Expeditious and effective treatment for borderline personality disorder (BPD) is a significant public health need. It is estimated that between 7%–22% percent of psychiatric outpatients1
and 19% of inpatients2
meet criteria for this disorder. Suicidality and self-injury are common among these patients, with 70%–75% of patients with BPD having a history of at least one act of deliberate self-harm.3
Estimated rates of completed suicide average around 10%.4
Functional deficits may be extreme, comorbid diagnoses are the norm, mental health utilization costs are great, and treatment dropout rates are high in the population of patients with BPD.
Despite the heterogeneity and morbidity of BPD, recent data have challenged longstanding beliefs about the chronicity and treatment resistance of this disorder. Data from several large-scale, naturalistic, longitudinal studies demonstrate that many of the diagnostic criterion behaviors do remit.5–7
Furthermore, randomized, controlled treatment studies have found that psychosocial interventions, specifically dialectical behavior therapy (DBT), mentalization based therapy (MBT), and schema-focused therapy (SFT), can be effective in treating BPD.8–14
However, these treatments are long-term, with a minimum duration of 1 year.
The American Psychiatric Association’s guidelines echo the consensus that long-term individual psychotherapy is required for successful treatment of BPD.15
However, patients with BPD often utilize more intensive services such as inpatient hospitalization,16
with an estimated 20% of psychiatric inpatients meeting diagnostic criteria for BPD.17
Patients with BPD also face practical challenges in sustaining weekly outpatient psychotherapy.16
DBT has been adapted for shorter durations of treatment and use in more intensive settings.18–20
However, adaptations requiring 3-month inpatient stays18,19
are not consistent with standard practice in the United States. Such patients are also at risk of becoming so accustomed to being in an inpatient setting that a return to normal life outside the institution is impeded and that any treatment gains made are not easily generalized to more normative settings.
Partial hospitalization represents a modality that may address the needs of many patients in a more cost-effective and practical manner. DBT has been modified for delivery in intensive outpatient and partial hospitalization programs,20,21
but very little research has been done concerning the outcome of such treatments. One study of 87 patients in a 3-week intensive DBT program found that patients showed statistically significant improvements on measures of depression (medium effect size) and hopelessness (small effect size),20
but no improvement on a measure of social functioning. However, there is no information on the post-discharge status of these patients, so the question remains whether the treatment gains were sustained after discharge.
BPD is a heterogeneous disorder that encompasses diverse criteria across affective, behavioral, interpersonal, and cognitive dimensions. Results of treatment outcome studies that presume homogeneity on the basis of the BPD diagnosis are likely to underrepresent the variability within their samples. Other studies of BPD have reported that affective instability22
have been associated with suicidal behaviors. These two traits have also been identified as particularly strong predictors of poor functioning and outcome in young adults with BPD.24
Identification of specific criteria associated with specific outcomes might allow more precise targeting of interventions.
In this article, we report findings from a 3-month naturalistic follow-up after discharge from a 5-day partial hospital program based on an adaptation of DBT. The length of stay in this program is consistent with the typical duration of inpatient psychiatric hospitalizations. The purpose of this investigation was two-fold: 1) to determine whether women with BPD enrolled in this 5-day partial hospitalization DBT program showed clinically significant improvement 3 months post-discharge, and 2) secondarily, to examine whether specific BPD criteria at baseline predicted treatment outcome. We hypothesized that patients with affective instability and impulsivity would be less likely to have positive outcomes. Our data are largely descriptive, we did not have a comparison group, and treatment after discharge was naturalistic and therefore varied among participants. However, we believe that descriptive data of this nature (i.e., follow-up from a “real-world” setting) can be very informative.