Correspondence

Psychotherapy Section, Department of Psychiatry, Institute of Psychiatry, De Crespigny Park, London SE58AZ;e-mail:spjustp{at}iop.kcl.ac.uk

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 (Lees 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.

References

1. Bateman, A. & Fonagy, P. (1999) Effectiveness of partial hospitalisation in the treatment of borderline personality disorder: a randomised controlled trial. American Journal of Psychiatry, 156, 1563–1569.[Abstract/Free Full Text]
2. Lees, J., Manning, N. & Rawlings, B. (1999) Therapeutic Community Effectiveness: A Systematic Interactional Review of Therapeutic Community Treatment for People with Personality Disorders and Mentally Disordered Offenders. CRD report 17. York: NHS Centre for Reviews and Dissemination.
3. Winston, A. P. (2000) Recent developments in borderline personality disorder. Advances in Psychiatric Treatment, 6, 211–218.[Free Full Text]

University Department of Psychiatry, Brandon Mental Health Unit, Leicester General Hospital, Gwendolen Road, Leicester LE54PW;e-mail:awinston{at}lgh.u-net.com

Author's reply: I am grateful to Dr Pearce (2000, this issue) for drawing attention to two significant pieces of research. The study by Bateman and Fonagy (1999) was omitted simply because it had not been published at the time of writing. I agree that it is an important study, which demonstrates the effectiveness of an eclectic, but psychoanalytically based treatment approach. Moreover, the model of day treatment for BPD is one that may potentially be replicated in the National Health Service and is already attracting considerable interest.

The study by Lees et al (1999) is different in that it is essentially a meta-analysis of studies of the effectiveness of therapeutic communities, rather than the treatment of BPD. Furthermore, the conclusion that Pearce quotes refers to their effectiveness in the treatment of personality disorder in general. The analysis included studies of both concept-based therapeutic communities devoted to the treatment of substance misuse and forensic units where there is likely to be a preponderance of patients with antisocial personality disorder. Furthermore, a wide range of research methods and outcome measures was used in the studies included, many of them not specific for BPD. Although the findings of Lees et al are encouraging, their relevance to the treatment of BPD is therefore somewhat uncertain.

However, these studies do form part of an increasing and welcome trend towards the empirical evaluation of treatments for personality disorders. It is to be hoped that this trend will continue and will stimulate a debate about the rational provision of services for this important group of patients.

References

1. Bateman, A. & Fonagy, P. (1999) Effectiveness of partial hospitalisation in the treatment of borderline personality disorder: a randomised controlled trial. American Journal of Psychiatry, 156, 1563–1569.
2. Lees, J., Manning, N. & Rawlings, B. (1999) Therapeutic Community Effectiveness: A Systematic Interactional Review of Therapeutic Community Treatment for People with Personality Disorders and Mentally Disordered Offenders. CRD report 17. York: NHS Centre for Reviews and Dissemination.
3. Winston, A. P. (2000) Recent developments in borderline personality disorder. Advances in Psychiatric Treatment, 6, 211–218.

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