al., 2003), with Dialectical Behavior Therapy (DBT; Linehan, 1993), to date, being perhaps the most extensively studied treatment in randomized controlled trials (RCTs). However, a number of other treatments for BPD have been developed that have demonstrated effectiveness (Blum, Pfohl, St. John, Monahan, & Black, 2002; Brown, Newman, Charlesworth, Crits-Christoph, & Beck, 2004; Clarkin et al., 2001; Levy, Clarkin, Schiavi, Foelsch, & Kernberg, 2006; Ryle & Golynkina, 2000; Stevenson & Meares, 1992). Meanwhile, additional studies testing the effectiveness and efficacy1 of new treatments have recently been completed, presented at conferences but remain unpublished (Arnt, 2005; Clarkin, Levy, Lenzenweger, & Kernberg, 2006), or are currently being conducted (Markowitz, Skodal, Bleiberg, & Strasser-Vorus, 2004).
Despite the emergence of new treatments for BPD that have garnered empirical support in both effectiveness and efficacy studies, a growing number of researchers have espoused limiting psychotherapy practice and training to treatments that have demonstrated efficacy in RCTs (Calhoun, Moras, Pilkonis, & Rehm, 1998; Chambless & Hollon, 1998). In addition, managed health care companies often reimburse only for those treatments for BPD that have demonstrated efficacy data and refuse to reimburse for those that have not yet been tested in an RCT. With the proliferation of evidence for the efficacy of DBT and the increasing focus on the dissemination of empirically supported treatments (ESTs), the added value of naturalistic studies that bear on the ecological validity of ESTs is often overlooked. However, there are a number of important limitations to RCTs. RCTs are frequently limited in their generalizability to clinical practice (Borkovec & Castonguay, 1998; Goldfried & Wolfe, 1996; Goldfried & Wolfe, 1998; Morrison, Bradley, & Westen, 2003; Seligman, 1995; Westen & Morrison, 2001), and naturalistic studies may be necessary to help bridge the gap between practice and research (Morrison et al., 2003). Likewise, the utility of RCTs for evaluating a treatment's putative mechanisms of action and underlying theoretical constructs is frequently indirect and limited. In other words, studies that compare purportedly distinct treatments can only tell us which treatment yields the most favorable outcome. The active ingredients or dimensions of the more effective therapy remain unknown and can only be indirectly inferred. Limiting research, practice, and training exclusively to treatments that have been validated in RCTs could impede reasonable avenues of study in the treatment of BPD and obstruct access to treatments that might be better-suited to specific patient subgroups.
In this chapter we will summarize the pros and cons of RCTs, present a hierarchical model of evidence in psychotherapy studies that balances concerns about adequate controls and generalizability, and examine more broadly the psychotherapy research which bears on BPD. We will then report results from a series of studies performed at the Personality Disorders Institute at Cornell Medical Center on the treatment of BPD. Finally, we will summarize conclusions that can be drawn from this broader examination of the literature.
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This guide Don't Panic has tips and additional information on what you should do when you are experiencing an anxiety or panic attack. With so much going on in the world today with taking care of your family, working full time, dealing with office politics and other things, you could experience a serious meltdown. All of these things could at one point cause you to stress out and snap.