July 10, 2014
Adding individualized therapy to a short version of a good psychiatric management model improves mood, emotional control, and some interpersonal skills in patients with borderline personality disorder (BPD), although it does not appear to further reduce borderline symptoms, a new study shows.
"The good psychiatric model was developed by John Gunderson and Paul Links and is one of several effective treatment options to intervene with BPD, and for a short version, it seems good enough for quite rapidly reducing specific borderline symptoms, such as impulsive behaviors," lead author Ueli Kramer, PhD, currently adjunct professor in clinical psychology at the University of Windsor, Ontario, Canada, and at the Institute of Psychotherapy and General Psychiatry Services, Department of Psychiatry-CHUV, University of Lausanne, Switzerland, told Medscape Medical News.
"However, for broader problems in interpersonal relationships, social role, along with depression and anxiety, which are all problems that may go along with borderline symptomatology, there's a benefit of adding an individualized way of intervening, based on the motive-oriented therapeutic relationship [MOTR]."
The study was published in the July issue of Psychotherapy and Psychosomatics.
Patients with BPD typically experience interpersonal relationships as challenging and have difficulty with mood regulation and with expressing emotions in effective ways, along with having identity disturbances.
They may suffer from angry outbursts, exhibit self-harm behaviors such as cutting, and feel abandoned or rejected by harmless gestures from others. A number will make dangerous suicide attempts. Experts agree that BPD is best treated by structured psychological and psychotherapeutic interventions.
BPD affects about 1% to 2% of the population, a prevalence that is just above that of schizophrenia.
Patients with BPD vary tremendously in their symptom span and ways of interacting. Therefore, researchers wanted to test the hypothesis that tailoring therapy to the individual patient, according to the case formulation model of plan analysis developed by Klaus Grawe and Franz Caspar in Switzerland and satisfying their underlying motives, would result in lessening their problematic behaviors, said Dr. Kramer.
The study enrolled 85 adults with a confirmed diagnosis of BPD, as determined on the basis of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnostic criteria. They were randomly assigned into 1 of 2 groups: a group receiving good psychiatric management (GPM), or a group receiving GPM plus MOTR (based on the plan analysis case formulation). Both groups received 10 therapy sessions.
"We were interested in studying the optimizing of patient engagement in treatment from the very first contact on, up until session 10," explained Dr. Kramer. Engagement in therapy is a central aspect of clinical work with patients presenting with BPD.
According to the authors, this short version of psychiatric intervention includes identifying the main problems to be treated, establishing a treatment focus, defining short-term objectives, and formulating relational interpretations of core conflictual themes.
"The interpersonal is at the center of the GPM model" when working with BPD clients, said Dr. Kramer. "It's a way of dealing with a client's problems in a useful and straightforward way."
The MOTR element assumes that every client is different and tailors the treatment approach accordingly. For each patient, a unique case formulation (the plan analysis) is established by the therapist. On the basis of this formulation, the therapist implements the motive-oriented therapeutic relationship.
The principle behind MOTR is to ensure that therapy provides a means to satisfy the patient's needs and motives within the limits of the therapeutic relationship, without reinforcing problematic behaviors and plans.
Dr. Kramer used the example of 2 female patients with BPD who both engage in self-cutting, but their underlying motives may be quite different – one cuts in order to gain attention that may serve her by allowing her to get close to others who try to soothe her, whereas the other cuts to let off steam and control her emotions, which may serve her by maintaining perceived integrity and control. Whereas the behaviors are identical, the underlying motives are not.
This, according to the MOTR model, calls for a different, individualized, therapeutic intervention. First, the therapist may intervene by explicitly affirming his presence; second, the therapist may ensure explicitly that the patient maintains her integrity in the therapy room.
For both interventions, the model assumes that if the motivational basis of the problematic behavior (the self-cutting) is taken away by a proactive therapist through complementarity to the motives, the behavior lessens.
In the study, MOTR was "infused" into the process after the intake session, from session 2 to session 10.
A comparable percentage of patients in both groups were taking psychiatric medications (around 60%), receiving alcohol or drug counseling, and getting short-term inpatient treatment. "The therapist gives what is useful," commented Dr. Kramer.
Study participants, coordinators, and MOTR adherence raters were all blinded to the treatment allocation, but the principal investigator and the 22 trained therapists involved were not. Each therapist conducted treatment sessions for only 1 condition.
The intent-to-treat (ITT) analysis included 74 patients (38 in the GPM group and 36 in the GPM plus MOTR group). Most were women (79% in the GPM and 58% in the GPM plus MOTR group), and most had a comorbid psychiatric condition, primarily depression (68% in the GPM and 83% in the GPM plus MOTR group). Attrition analysis yielded between-group equivalence.
The primary analysis used the Outcome Questionnaire–45.2 (OQ-45), a self-report questionnaire with 45 items, looking at a global score and scores for 3 subscales: symptomatic level, interpersonal relationships, and social role. The ITT analysis showed a between-group effect on the total OQ-45 score (P ˂ .02), significant effects favoring MOTR for all subscales, and a nearly significant effect favoring MOTR on the 3 subscales taken together (P = .06).
There were no between-group differences on 2 secondary self-reported outcomes in the ITT analyses: the Inventory of Interpersonal Problems (IIP), which assesses interpersonal function, and the Borderline Symptoms List (BSL), which measures specific borderline symptomatology.
However, noted Dr. Kramer, there were significant reductions on both scales in both groups, and for the completers, MOTR did better than GPM alone in reducing interpersonal problems.
"The general symptoms like depressive mood, anxiety, and emotion dyscontrol and some interpersonal and social aspects were better after 10 sessions in patients who got MOTR," said Dr. Kramer. "For borderline symptoms, we actually saw quite a steep decrease in symptoms in both groups ― there might not have been room for more improvement in this short time frame."