Is treatment in a day hospital step-down program superior to outpatient individual psychotherapy for patients with personality disorders? 36 months follow-up of a randomized clinical trial comparing different treatment modalities

Abstract

Despite increasing interest in the development of effective treatments for patients with PDs, there is still no consensus about the optimal treatment setting for this group of patients. This study reports the 36 months follow-up of the Ullevål Personality Project (UPP) (n=113), a randomized clinical trial comparing two treatment modalities for patients with PDs: an intensive long-term step-down treatment program, consisting of short-term day hospital treatment followed by combined group and individual psychotherapy organized in a hospital setting, with "ordinary" outpatient individual psychotherapy in private practice for patients with moderate to severe PDs. Patients in both treatment groups showed improvements in several clinical measures after 36 months. However, contrary to our expectations, patients in the outpatient treatment setting improved significantly more. Possible explanations for this surprising finding are discussed. The study cannot exclude the possibility that treatment aspects other than differences in modalities could explain some of the differential effectiveness (e.g. differences between therapists).

Favourable outcome of long-term combined psychotherapy for patients with borderline personality disorder: Six-year follow-up of a randomized study

“…However, the transition from day-hospital to outpatient treatment in the CP that included a change of therapists may have represented a disruption of the therapeutic process, causing delayed improvement for patients in the CP (Hummelen, Wilberg, & Karterud, 2007). This possibility is supported by the higher level of psychosocial functioning in the OIP condition at three-year follow-up (Gullestad et al, 2012). Further, publications by Bateman and Fonagy (2009) and Jørgensen et al (2013) support the effectiveness of intensive combination therapy in an outpatient setting.…”

“…Originally, UPP was a study including a mixed PD sample, and we have previously reported results for the total sample from the follow-up investigations at 8 months, 18 months, 3 years, and 6 years after the initial random assignment (Antonsen et al, 2014;Arnevik et al, 2009Arnevik et al, , 2010Gullestad et al, 2012). At six-year follow-up, differences between the two treatment conditions were below levels of significance, although different trends were observable (Antonsen et al, 2014).…”

“…Written informed consent was obtained from all included patients, and the project was approved by the Regional Ethics Committee in Norway. The subjects' characteristics, the original trial methodology, and the treatment details have previously been described in greater detail (Arnevik et al, 2009;Gullestad et al, 2012).…”

Attachment and Reflective Functioning in Women With Borderline Personality Disorder

“…Agrawal, Gunderson, Holmes, & Lyons-Ruth, 2004 for a review) as well as between BPD and RF dysfunctions (e.g., Fonagy et al, 1996;Gullestad et al, 2012;Harari, Shamay-Tsoory, Ravid, & Levkovitz, 2010;Preissler, Dziobek, Ritter, Heekeren, & Roepke, 2010). These studies underline the relevance of adult attachment patterns sustained by negative self internal working model while other findings have also highlighted the importance of negative internal working model of others.…”

“…These studies underline the relevance of adult attachment patterns sustained by negative self internal working model while other findings have also highlighted the importance of negative internal working model of others. As a whole, these results lead many to consider that BPD patients may fluctuate in the valence of internal working models of self and others (for a review see Agrawal et al, 2004) In terms of mentalization, BPD patients are typically described as struggling to effortfully engage cognitive resources when attributing mental states (e.g., Fonagy et al, 1996;Gullestad et al, 2012;Harari et al, 2010;Preissler et al, 2010). This feature in their mentalization profile may bias the interpretation of mental states that motivate self and other"s action, towards automatic and affectively-based reasoning, which strongly reduces their emotion regulation success (Fonagy & Luyten, 2009).…”