Personality Disorders

Personality Disorders

At present, 16+X randomized controlled trials (RCTs) for psychodynamic therapy (PDT) in personality disorders exist (Barber et al., 2021; Keefe et al., 2020). The quality of studies is sufficient for most studies (Barber et al., 2021)

borderline (BPD) and Cluster C personality disorders

• Efficacy( PDT vs controls): For core personality disorder symptoms, PDT achieved a medium clinically significant effect size in comparison to all controls (g=-0.63, 95% CI -0.87, -0.41, k=5, I2=11%) (Barber et al., 2021; Leichsenring et al., 2023). Compared to active controls (e.g. TAU, placebo, minimal treatment), PDT achieved a medium effect size (g=-0.65, -0.99, -0.32, I2=15%, k=4, N=200), with no indication of publication bias, although the number of studies is small to determine any effects of publication bias(Barber et al., 2021; Keefe, 2022). CI ????

• Suicidality: For suicidality PDT was superior to active control groups with a clinically significant medium effect size (g=-0.67, 95% CI  -1.13, -0.20, k=4, I2=40%, N=239)(Barber et al., 2021; Keefe, 2022; Leichsenring et al., 2023).

• Functioning: For functioning PDT yielded aa clinically significant medium to large effect size compared to controls  (g=-0.72, 95% CI  -1.04, -0.41, k=6, I2=42%)(Barber et al., 2021).

• Comparative efficacy: No significant differences between PDT and other active treatments with regard to core personality disorder criteria were found (g=-0.04, 95% CI -0.31, 0.22, k=6, I2=38%)(Barber et al., 2021). This is true for interpersonal problems (g=-0.05, 95% CI  -0.20, 0.12, k=4, I2=2%, N=394) and functioning (g=0.12, 95% CI -0.12, 0.36, k=4, I2=2%, N=394) (Barber et al., 2021; Leichsenring et al., 2023). There are also no significant differences in follow-up studies comparing PDT with active treatments with regard to core personality disorder symptoms (g=-0.18, 95% CI  -0.38, 0.03, I2=5%). No differences between PDT and other active treatments in follow-ups were found for general psychiatric symptoms (g=-0.20, 95% CI  -0.44, 0.05, k=4, I2=12%, N=370) and interpersonal problems (g=-0.23, 95% CI  -0.28, -0.17, k=4, I2=0%, N=370)(Barber et al., 2021; Leichsenring et al., 2023).

• Mechanisms of change: In addition, there is evidence for mechanisms of change of PDT in personality disorders (Leichsenring et al., 2023)

• Adverse events: Serious adverse events, adverse events and side effects were rarely reported in studies of personality disorders. In one RCT of PDT, non-occurrence of any adverse events was explicitly reported (Abbass et al., 2008).

• Efficacy under real world conditions: Manual-guided and non-manual guided PDT for personality disorders proved to be equally efficacious.(Vinnars et al., 2005) This was true for an inpatient treatment for PDT in Cluster B personality disorders in which manual-guided and non-manual guided PDT were superior to a waiting list condition.(Leichsenring et al., 2016)

• Cost-effectiveness: There is evidence to suggest that PDT is a cost-effective treatment in personality disorders and high utilizers of psychiatric services.(Abbass et al., 2008; Guthrie et al., 1999). Thus, the benefits of PDT seem to outweigh the costs and harms as required by GRADE(Andrews et al., 2013; Guyatt et al., 2008).

• Unique effects of PDT: Consistent with the psychodynamic model and treatment of personality disorders, an RCT found PDT to be superior to dialectical behavior therapy and supportive therapy in improving reflective functioning and attachment, thus showing an additional gain(Levy et al., 2006). For improving reflective functioning effect sizes in favour of PDT were large (d=0.84) compared to supportive therapy and medium (d=0.55) compared to DBT(Levy et al., 2006).

• Mechanisms of change ?

• Cost-effectiveness: There is evidence that PDT is a cost-effective treatment in personality disorders and high utilizers of psychiatric services.(Abbass et al., 2008; Guthrie et al., 1999)

Summing up, in personality disorders PDT achieves clinically significant effects in comparison to controls and is as efficacious as other active treatments. In addition, PDT achieves clinically significant effects in suicidality and functioning. Effects are stable in follow-ups. Furthermore PDT is efficacious under real world conditions and there is evidence for mechanisms of change of PDT.

As a result, PDT fulfils the updated criteria of the American Psychological Association  for empirically supported therapies (Tolin et al., 2015), warranting a strong recommendation for the treatment of personality disorders (Leichsenring et al., 2023)