Psychological therapies for people with borderline personality disorder

259 Pages·2013·2.5 MB·English

Psychological therapies for people with borderline personality
disorder (Review)
Stoffers JM, Völlm BA, Rücker G, Timmer A, Huband N, Lieb K
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2013, Issue 2
http://www.thecochranelibrary.com
Psychological therapies for people with borderline personality disorder (Review)
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
T A B L E O F C O N T E N T S
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
SUMMARY OF FINDINGS FOR THE MAIN COMPARISON . . . . . . . . . . . . . . . . . . . 3
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Figure 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Figure 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
ADDITIONAL SUMMARY OF FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . . 39
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Figure 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Analysis 1.1. Comparison 1 Comprehensive psychotherapies: active vs. control conditions, Outcome 1 BPD total
severity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Analysis 1.2. Comparison 1 Comprehensive psychotherapies: active vs. control conditions, Outcome 2 Inappropriate
anger. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
Analysis 1.3. Comparison 1 Comprehensive psychotherapies: active vs. control conditions, Outcome 3 Affective
instability. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
Analysis 1.4. Comparison 1 Comprehensive psychotherapies: active vs. control conditions, Outcome 4 chronic feelings of
emptiness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
Analysis 1.5. Comparison 1 Comprehensive psychotherapies: active vs. control conditions, Outcome 5 Impulsivity. . 173
Analysis 1.6. Comparison 1 Comprehensive psychotherapies: active vs. control conditions, Outcome 6 Suicidality. . 174
Analysis 1.7. Comparison 1 Comprehensive psychotherapies: active vs. control conditions, Outcome 7 Suicidality. . 175
Analysis 1.8. Comparison 1 Comprehensive psychotherapies: active vs. control conditions, Outcome 8 Parasuicidality. 176
Analysis 1.9. Comparison 1 Comprehensive psychotherapies: active vs. control conditions, Outcome 9 Parasuicidality. 177
Analysis 1.10. Comparison 1 Comprehensive psychotherapies: active vs. control conditions, Outcome 10 Interpersonal
problems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
Analysis 1.11. Comparison 1 Comprehensive psychotherapies: active vs. control conditions, Outcome 11 Avoidance of
abandonment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
Analysis 1.12. Comparison 1 Comprehensive psychotherapies: active vs. control conditions, Outcome 12 Identity
disturbance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
Analysis 1.13. Comparison 1 Comprehensive psychotherapies: active vs. control conditions, Outcome 13
Dissociation/psychoticism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
Analysis 1.14. Comparison 1 Comprehensive psychotherapies: active vs. control conditions, Outcome 14 Depression. 183
Analysis 1.15. Comparison 1 Comprehensive psychotherapies: active vs. control conditions, Outcome 15 Anxiety. . 185
Analysis 1.16. Comparison 1 Comprehensive psychotherapies: active vs. control conditions, Outcome 16 General
psychopathology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
Analysis 1.17. Comparison 1 Comprehensive psychotherapies: active vs. control conditions, Outcome 17 Mental health
status/functioning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188
Analysis 1.18. Comparison 1 Comprehensive psychotherapies: active vs. control conditions, Outcome 18 Leaving the study
early. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190
Analysis 1.19. Comparison 1 Comprehensive psychotherapies: active vs. control conditions, Outcome 19 Leaving the study
early: sensitivity analysis (non-rural areas only). . . . . . . . . . . . . . . . . . . . . . . 193
Psychological therapies for people with borderline personality disorder (Review) i
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 2.1. Comparison 2 Non-comprehensive psychotherapeutic interventions: active vs. control conditions, Outcome 1
BPD total severity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
Analysis 2.2. Comparison 2 Non-comprehensive psychotherapeutic interventions: active vs. control conditions, Outcome 2
Inappropriate anger. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
Analysis 2.3. Comparison 2 Non-comprehensive psychotherapeutic interventions: active vs. control conditions, Outcome 3
Affective instability. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196
Analysis 2.4. Comparison 2 Non-comprehensive psychotherapeutic interventions: active vs. control conditions, Outcome 4
Chronic feelings of emptiness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
Analysis 2.5. Comparison 2 Non-comprehensive psychotherapeutic interventions: active vs. control conditions, Outcome 5
Impulsivity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198
Analysis 2.6. Comparison 2 Non-comprehensive psychotherapeutic interventions: active vs. control conditions, Outcome 6
Impulsivity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
Analysis 2.7. Comparison 2 Non-comprehensive psychotherapeutic interventions: active vs. control conditions, Outcome 7
Suicidality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
Analysis 2.8. Comparison 2 Non-comprehensive psychotherapeutic interventions: active vs. control conditions, Outcome 8
Parasuicidality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
Analysis 2.9. Comparison 2 Non-comprehensive psychotherapeutic interventions: active vs. control conditions, Outcome 9
Parasuicidality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202
Analysis 2.10. Comparison 2 Non-comprehensive psychotherapeutic interventions: active vs. control conditions, Outcome
10 Interpersonal problems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
Analysis 2.11. Comparison 2 Non-comprehensive psychotherapeutic interventions: active vs. control conditions, Outcome
11 Dissociation/psychoticism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204
Analysis 2.12. Comparison 2 Non-comprehensive psychotherapeutic interventions: active vs. control conditions, Outcome
12 Depression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
Analysis 2.13. Comparison 2 Non-comprehensive psychotherapeutic interventions: active vs. control conditions, Outcome
13 Anxiety. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
Analysis 2.14. Comparison 2 Non-comprehensive psychotherapeutic interventions: active vs. control conditions, Outcome
14 General psychopathology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
Analysis 2.15. Comparison 2 Non-comprehensive psychotherapeutic interventions: active vs. control conditions, Outcome
15 Mental health status/functioning. . . . . . . . . . . . . . . . . . . . . . . . . . . 208
Analysis 2.16. Comparison 2 Non-comprehensive psychotherapeutic interventions: active vs. control conditions, Outcome
16 Leaving the study early. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
Analysis 3.1. Comparison 3 Comprehensive psychotherapies: active vs. active conditions, Outcome 1 BPD total severity. 211
Analysis 3.2. Comparison 3 Comprehensive psychotherapies: active vs. active conditions, Outcome 2 Inappropriate
anger. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212
Analysis 3.3. Comparison 3 Comprehensive psychotherapies: active vs. active conditions, Outcome 3 Impulsivity. . 213
Analysis 3.4. Comparison 3 Comprehensive psychotherapies: active vs. active conditions, Outcome 4 Suicidality. . . 214
Analysis 3.5. Comparison 3 Comprehensive psychotherapies: active vs. active conditions, Outcome 5 Parasuicidality. 215
Analysis 3.6. Comparison 3 Comprehensive psychotherapies: active vs. active conditions, Outcome 6 Psychoticism. . 216
Analysis 3.7. Comparison 3 Comprehensive psychotherapies: active vs. active conditions, Outcome 7 Depression. . 217
Analysis 3.8. Comparison 3 Comprehensive psychotherapies: active vs. active conditions, Outcome 8 Anxiety. . . . 218
Analysis 3.9. Comparison 3 Comprehensive psychotherapies: active vs. active conditions, Outcome 9 General
psychopathology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219
Analysis 3.10. Comparison 3 Comprehensive psychotherapies: active vs. active conditions, Outcome 10 Mental health
status/functioning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220
Analysis 3.11. Comparison 3 Comprehensive psychotherapies: active vs. active conditions, Outcome 11 Leaving the study
early. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
Analysis 4.1. Comparison 4 Non-comprehensive psychotherapeutic interventions: active vs. active conditions, Outcome 1
BPD total severity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
Analysis 4.2. Comparison 4 Non-comprehensive psychotherapeutic interventions: active vs. active conditions, Outcome 2
Affective instability. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
Analysis 4.3. Comparison 4 Non-comprehensive psychotherapeutic interventions: active vs. active conditions, Outcome 3
Suicidality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
Psychological therapies for people with borderline personality disorder (Review) ii
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Analysis 4.4. Comparison 4 Non-comprehensive psychotherapeutic interventions: active vs. active conditions, Outcome 4
Parasuicidality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224
Analysis 4.5. Comparison 4 Non-comprehensive psychotherapeutic interventions: active vs. active conditions, Outcome 5
Interpersonal problems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
Analysis 4.6. Comparison 4 Non-comprehensive psychotherapeutic interventions: active vs. active conditions, Outcome 6
Identity disturbance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
Analysis 4.7. Comparison 4 Non-comprehensive psychotherapeutic interventions: active vs. active conditions, Outcome 7
Leaving the study early. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226
Analysis 5.1. Comparison 5 Funnel plot, Outcome 1 Parasuicidality. . . . . . . . . . . . . . . . . . 227
Analysis 5.2. Comparison 5 Funnel plot, Outcome 2 By sample size - parasuicidality. . . . . . . . . . . . 230
ADDITIONAL TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246
WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254
DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . . 254
NOTES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
Psychological therapies for people with borderline personality disorder (Review) iii
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
[Intervention Review]
Psychological therapies for people with borderline personality
disorder
1,2 3 4 5 6 2
Jutta M Stoffers , Birgit A Völlm , Gerta Rücker , Antje Timmer , Nick Huband , Klaus Lieb
1 2
Department of Psychiatry and Psychotherapy, University Medical Center Freiburg, Freiburg, Germany. Department of Psychiatry
3
and Psychotherapy, University Medical Center Mainz, Mainz, Germany. Section of Forensic Mental Health, Division of Psychiatry,
4
University of Nottingham Innovation Park, Nottingham, UK. German Cochrane Centre, Institute of Medical Biometry and Medical
5
Informatics, University Medical Center Freiburg, Freiburg, Germany. Clinical Epidemiology, BIPS Institute for Epidemiology and
6
Prevention Research, Bremen, Germany. Forensic Mental Health, Institute of Mental Health, University of Nottingham Innovation
Park, Nottingham, UK
Contact address: Klaus Lieb, Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany.
Main results
Twenty-eight studies involving a total of 1804 participants with BPD were included. Interventions were classified as comprehensive
psychotherapies if they included individual psychotherapy as a substantial part of the treatment programme, or as non-comprehensive
if they did not.
Among comprehensive psychotherapies, dialectical behaviour therapy (DBT), mentalisation-based treatment in a partial hospitalisation
setting (MBT-PH), outpatient MBT (MBT-out), transference-focused therapy (TFP), cognitive behavioural therapy (CBT), dynamic
deconstructive psychotherapy (DDP), interpersonal psychotherapy (IPT) and interpersonal therapy for BPD (IPT-BPD) were tested
against a control condition. Direct comparisons of comprehensive psychotherapies includedDBT versus client-centered therapy (CCT);
schema-focused therapy (SFT) versus TFP; SFT versus SFT plus telephone availability of therapist in case of crisis (SFT+TA); cognitive
therapy (CT) versus CCT, and CT versus IPT.
Non-comprehensive psychotherapeutic interventions comprised DBT-group skills training only (DBT-ST), emotion regulation group
therapy (ERG), schema-focused group therapy (SFT-G), systems training for emotional predictability andproblem solving for borderline
personality disorder (STEPPS), STEPPS plus individual therapy (STEPPS+IT), manual-assisted cognitive treatment (MACT) and
psychoeducation (PE). The only direct comparison of an non-comprehensive psychotherapeutic intervention against another was
MACT versus MACT plus therapeutic assessment (MACT+). Inpatient treatment was examined in one study where DBT for PTSD
(DBT-PTSD) was compared with a waiting list control. No trials were identified for cognitive analytical therapy (CAT).
Data were sparse for individual interventions, and allowed for meta-analytic pooling only for DBT compared with treatment as usual
(TAU) for four outcomes. There were moderate to large statistically significant effects indicating a beneficial effect of DBT over TAU
2
for anger (n = 46, two RCTs; standardised mean difference (SMD) -0.83, 95% confidence interval (CI) -1.43 to -0.22; I = 0%),
2
parasuicidality (n = 110, three RCTs; SMD -0.54, 95% CI -0.92 to -0.16; I = 0%) and mental health (n = 74, two RCTs; SMD 0.65,
2
95% CI 0.07 to 1.24 I = 30%). There was no indication of statistical superiority of DBT over TAU in terms of keeping participants
in treatment (n = 252, five RCTs; risk ratio 1.25, 95% CI 0.54 to 2.92).
All remainingfindingswere based on single study estimates of effect. Statistically significant between-groupdifferences for comparisons of
psychotherapies against controls were observed for BPD core pathology and associated psychopathology for the following interventions:
DBT, DBT-PTSD, MBT-PH, MBT-out, TFP and IPT-BPD. IPT was only indicated as being effective in the treatment of associated
depression. No statistically significant effects were found for CBT and DDP interventions on either outcome, with the effect sizes
moderate for DDP and small for CBT. For comparisons between different comprehensive psychotherapies, statistically significant
superiority was demonstrated for DBT over CCT (core and associated pathology) and SFT over TFP (BPD severity and treatment
retention). There were also encouraging results for each of the non-comprehensive psychotherapeutic interventions investigated in
terms of both core and associated pathology.
No data were available for adverse effects of any psychotherapy.
Authors’ conclusions
There are indications of beneficial effects for both comprehensive psychotherapies as well as non-comprehensive psychotherapeutic
interventions for BPD core pathology and associated general psychopathology. DBT has been studied most intensely, followed byMBT,
TFP, SFT and STEPPS. However, none of the treatments has a very robust evidence base, and there are some concerns regarding the
quality of individual studies. Overall, the findings support a substantial role for psychotherapy in the treatment of people with BPD
but clearly indicate a need for replicatory studies.
P L A I N L A N G U A G E S U M M A R Y
Psychological therapies for borderline personality disorder
People with borderline personality disorder often have difficulties controlling their emotions and impulses, and find it hard to keep
relationships. They can experience feelings of emptiness, suffer quick changes in mood and they may harm themselves. Problems coping
with abandonment and a rapidly changing view of other people can form part of their difficulties. All of these things make it hard for
them to engage with any treatment they may be offered. Those who are able to engage often find it hard to stick with the treatment and
leave before the end. Certain types of psychological treatment (’talking therapies’) have been developed in recent years to help people
with this disorder. This review summarises what is currently known about the effects of these treatments. It updates a review published
in the Cochrane Database of Systematic Reviews in 2006.
Psychological therapies for people with borderline personality disorder (Review) 2
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
We found 28 studies that had involved a total of 1804 people with borderline personality disorder. These studies examined various
psychological treatments. Some of these are called ’comprehensive’ treatments because the person talks one-to-one with a professional
for at least part of the time. Other treatments are called ’non-comprehensive’ because they do not involve this one-to-one work.
A number of studies have been carried out on one particular type of comprehensive treatment, called Dialectical Behaviour Therapy. For
this treatment, there were sufficient studies for us to pool the results and draw conclusions. The results indicate Dialectical Behaviour
Therapy is helpful for people with borderline personality disorder. Effects included a decrease in inappropriate anger, a reduction in
self-harm and an improvement in general functioning.
There were generally too few studies to allow firm conclusions to be drawn about the value of all the other kinds of psychotherapeutic
interventions evaluated. However, single studies show encouraging findings for each treatment that was investigated, both ’compre-
hensive’ and ’non-comprehensive’ types. More research is needed.
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Psychological therapies for people with borderline personality disorder (Review) 4
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
S U M M A R Y O F F I N D I N G S F O R T H E M A I N C O M P A R I S O N [Explanation]
DBT vs. TAU for people with borderline personality disorder
Patient or population: patients with borderline personality disorder
Settings: outpatient
Intervention: DBT
Comparison: TAU
Outcomes Illustrative comparative risks* (95% CI) Relative effect No of Participants Quality of the evidence Comments
(95% CI) (studies) (GRADE)
Assumed risk Corresponding risk
Control DBT
BPD total severity - DBT The mean BPD total The mean BPD total 20 ⊕⊕⃝⃝ SMD -0.29 (-1.17 to 0.
1
vs. TAU severity score - DBT vs. severity score - DBT vs. (1 study) low 59)
mean number of BPD cri- TAU in the control groups TAU in the intervention
teria met was groups was
Follow-up: 6 months 4.2 criteria 0.29 standard deviations
lower
(1.17 lower to 0.59
higher)
Inappropriate anger - The mean inappropriate The mean inappropriate 46 ⊕⊕⃝⃝ SMD -0.83 (-1.43 to -0.
1
DBT vs. TAU anger score - DBT vs. anger score - DBT vs. (2 studies) low 22)
2
STAXI anger out, STAXI TAU ranged across con- TAU in the intervention
anger trait trol groups from groups was
Follow-up: 6-12 months 17.9 to 40.08 points 0.83 standard deviations
lower
(1.43 to 0.22 lower)
Impulsivity - DBT vs. The mean impulsivity The mean impulsivity 48 ⊕⊕⃝⃝ SMD -0.17 (-0.74 to 0.
1
TAU score - DBT vs. TAU in score - DBT vs. TAU in the (1 study) low 39)
3
BPDSI-IV the control groups was intervention groups was
Follow-up: 12 months 1.06 points 0.17 standard deviations
lower
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(0.74 lower to 0.39
higher)
Suicidality - DBT vs. TAU The mean suicidality The mean suicidality 20 ⊕⊕⃝⃝ SMD -1.26 (-2.24 to -0.
4 1
BSS score - DBT vs. TAU in score - DBT vs. TAU in the (1 study) low 29)
Follow-up: 6 months the control groups was intervention groups was
41.5 points 1.26 standard deviations
lower
(2.24 to 0.29 lower)
Parasuicidality - DBT vs. The mean parasuicidal- The mean parasuicidality 110 ⊕⊕⊕⃝ SMD -0.54 (-0.92 to -0.
5
TAU ity score - DBT vs. score - DBT vs. TAU in the (3 studies) moderate 16)
acts of self-mutilation TAU ranged across con- intervention groups was
Follow-up: 6-12 months trol groups from 0.54 standard deviations
1.0 to 41.6 points lower
(0.92 to 0.16 lower)
parasuicidality - DBT vs. 677 per 1000 751 per 1000 RR 1.11 51 ⊕⊕⃝⃝
1
TAU (528 to 1000) (0.78 to 1.57) (1 study) low
acts of self-mutilation
Follow-up: 6 months
Interpersonal problems - The mean interpersonal The mean interpersonal 48 ⊕⊕⃝⃝ SMD -0.04 (-0.61 to 0.
1
DBT vs. TAU problems score - DBT vs. problems score - DBT vs. (1 study) low 54)
WHOQOL- TAU in the control groups TAU in the intervention
6
Bref -social relationships was groups was
multiplied by (-1) 49.73 points 0.04 standard deviations
Follow-up: 12 months higher
(0.54 lower to 0.61
higher)
Dissociation/ The mean dissociation/ The mean dissociation/ 20 ⊕⊕⃝⃝ SMD -0.9 (-1.83 to 0.03)
1
psychoticism - DBT vs. psychoticism score - DBT psychoticism score - DBT (1 study) low
TAU vs. TAU in the control vs. TAU in the intervention
7
DES groups was groups was
Follow-up: 6 months 30.6 points 0.9 standard deviations
lower
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(1.83 lower to 0.03
higher)
*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the
assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval
GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.
1
Total sample size less than 100
2
Spielberger Anger Expression Scale
3
Borderline Personality Disorder Severity Index
4
Beck Scale for Suicidal Ideation
5
Total sample size less than 400
6
World Health Organization quality of life assessment
7
Dissociative Experiences Scale