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The empirically supported treatment of borderline personality disorders.

Autor/autores: José Guimón , Wendy Dávila
Fecha Publicación: 28/10/2010
Área temática: .
Tipo de trabajo: 

RESUMEN

The assessment of efficacy and efficiency of treatment are presently taking on growing importance for the psychiatric practice. For this assessment, scientifically proven therapeuticmeasures or "Empirically Supported Treatments" are applied using techniques such as randomized controlled trials, the meta-analysis and the "Consumer Reports" studies. The present discussion seeks to evaluate the advantages and disadvantages of these procedures.

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Avances en Salud Mental Relacional / Advances in relational mental health
Vol. 6, núm.1 - Marzo 2007
Órgano Oficial de expresión de la Fundación OMIE
Revista Internacional On-line / An International On-line Journal

THE

EMPIRICALLY

SUPPORTED

TREATMENT

OF

BORDERLINE

PERSONALITY DISORDERS

José Guimón and Wendy Dávila
onpquugj@ehu.es

The assessment of efficacy and efficiency of treatment are presently taking on growing
importance for the psychiatric practice. For this assessment, scientifically proven therapeutic
measures or "Empirically Supported Treatments" are applied using techniques such as
randomized controlled trials, the meta-analysis and the "Consumer Reports" studies. The
present discussion seeks to evaluate the advantages and disadvantages of these procedures.
1. THE ETIOLOGICAL BASIS FOR CONTEMPORARY THERAPIES
Personality disorders involve un-adapted, invasive, and permanent behaviours, deeply
ingrained, and which are not due to any physical illness, nor to cultural alterations. The
borderline personality disorder, (BPD), is prevalent, (2% in the general population, 20%
among psychiatric in-patients), and has a major impact on health facilities, even if these
patients make a poor use of attempts to help them.
The term borderline is inadequate, because it describes, above all, impulsiveness,
disordered hostility, self-destructive acts, mood swings, and splitting; i.e., it defines
symptoms, not traits. The validity of this concept is thus, not high, because although it has
been similarly described in many countries, the biological findings remain doubtful, in spite
of some reliable neurophysiological findings.
The patients with BPD have a significantly increased risk of self-destructive and
suicidal behaviour (Brodsky et al., 1997), although this risk decreases in the long-term, as
there is a decrease in suicidality (Stone, 1993). Some predictors of increased risk for suicidal
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Avances en Salud Mental Relacional / Advances in relational mental health
Vol. 6, núm.1 - Marzo 2007
Órgano Oficial de expresión de la Fundación OMIE
Revista Internacional On-line / An International On-line Journal

behaviour have been detected , mainly impulsivity (Brodsky et al., 1997), comorbid disorders,
recent negative life events, a history of childhood sexual abuse (Links, Gould, & Ratnayake,
2003) and neuropsychological disturbances (Krysinska, Heller, & De Leo, 2006).
There has been different aetiological hypotheses proposed to explain this disorder,
ranging from constitutional factors, (difficulty in regulating affect), to family and
psychodynamic factors: perturbations in the establishment of object relations and inadequate
processes of identification during early infancy (Herman, 1992).

From an anamenesic

viewpoint, in women there seems to be a relationship with childhood abuse and incest.
Clarkin & Posner (Clarkin & Posner, 2005) propose a developing model of borderline
personality disorder based upon the study of normal attention, individual differences in
temperament, self definition and attachment organization. This theoretical construction can
relate the symptoms to more enduring temperamental aspects of the patients, with the
potential to illuminate the psychology and psychobiology of the disorder and to contribute to
psychotherapeutic intervention. The goal, say the authors, will be to "understand the
development of neural networks that underlie the abnormalities of adults, and eventually work
out the interaction between temperament, genes, and experience, that produce the disorder,
and potentially inform intervention".
Kernberg (Kernberg, 1986; Kernberg, 1980) related personality disorders to early
defence mechanisms against sexual and aggressive drives. He referred to a pathological superego, an alteration in the ego organisation, a difficulty in internalising object relations, and a
pathological development of the narcissistic functions. The author highlighted the role played
by the dysfunctions in object relations, established during early infancy. It is in childhood
when the patient sets in motion pathological defence mechanisms: systematically using
dissociation, acting out, projective identification etc., which will lead to relational difficulties
in the adult life. Later studies contend that most core symptoms of the disorder, such as: a
diffuse sense of self, bursts of rage, unstable interpersonal relationships, feelings of emptiness
and abandonment, chronic fears of, and an intolerance for aloneness, have their roots in an
impaired organization of the underlying attachment (in Bowlby's sense). Levy et al (Levy,
2005) underline that individual differences in the attachments of adult people are rooted in the
early patterns of interaction with caregivers. These patterns have important implications for
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understanding the aetiology and treatment of the borderline personality disorder. The factor
analysis of ninety-nine outpatients reliably diagnosed with BPD, and the completion of a
number of attachment measures, revealed six factors that clustered into three groups
corresponding to: an avoidant attachment pattern, a preoccupied attachment pattern, and a
fearfully preoccupied pattern. The preoccupied pattern group showed more concern and
behavioural reaction to real or imagined abandonment, whereas the avoidant group had higher
ratings of inappropriate anger. The fearfully preoccupied group had higher ratings on identity
disturbance, although only at the trend level.
2. THE BIOLOGICAL TREATMENTS
There is no specific treatment for BPD. The treatments based on drugs are only useful
in the presence of such symptoms as anxiety or depression, but have no influence on the
underlying personality traits. Thus, in cases of anxiety, anxiolytics can be useful, as can
antidepressants, if a depression appears. In transitory episodes of borderline disorder,
neuroleptics can reduce the anxiety. A combination of drugs, such as: reuptakes of serotonin
inhibitors, mood stabilizers and neuroleptics at a low dose level, have been proposed based on
some non-controlled studies.
As for hospitalization, it is of unproven value in preventing the suicide of BPD
patients, and can sometimes even have negative effects. On the other hand, day treatment is
an evidence-based alternative to full admission, but clinicians fear potential litigation
resulting from a completed suicide and they end up opting for hospitalization. It is notable,
though, that chronic suicidality can be best managed in an outpatient setting (Paris, 2002;
Paris, 2004) and is best understood as a way of communicating distress.
Binks et al. (C Binks et al., 2007) review the efficacy of the pharmacological
interventions for people with borderline personality, including ten randomised clinical trials,
(RCT), comparing any psychoactive drug with any other treatment for people with BPD. It
was discovered through two studies comparing antidepressants with placebo that, for ratings
of anger, fluoxetine may offer some improvement for those in antidepressant therapy over
placebo. The small RCT investigating the important outcome of attempted suicide found no
difference between mianserin and placebo. It was concluded that haloperidol may be better
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than antidepressants for symptoms of hostility and psychotism. There were few differences
between the monoamine oxidase inhibitors, (MAOIs) and the placebo, except that people
given MAOIs were less hostile in the RCT. The differences between the MAOIs and
antipsychotics were also studied, and the results showed no convincing differences. Regarding
the RCT's with antipsychotics and placebo, it was found that antipsychotics may affect some
mental state symptoms more effectively than placebo, but the results are difficult to interpret
clinically and there is little evidence of the advantage of one antipsychotic over another.
Finally, in another RCT, it was concluded that divalporex (a mood stabiliser) may help the
overall mental state, but the data is far from conclusive.
3. THE PSYCHOTHERAPEUTIC APPROACHES
Previously in this paper, we have stated the fact that there exists no specific, all
efficient treatment for BPD. In the following section, we aim to highlight those
psychotherapeutic approaches that are currently more in use and the conclusions obtained
through different relevant studies, concerning the advantages and disadvantages of each
treatment, as well as which has proven to give the more efficient results.
The psychotherapy of personality disorders has been evaluated by Perry et al (Perry et
al., 1999). They examined the evidence of the effectiveness of fifteen studies, including three
randomized, controlled, treatment trials. These studies analyzed different approaches: the
psychodynamic/interpersonal, the cognitive-behaviour, the mixed, and the supportive
therapies. All studies reported improvement in personality disorders with psychotherapy.
They estimated that 25.8% of personality disorder patients recovered, per year, of therapy, a
rate sevenfold larger than that in a published model of the natural history of borderline
personality disorder.
Bradley & Westen (Bradley & Westen, 2005) describe the psychodynamic
conceptions of treatment and the way BPD phenomena manifests itself in treatment. Bender
(Bender, 2005) outlines that in BPD, building a good therapeutic alliance is vital in the
earliest phase of treatment during which these patients tend systematically to push the limits.
One of these treatments, based on psychodynamic concepts, for BPD is the so called
"Transference Focused Psychotherapy", (TFP),(Levy et al., 2006). This individual
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psychotherapy involves, at the level of the patient: the integration of polarized representations
of self and others, and at the level of the therapist's interventions: the structured treatment
approach and the use of clarification, confrontation, and "transference" interpretations, in the
"here and now" of the therapeutic relationship. Levy et al. give evidence of the usefulness of
the following mechanisms of change: contract setting, integration of representations, and
changes in reflective functioning and affect regulation, present in this form of therapy.
Group therapy, along with individual therapy, is a primary tool when treating patients
diagnosed of BPD. This therapy is frequently part of a multidimensional programme,
including medication and other different types of psychotherapy. The treatment through group
work is traditionally used on these patients when they are hospitalised, and it is currently
considered of particular interest for out-patients. Springer and Silk (Akrich, 1996; Springer &
Silk, 1996) designed an efficient, short programme in this regard. Similarly, Dawson
(Agazarian & Janoff, 1993; Dawson, 1988; Dawson & MacMillan, 1993) proposes a
programme with the aim of « managing emotions », in which the therapists show themselves
as permissive even if they forbid acting out. A controlled study that compared individual and
group psychotherapy (Clarkin, Marziali, & Munroe-Blum, 1991; Clarkin, Yeomans, &
Kernberg, 1999) showed better results with this second approach.
Nowadays, the therapeutic groups tend to be heterogeneous in composition, although
the present most popular programmes (Linnehnan´s, Kernberg´s and Bateman´s) are
homogeneous. The orientation of groups tends to be eclectic, and although open
psychodynamic groups are the most frequent, others (Klein, 1993; Klein & Carroll, 1986)
focus on such aspects as acting out, splitting, countertransference, and the focus and
eroticisation of relationships.
There is an approach that combines both individual and the group psychotherapy. It is
the "Dialectic Behaviour Therapy, or DBT. Significant positive results have been found with
this cognitive-behavioural approach created by Linehan. From a theoretical point of view,
Linehan made reference to a "dialectic reasoning", which brings into opposition poles such
as: emotional vulnerability vs. invalidation, active passiveness vs. competency, and
demonstrative crises vs. emotional inhibition. As mentioned, these programs combine
individual and group approaches in problem solving and in training in skills. The patients take
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part in these groups during at least one year, and then take part in help groups or in groups to
reinforce the application of skills. At the individual and concomitant therapy, which also lasts
at least one year, the patients are taught to integrate these skills into daily life. The rules to
generalize the apprenticeship to the outside world (even with the use of the telephone) are
proposed. The group is closed or, at the most, slowly opened.
The DBT has shown efficacy in reducing the suicide rates in the BPD patients
(Bateman, 2002; Bateman & Fonagy, 1999)Bateman et al., 1999) (Linehan et al., 2006),
(Davidson et al., 2006)
In general, the psychoanalytical approaches are especially based on the theory of
object relations. Most of the approaches have been developed in hospital environments or in
half-way centers. It is principally the work of Kernberg that uses the psychoanalytical model
of object relations (Kernberg, Kibel, Russakoff) in the programme, previously mentioned, of
"Transference Focus Psychotherapy". In this therapy, the importance is placed on increasing
the strength of the ego and improving the experience of reality with an attempt at internal
reconstitution.

From a technical point of view, the splitting mechanism is rather more

reinforced than struggled against and an open exteriorization of aggression and the realization
of group interpretation based on the « here and now », favouring cohesion, is encouraged.
On their side, Dolan et al. (Dolan, Evans, & Norton, 1995; Dolan, Warren, & Norton,
1997; Dolan, Evans, & Wilson, 1992) in a non-controlled study evaluated the impact of
psychotherapeutic treatment in 137 patients hospitalized on the principal symptoms of
personality disorder. They noted a significantly greater improvement in those treated than in
the group « not admitted » having a significant positive correlation with length of treatment.
And further on, in a naturalistic study, Sabo et al. (Sabo, Gunderson, Navajavits,
Chauncey, & Kisiel, 1995) find that suicidal conduct diminished significantly.
More currently, A recent Cochrane review (CA Binks et al., 2007) identified seven
studies involving 262 people, and five separate comparisons. In the studies comparing
dialectical behaviour therapy (DBT), with treatment as usual, no difference was found in the
outcome of hospital admissions in the previous 3 months, or in the outcome 6 months after
being discharged. One study detected statistical difference in the average scores of suicidal
ideation at 6 months, in favour of people receiving DBT, compared with those allocated to
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treatment as usual. There was no difference in the outcome of leaving the study early. For
the outcome of interviewer-assessed alcohol free days, skewed data have been reported and
tend to favour DBT. When a substance abuse focused DBT was compared with
comprehensive validation therapy, plus a 12-step substance misuse programme, no clear
differences were found for service outcomes or leaving the study early. In similar fashion,
when DBT was compared with client centred therapy, no differences were found for service
outcomes. However, fewer people in the DBT group displayed indicators of parasuicidal
behaviour. There were no differences for outcomes of anxiety and depression, but people
who received DBT had less general psychiatric severity than those in the control group.
Finally, this one relevant study reports skewed data for suicidal ideation with considerably
lower scores for people allocated to DBT. When psychoanalytically oriented partial
hospitalization was compared with general psychiatric care, the former tended to come off
best. They also observed that people who received treatment in a psychoanalytic orientated
day hospital were less likely to be admitted into inpatient care, when measured at different
times. In addition, fewer people in psychoanalytically oriented partial hospitalization needed
day hospital intervention during the 18 months after discharge. In contrast, more people in
the control group took psychotropic medication by the 30 to 36 month follow-up, than those
receiving psychoanalytic treatment. The anxiety and depression scores were generally lower
in the psychoanalytically oriented partial hospitalization group, as were the global severity
scores. The patients receiving psychoanalytic care in a day hospital had better social
improvement and social adjustment, using the SAS-SR at 6 to 12 months, than those in
general psychiatric cares, though the rates of attrition were the same.
The authors suggest that some of the problems frequently encountered by people with
BPD may be amenable to talking/behavioural treatments, but all therapies remain
experimental. The studies are too few and too small to inspire full confidence in their results,
and the findings must be replicated in larger 'real-world' studies.
These are not controlled studies on the effectiveness of therapeutic community
programs, and the multiplicity of variables intervening in the therapeutic process in these
settings will make this kind of approaches most unlikely.
Hafner and Holme (Hafner & Holme, 1996) made a prospective study with 48
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residents of a therapeutic community with borderline personality disorders. A reduction in
significant symptoms took place at discharge after an average stay of 64 days, and the rates
of admission to hospital fell in a significant fashion during the year after discharge. Patients
rated group therapy as the most useful element of the program.
A training process which corresponds to therapeutic community principles should
encourage the growth and differentiation of patients and, as Campling and Haigh (Campling
& Dixon Lodge, 1999a, 1999b) warn, avoid indoctrination and infantilization that are typical
of medical training but also of psychoanalytical training. Although the philosophy of
therapeutic communities has become especially widespread over the last few years in halfway institutions, the hospital-based therapeutic community will continue to justify itself in
the treatment of BPD (Schimmel, 1997).
On our side (Guimón, 1998), over the past 20 years we have developed a certain
number of group programs, the so called "decaffeinated therapeutic communities" (Guimón,
1999 #2774). These programmes have been developed in many psychiatric services with an
orientation towards community therapy in a dozen different care units (short-stay units in
general hospitals, day hospitals etc.), both in Spain and in Switzerland (Guimón, 2001a,
2001b; J Guimón, 2002; José Guimón, 2002). They include, at the minimum, a daily
medium-sized group bringing together patients and staff and a "small" group of patients,
with a dynamic orientation but with occasional cognitive-behavioural tendencies, as well as
group activities, (« group work » in Foulkes' sense).
4. THE USES AND ABUSES OF EVIDENCE BASED PSYCHIATRY
The language of medicine is at once scientific, moral and political. These three
languages make up a social body ­ which has come to be known as the « body of medicine ».
Medicine is a "practical", operational science". But as Gracia says , it is no longer quite as
easy, as it was a few decades ago, to defend the scientific nature of medicine. Admittedly
anatomy is a science, just like physiology, biochemistry or microbiology. But none of these
sciences strictly identifies with medicine, even if the doctor has to be familiar with all of them
to do his job.
Even if psychiatry was one of the first medical specialties to use the tools of evidencebased medicine, these tools, so far, have been applied more often to pharmacological than to
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psychological treatments. As we have seen, the conclusions of the last Cochrane review about
the efficacy of pharmacological treatments for BPD seem discouraging. The authors conclude
that until now, current trials regarding pharmacological treatment of people with BPD are not
based on good evidence. However, they suggest that the positive effect of antidepressants in
particular, could be considerable. One must keep in mind, though, the fact that "not finding
evidence of efficacy of treatment" does not mean that this treatment is ineffective, but that, as
the authors of this review used to say: "further well designed, conducted, and reported
clinically meaningful trials are needed". Unfortunately, there still not a controlled study on the
efficacy of the combined use of Impulsivity Rating Scales, (IRSS), humour stabilizing drugs,
and low dosages of antipsychotics. The example of the beneficial use of medication
"cocktails" in the treatment of AIDS should be encouraging the evaluation of these
combinations in BPD. In this challenging domain of the efficacy of psychotherapy, some
Cochrane collaboration systematic reviews and other reviews, (i.e. the Patient Outcomes
Research Team programme in Baltimore), have appeared during the last years (Thornicroft &
Szmukler, 2001).This growing interest has led to the formation of task forces to: define,
identify, and disseminate information about empirically supported psychological interventions
(Barlow, Levitt, & Bufka, 1999; Chambless & Hollon, 1998; Sanderson, 1998). The
American Psychological Association Task Force on the Promotion and Dissemination of
Psychological Procedures, proposes some characteristics of empirically supported
psychotherapy treatments (O'Donohue, Buchanan, & JE, 2000). They include skill building,
have a specific problem focus, incorporate continuous assessment of client progress, and
involve brief treatment contact, requiring 20 or fewer sessions. To be "well-established", the
treatments for specific disorders must be shown to be efficient in at least two independent
RCTs. However, the task force recognizes that these findings are in part an artefact of
sociological factors present in contemporary psychotherapy
Many psychiatrists have reservations .about the "evidence-based' approach because
of perceived limitations in methodology (Mundt & Backenstrass, 2001), gaps in interpreting
the available evidence, and neglect of the individual patient uniqueness in quantitative
research through annualised treatment procedures (Beutler, 2000).
Concerning BPD, the settings of the psychotherapy RCTs are highly artificial. The
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naturalistic studies should be complemented, and efficiency studies in whole health care
systems should be done, if they pretend to be relevant to practice. Finally, empirically
supported BPD psychological treatments (Linnehan's and Bateman´s) have not been
effectively disseminated among the mental health professionals who deliver therapy around
the world, and thus, are not readily available to the public who require them (Barlow et al.,
1999) (Goldfried, TD, Clarkin, Johnson, & Parry, 1999).
The therapists complain that therapy research on BPD has only a remote resemblance
to what goes on in actual clinical practice. There is a need of training of staff to implement
new psychological treatments, addressing professional barriers that may limit the uptake, and
of leading investigations that study the `minimum effective dose' or the key active ingredients
of the interventions.
To overcome these difficulties, some authors propose to make more naturalistic
studies, and others plead to add criteria deriving from mental health policy and economics
(Buchkremer & Klingberg, 2001). In this sense, Barlow (Barlow et al., 1999) offers a way to
overcome the problems of rigid manuals, as well as those associated with forcing clinicians to
adhere to theories and practices that are outside of their interest, experience, and expertise.
New models of research have also been proposed. Margison (Margison et al., 2000)
supports a model of professional self-management 'practice-based evidence', as a
complementary paradigm to improve clinical effectiveness in routine practice via the
infrastructure of "Practice Research Networks". For the prediction of responses to the course
of treatment, Lutz et al (Lutz, Lowry, Kopta, Einstein, & Howard, 2001) combine a doseresponse model with growth curve modelling, to determine dose-response relations for wellbeing, symptoms, and functioning. Barkham, (Barkham et al., 2001) argues for a core
outcome measure, (the "Clinical Outcomes in Routine Evaluation-Outcome Measure"), to
provide practice-based evidence for the psychological therapies to complement the existing
evidence-based practice paradigm. Kendall et al. (Kendall, Marrs-Garcia, Nath, & Sheldrick,
1999) propose "normative comparisons", a procedure for evaluating the clinical significance
of therapeutic interventions, consisting of comparing data on treated individuals with that of
normative individuals. Mundt and Backenstrass emphasize the importance of a more detailed
psychopathology, (through data that can be expected from neurosciences), which can then be
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matched to specific psychotherapy tools (Mundt, 2001).
SUMMARY
Evidence-based pharmacological and psychotherapeutic interventions have claimed
positive results in several randomized controlled studies of BPD. However, two recent metaanalytical Cochrane reviews consider that there is not yet "good evidence" of their efficacy,
and that further controlled studies are possible and needed. The authors of the present paper
remind that "not finding evidence of efficacy of treatment" does not mean that the treatment is
ineffective, but as those who made this kind of meta-analytic enquiries say "further well
designed, conducted and reported clinically meaningful trials are needed".
The authors underline the usefulness of the "evidence-based" movement that has
appeared in medicine and in psychiatry, as a regulative idea and a research method. It is, also,
a powerful socio-political endeavour; and, it entails important ethical implications, since
moral neutrality is a myth when referring to the incompatible ethical positions inherent in
clinical and research practices..
RESUMEN
Los pacientes con TLP tienen un riesgo significativamente mayor de conductas
autodestructivas y suicidas, aunque este riesgo disminuye a largo plazo, al haber una
disminución de los comportamientos autoagresivos y se ha descubierto que ambos pueden
disminuir, si se tratan de forma efectiva en los años de juventud. Por ello, en la evaluación
de pacientes con TLP es muy importante incluir la detección de predictores de un riesgo
elevado de conducta suicida.
No hay un tratamiento específico para el TLP. El tratamiento farmacológico es útil
únicamente frente a síntomas, tales como la ansiedad o depresión, pero no tienen influencia
alguna en los rasgos de personalidad subyacentes. El valor de la hospitalización a la hora de
prevenir el suicidio en pacientes con TLP, no está probado, y a veces, incluso puede tener
efectos negativos. Por otro lado, el tratamiento en unidades de día es una alternativa a la
hospitalización, pero los clínicos temen un posible litigio, debido al temor a que el paciente se
suicide y acaban optando por la hospitalización.
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Una Revisión Chochrane de Binks et al. en 2007 concluye a través de dos estudios
que comparaban los antidepresivos con el placebo que, para el índice de ira, la fluoxetina
puede provocar alguna mejora respecto al grupo placebo y que el haloperidol podía ser más
efectivo que los antidepresivos para síntomas de hostilidad y psicoticismo. No existían
diferencias entre los inhibidores de monoamino oxidasa, (IMAO), y el placebo, excepto que
las personas a las que se les administraron IMAOs se mostraban menos hostiles Los
antipsicóticos pueden afectar algunos estados mentales sintomáticos de forma más efectiva
que el placebo, pero los resultados son difíciles de interpretar clínicamente y hay poca
evidencia de la ventajas de un antipsicótico sobre otro. Finalmente, en otro estudio controlado
se concluyó que el divalporex, (un estabilizador del humor), puede ayudar al estado mental
general, pero los datos están lejos de ser concluyentes.
La psicoterapia de los trastornos de la personalidad fue revisada por Perry et al. en
quince estudios, incluidos tres etudios controlados. Estos estudios analizaban diferentes
abordajes: el psicodinámico/interpersonal, el cognitivo-conductual, el mixto y las terapias de
apoyo. Todos los estudios informaron de una mejora en los trastornos de personalidad tras la
psicoterapia. Estimaron que el 25% de los pacientes con trastonos de personalidad se
recuperaban, cifra siete veces mayor que en un modelo publicado sobre el transcurso natural
del trastorno límite de la personalidad.
Uno de estos tratamientos, basado en la concepción dinámica, para los TLP, es la
llamada "Psicoterapia focalizada en la transferencia", (TFP) propuesta por el grupo de
Kernberg y Levy.
La terapia de grupo, junto con la terapia individual, es una herramienta clave en el
trtamiento de los TLP. Esta terapia es frecuentemente parte de un programa multidimensional,
incluyendo la medicación y otras formas de tratamiento. Los grupos terapéuticos tienden a ser
heterogéneos en su composición, aunque los programas más populares en la actualidad, (los
de Linehan, Kernberg y Bateman), son homogéneos. La orientación de los grupos tiende a ser
ecléctica, y aunque los grupos psicodinámicos abiertos son los más frecuentes.
Se han hallado resultados positivos significativos con la terapia cognitivocomportamental de Linehan que combina abordajes grupales e individuales en la resolución
de problemas y en el entrenamiento en habilidades. Esta terapia "dialéctica comportamental",
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ha mostrado ser eficaz para la disminución de los índices de suicidio en pacientes con TLP,
como demuestra un estudio controlado de Linehan en 2006), que comparaba la TDC y el
tratamiento comunitario por expertos.
En general, los abordajes psicoanalíticos están basados en la teoría de las relaciones
objetales. Los trabajos recientes de Bateman y Fonagy muestran resultados favorables con un
tratamiento basado en una psicoterapia dinámica (con una técnica que denominan
"mentalización" ) en un hospital de día. Los comportamientos automutiladores y los intentos
de suicidio decrecieron durante los 18 meses de programa y también disminuyó la estancia
hospitalaria media en contraste con aquellos que habían seguido un tratamiento general.
Una revision Cochrane reciente de Blinks y cols en 2007 identifica siete estudios que
implican a 262 personas, y con 5 comparaciones distintas. Los autores sugieren que algunos
de los problemas con los que usualmente se enfrentan las personas con un trastorno límite de
la personalidad pueden ser susceptibles de tratamientos verbales/comportamentales. Sin
embargo, todas las terapias continúan siendo de carácter experimental, y los estudios son
demasiado escasos y reducidos para suscitar una plena confianza en sus resultados. Estos
hallazgos requieren replicarse en estudios mayores más semejantes al "mundo real".
No existen estudios controlados acerca de la efectividad de los programas de las
Comunidades Terapéuticas, y la multiplicidad de variables que intervienen en el proceso
terapéutico en estos ambientes hace que este tipo de abordaje sea poco probable. Existen
algunos estudios "naturalísticos" que muestran la eficacia, entre ellos, unos realizado en
Bilbao en que se muestra la eficacia de un programa de día de 50 días, de media de duración
de cuatro horas semanales.

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