Bados López, Arturo

Guilera Ferré, Georgina

Ruiz Rodríguez, José

Álvarez Tomás, Irene

English

Diposit Digital de la Universitat de Barcelona

Prospective long-term course of Borderline Personality Disorder in adulthood:A systematic reviewIrene Alvarez-Tomas a,b, Arturo Bados a, José Ruiz a, Georgina Guilera ca    Department of Personality, Assessment and Psychological Treatments, Faculty of Psychology,  Universitat de Barcelonab    Adult Inpatient Unit. Mental Health Service,  Institute for Research and Health Innovation Parc Tauli (I3PT)c    Department of Behavioural Sciences Methods, Faculty of Psychology, Universitat de Barcelona. Contact:  irene.alvareztomas@gmail.com4th International Congress on Borderline Personality Disorder and Allied Disorders. Bridging the Gap - from Basic Science to Treatment Implementation. 8 – 10 September 2016. Vienna, Austria• BPD diagnosis tends towards remission over time. (Biskin, 2015; Zanarini, 2012)• Main prospective studies (MSAD, CLPS) carried out in US population. Recent studies in other countries provided data for generalization of findings.• Long-term follow-up data in clinical studies: Treatment response vs. natural remission (Paris, 2002)LONG-TERM REMISSION OF BPDBiskin, R. S. (2015). The Lifetime Course of Borderline Personality Disorder. Canadian Journal of Psychiatry, 60(7), 303–308.Paris, J. (2002) Implications of long-term outcome research for the management of patients with borderline personality disorder. Harv Rev Psychiatry, 10(6), 315–323. Zanarini, M. C. (2012). Diagnostic specificity and long-term prospective course of borderline personality disorder. Psychiatric Annals, 42(2), 53–58. QUESTIONS• What is the long-term course of BPD diagnostic remission in adulthood?• Is the initial treatment related to long-term BPD remission rates? Overall hours of formal therapy=  Nº of therapy sessions per month * hours per session * months in treatment• Medline, PsycINFO and Scopus • Between 1990 and 2015. Inclusion criteria: 1.   Adult BPD sample, diagnosed by semi-structured interview2.   BPD diagnosis at baseline and at least at one follow-up assessment3.   5 years or more of follow-upSEARCH STRATEGY& INCLUSION CRITERIARecords identified through database searching(n = 1408)Additional records identified through other sources(n =  37)Records screened (after duplicated removed)(n = 601)Records excluded (n=445)No prospective studies (n = 306)No adult sample (n= 39)No BPD sample (n= 100)Full-text articles assessed for eligibility(n = 156)Full-text articles excluded (n = 146)No diagnostic interview (n=4)No repeated outcome measure         (BPD diagnosis)  (n= 50)< 5 years of follow-up (n= 92)Studies included in qualitative synthesis(n = 10)Studies included in meta-analyses(n = 9)FLOW CHARTCumulative remission rate: % n-period of remission over time offollow-up, by cumulative survival analyses  (CLPS/MSAD, except at 6y)Remission rate: % remission at an specific time point– BPD diagnostic criteria:  DSM-III /DSM-III-R/ DSM-IV– Semistructured interviews:  DIB / SCID / IPDENo publication biasEgger’s test:t = 0.61, df = 10, p = .56SELECTION OF STUDIESStudy Country Time% RetentionTreatment GroupsN at FUMeanAge% WomenHours of formal therapyConversational Model Therapy TrialStevenson (2005)Australia 6y 63 Specialized Therapy30 29.4 63.3 96MBT TrialBateman (2008)UK 8y 93 Specialized Therapy22 30.3 68 612TAU 19 33.3 47 --Boscot Trial (CBT-PD)Davidson (2010)UK 6y 72 Specialized Therapy 43 32.4 83.3 192TAU 33 31.4 84.6 --Ullevål Trial (CP vs OIT)Antonsen (2015)Norway 6y 65 Specialized Therapy19 117,5TAU 15 60McMaster University Study Links (1999)Canada 7y 65 No exptreatment57 34.7 93MSAD StudyZanarini (2003)US 6y 91 No exptreatment264 26.9 80.3Vaanta Primary Care Depression Study (PD-VDS)Riihimäki (2014)Finland 5y 83 No exptreatment29 32 86Barcelona Study Spain 10y 64 No exptreatment41 26.9 92.7Germany Study Germany 14.4y 35 No exptreatment58 29.2 100Total  N= 630Naturalistic studiesFollow-up clinical studiesStudy name Subgroup within study Statistics for each study Event rate and 95%  CIEvent Lower Upper rate limit limit p-ValueConversational Model Therapy Trial Specialized Therapy 0,40 0,24 0,58 0,28Mentalization-based Trial Specialized Therapy 0,86 0,65 0,96 0,00Mentalization-based Trial TAU 0,11 0,03 0,34 0,00Boscot Trial Specialized Therapy 0,56 0,41 0,70 0,45Boscot Trial TAU 0,52 0,35 0,68 0,86Ullevål Trial Specialized Therapy 0,89 0,66 0,97 0,00Ullevål Trial TAU 0,93 0,65 0,99 0,01McMaster University Study No exp treatment 0,53 0,40 0,65 0,69MSAD Study No exp treatment 0,69 0,63 0,74 0,00Vaanta Primary Care Depression Study (PD-VDS) No exp treatment 0,31 0,17 0,50 0,05Barcelona Study No exp treatment 0,55 0,40 0,69 0,53Germany Study No exp treatment 0,72 0,60 0,82 0,000,59 0,48 0,69 0,13-1,00 -0,50 0,00 0,50 1,00Favours A Favours BMeta AnalysisMeta AnalysisStudy name Subgroup within study Stati ics for each study Event rate and 95%  CIEvent Lower Upper rate limit limit p-ValueConversational Model Th apy Trial Specialized Therapy 0,40 0,24 0,58 0,28Mentalization-based Trial Specialized Therapy 0,86 0,65 0,96 0,00Mentalization-based Trial TAU 0,11 0,03 0,34 0,0Boscot Trial Specialized Therapy 0,56 0,41 0,70 0,45Boscot Trial TAU 0,52 0,35 0,68 0,86Ullevål Trial Specialized Therapy 0,89 0,66 0,97 0,00Ullevål Trial TAU 0,93 0,65 0,99 0,01McMaster University Study No exp treatment 0,53 0,40 0,65 0,69MSAD Study No exp treatment 0,69 0,63 0,74 0,00Vaanta Primary Care Depress on Study (PD-VDS) No exp treatment 0,31 0,17 0,50 0,05Barcelona Study No exp treatment 0,55 0,40 0,69 0,53Germany Study No exp treatment 0,72 0,60 0,82 0,000,59 0,48 0,69 0,13-1,00 -0,50 0,00 0,50 1,00Favours A Favours BMeta AnalysisMeta AnalysisMean Remission rate:  59%  (48% - 69%)High heterogeneity: Q= 54.9, p < .001I2 = 80%  (> 75%)Long-term BPD remissionGeneral moderators:   Age  &  GenderMixed effects regression (unrestricted maximum likelihood)Mean age % RemissionQ = 5.36, p = .02% Women% RemissionQ = 2.86, p = .0988%73%50%27%12%5%88%73%50%27%12%5%Mixed effects regression (unrestricted maximum likelihood)95%90%81%67%49%31%Years of follow-up% RemissionQ = 1.11, p = .29General moderators:  Time of Follow-upDifferences between treatment groups:    Q = 0.76,  p = .69 Treatment moderators:Type of experimental TreatmentTreatment moderators: Formal TherapyDifferences between treatment groups:    Q = 2.7,  p = .10 Treatment moderators: Hours of Formal TherapyYears of follow-up% RemissionHours of therapy% RemissionQ = 0.41  p = .52Mixed effects regression (unrestricted maximum likelihood)95%91%83%70%53%35%Hours of formal therapyCONCLUSIONS: NATURAL COURSE Over a half of patients with BPD diagnosis mayachieve remission in the long term. A diagnosis of BPD at a younger age is associatedwith higher long-term remission rates Female gender might be related to better clinicaloutcome Time of follow-up seems not related to remissionafter 5 years or more of illness. Specialized therapies seem not to improve the long-term clinical outcome, compared to treatment as usualor the natural course of the disorder. Receiving any kind of formal therapy might be associated with higher percentages of remission in the long term. The intensity and length of formal therapy receivedappears not to be crucial in reaching a better outcomein the long term.CONCLUSIONS: TREATMENTLIMITATIONS & RESEARCH SUGGESTIONS Limited number of studies and small size of BPDsamples in the majority of studies reduce thestatistical power and might compromise the study ofmoderators Further research focused on the long-term outcomeof treatment interventions is strongly recommended. Longitudinal studies in untreated samples maycontribute to describe the natural course of BPD.

Prospective long-term course of Borderline Personality Disorder in adulthood: A systematic review

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Prospective long-term course of Borderline Personality Disorder in adulthood: A systematic review

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