La psicoterapia del disturbo borderline di personalità: attuali orientamenti e linee di ricerca
Psychotherapy of borderline personality disorder: current trends and research issues
S. Bellino, P. Bozzatello, A. Blandamura, F. Bogetto
Servizio per i Disturbi di Personalità, Struttura Complessa di Psichiatria 1 a Direzione Universitaria, Dipartimento di Neuroscienze, Università di Torino
Summary
Borderline personality disorder (BPD) is an Axis
II mental disorder characterized by a pervasive pattern of instability
in interpersonal relationships, affects, and identity, as well as severe
impulsive behaviors.
According to literature data and treatment guidelines of the American
Psychiatric Association, borderline personality disorder can be usefully
treated with both pharmacotherapeutic and psychotherapeutic interventions.
Clinical experience suggests that patients with BPD need extended psychotherapy
(at least 1 year) to attain and maintain lasting improvement in psychiatric
symptoms, interpersonal problems, and overall functioning. Main models
of psychotherapy that have been tested for BPD treatment in trials of
single or combined therapy are: psychodynamic psychotherapy, dialectical
behavior therapy (DBT), schema focused therapy (SFT) and system training
for emotional predictability and problem solving (STEPPS) interpersonal
psychotherapy (IPT). The present review aims to report and comment results
of clinical trials assessing the efficacy of the above listed models
of psychotherapy in the treatment of borderline personality disorder.
Psychodynamic psychotherapy is a therapy that
is focused on the transference relationship. The therapist provides
interpretations of transference choosing the most suitable times in
the therapeutic process. Authors proposed different approaches to psychodynamic
therapy of borderline patients, preferring the use of supportive or
explorative techniques. Psychodynamic psychotherapy is recommended for
treatment of patients with BPD on the basis of the positive results
of several randomized controlled trials. However, the use of this model
of psychotherapy in clinical practice is limited, probably due to the
high amount of resources required to both therapists and the patients.
Dialectical behavior therapy is a model proposed by Linehan and derived
from cognitive-behavioral therapy. It was specifically designed to treat
women who meet diagnostic criteria for BPD and engage in self-injurious
behaviors. DBT can be currently considered the psychotherapy with the
largest amount of controlled studies in BPD samples. It has been found
to be efficacious in the treatment of high-risk behaviors and suicide
attempts, but it is not so useful in reducing depressive symptoms and
increasing patients' degree of overall satisfaction. DBT has been also
studied to treat BPD patients with substance abuse or eating disorders
comorbidity. Interpersonal therapy was initially proposed to treat major
depression, but has been more recently considered a good option to treat
other psychiatric disorders, such as bipolar disorder, bulimia nervosa,
and anxiety disorders. Markowitz (2006) proposed an adaptation of IPT
to the peculiar clinical and relational features of patients with borderline
personality disorder (IPTBPD). Interpersonal therapy appears a suitable
approach to these patients, who show prominent relational problems and
high comorbidity rates with major depression.
Growing clinical evidence supports combination of psychotherapy and pharmacotherapy in treatment of BPD, but only few controlled trials comparing efficacy of combined and single therapy have been completed. Borderline personality disorder is characterized by various psychopathological dimensions, that could be more responsive to specific models of psychotherapy, to different drug interventions or to combined or sequential therapy. Further investigations are required to collect data on this core issue of BPD treatment, identifying response predictors and designing more individualized treatment projects.