IMPORTANCE Borderline personality disorder (BPD) is a debilitating condition, but several psychotherapies are considered effective.OBJECTIVE To conduct an updated systematic review and meta-analysis of randomized clinical trials to assess the efficacy of psychotherapies for BPD populations.DATA SOURCES Search terms were combined for borderline personality and randomized trials in PubMed, PsycINFO, EMBASE, and the Cochrane Central Register of Controlled Trials (from database inception to November 2015), as well as the reference lists of earlier meta-analyses.STUDY SELECTION Included were randomized clinical trials of adults with diagnosed BPD randomized to psychotherapy exclusively or to a control intervention. Study selection differentiated stand-alone designs (in which an independent psychotherapy was compared with control interventions) from add-on designs (in which an experimental intervention added to usual treatment was compared with usual treatment alone). DATA EXTRACTION AND SYNTHESISData extraction coded characteristics of trials, participants, and interventions and assessed risk of bias using 4 domains of the Cochrane Collaboration Risk of Bias tool (independent extraction by 2 assessors). Outcomes were pooled using a random-effects model. Subgroup and meta-regression analyses were conducted.MAIN OUTCOMES AND MEASURES Standardized mean differences (Hedges g) were calculated using all outcomes reported in the trials for borderline symptoms, self-harm, suicide, health service use, and general psychopathology at posttest and follow-up. Differential treatment retention at posttest was analyzed, reporting odds ratios.RESULTS Thirty-three trials (2256 participants) were included. For borderline-relevant outcomes combined (symptoms, self-harm, and suicide) at posttest, the investigated psychotherapies were moderately more effective than control interventions in stand-alone designs (g = 0.32; 95% CI, 0.14-0.51) and add-on designs (g = 0.40; 95% CI, 0.15-0.65). Results were similar for other outcomes, including stand-alone designs: self-harm (g = 0.32; 95% CI, 0.09-0.54), suicide (g = 0.44; 95% CI, 0.15-0.74), health service use (g = 0.40; 95% CI, 0.22-0.58), and general psychopathology (g=0.32; 95% CI, 0.09-0.55), with no differences between design types. There were no significant differences in the odds ratios for treatment retention (1.32; 95% CI, 0.87-2.00 for stand-alone designs and 1.01; 95% CI, 0.55-1.87 for add-on designs). Thirteen trials reported borderline-relevant outcomes at follow-up (g = 0.45; 95% CI, 0.15-0.75). Dialectical behavior therapy (g=0.34; 95% CI, 0.15-0.53) and psychodynamic approaches (g=0.41; 95% CI, 0.12-0.69) were the only types of psychotherapies more effective than control interventions. Risk of bias was a significant moderator in subgroup and meta-regression analyses (slope β = −0.16; 95% CI, −0.29 to −0.03; P = .02). Publication bias was persistent, particularly for follow-up.CONCLUSIONS AND RELEVANCE Psychotherapies, most notably dialectical behavior therapy and psychodynamic ...

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This study investigated the temporal dynamics of emotional and cognitive processing underlying decision-making in moral judgment. Thirty-seven participants were presented with a set of 60 dilemmas varying in whether killing one individual was an intended means to save others (instrumental dilemmas) or a foreseen but unintended consequence (incidental dilemmas). Participants were required to decide between Options A (letting a specific number of people die) and B (killing one person to save a specific number of people). ERPs were recorded to a slide displaying the letters A and B while subjects were deciding between the options, and movement-related potentials were recorded time-locked to the behavioral response, thus allowing the investigation of both stimulus- and response-related processes during decision-making. Ratings of emotional valence and arousal experienced during decision-making were collected after each decision. Compared with incidental dilemmas, instrumental dilemmas prompted a lower number of B choices and significantly more unpleasant decisions. A larger P260 component was found in the frontopolar and frontal areas when subjects were deciding on instrumental than incidental dilemmas, possibly reflecting an immediate affective reaction during the early stage of assessment and formation of preferences between available options. On the other hand, decisions on incidental dilemmas required greater attentional resources during the fairly controlled later processing, as reflected in the larger slow wave amplitudes. In addition, facilitation of action selection and implementation was found for incidental dilemmas during the second stage of decision-making, as supported by the larger amplitudes of both components of the Bereitschaftspotential.

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