From the Editor
May, 2019. For some time, there has been a widely endorsed view that patients with borderline personality disorder (BPD) should only be hospitalized when it is essential for patient safety, and that hospitalization, when necessary, should be as brief as possible. A patient with self-acknowledged BPD, for example, provided the following advice to clinicians: “Do not hospitalize a person with BPD for any more than 48 hours.”1 A chorus of experts has aligned with this advice, arguing that regression and deterioration would predictably occur if patients with BPD remained in the hospital for more than a couple of weeks at most.
I believe that this advice is well-intended and, in general, well-founded based on the experience and wisdom of clinical experts. Deriving from the days many years ago when patients with BPD were hospitalized for a year or more, concern about the regressive impact of extended hospitalization became widespread. And with the development of evidence-based psychotherapies for patients with BPD, such as dialectical behavior therapy (DBT), mentalization-based therapy (MBT), and transference-focused psychotherapy (TFP), promising progress has been made that does not involve lengthy inpatient care. The American Psychiatric Association’s (APA) Practice Guideline for the Treatment of Borderline Personality Disorder2 recommends psychotherapy as the primary, or core, treatment for BPD, as do subsequently published practice guidelines for BPD that have been developed in a number of countries throughout the world.
But what can we do for those patients with BPD who have other comorbid psychiatric disorders and who have not been able to get better? The APA Guideline advises that, for BPD patients with complex illnesses who are high risk and whose functioning is severely impaired, nonbrief inpatient care may be indicated. A group of colleagues and I at the Menninger Clinic recently published a study3 that considers this question, comparing 245 inpatients with BPD with a matched sample of 220 inpatients without BPD. The average length of stay for the combined groups was 41 days, and both groups received intensive treatment. Contrary to common predictions, clinical deterioration was rare in both groups, and patients with BPD showed improvement with a large effect size, with comparable change scores in the comparison group without BPD.
In this issue of the Journal, Probst and colleagues present results of a study of a 5-week inpatient DBT treatment program for patients with BPD. They found that BPD symptoms and self-reported emotion dysregulation were significantly reduced at the end of the 5-week program. Although this was an effectiveness study without a control group, its results were consistent with those reported in other recent studies4 that had similar results utilizing more rigorous methodology that included controls. Also in this issue, Savard and coauthors report on the effectiveness of a 6-week day hospital treatment program for patients with personality disorders, 68% of whom were diagnosed with BPD. Their results showed that, at the end of the 6-week program, patients showed reductions in “symptom distress,” and improved quality of interpersonal relationships and social role functioning.
There will never be a “one size fits all” algorithm or formula for the treatment of patients with BPD. But continued efforts like those described above advance our knowledge about potentially effective treatment options for patients with this highly disabling condition.
John M. Oldham, MD
1. Williams L. A “classic” case of borderline personality disorder. Psychiatr Serv. 1998;49:173–174.
2. Oldham JM, Gabbard GO, Goin MK, et al. Practice guideline for the treatment of borderline personality disorder. Am J Psychiatry. 2001;158:1–52.
3. Fowler JC, Clapp JD, Madan A, et al. A naturalistic longitudinal study of extended inpatient treatment for adults with borderline personality disorder: an examination of treatment response, remission and deterioration. J Affect Disord. 2018;235:323–331.
4. Bohus M, Haaf B, Simms T, et al. Effectiveness of inpatient dialectical behavioral therapy for borderline personality disorder: a controlled trial. Behav Res Ther. 2004;42:487–499.