Mentalization Based Treatment vs care as ususal in the treatment of severe Borderline Personality Disorder

Although there is a growing demand, evidence based treatments for patients with
severe personality disorders (mostly borderline personality disorders) are not
readily available. Recently, Mentalized Based Treatment (MBT) has been
developed for patients with borderline personality disorder. One randomized
controlled study demonstrated that a 5-day part-time MBT resulted in a clinical
improvement up to 5 years after treatment compared to care as usual for
patients with severe personality disorders (mostly borderline personality
disorders). MBT also proved to be cost efficient. Given the fact that evidence
for efficacy is based on only one RCT, it is essential new studies examine the
effects of MBT.

A randomized multicentre trial is proposed. The aim of this study is to find
answers to the following questions; 1) what is, compared to care as usual, the
effect of MBT with respect to symptoms, level of functioning and well being,
(mental) health care consumption, and 2) what is the long term cost efficiency
of MBT. Based on the results we hope to be able to determine if further
implementation of intensive part time MBT can be recommended.

Patients with borderline personality disorder will be randomly assigned to one
of two trial arms. In the experimental condition patients receive MBT, in the
control condition patients receive care as usual. The intervention has a total
duration of 36 months and. A base line measurement will be performed at the
start of the intervention, and 6, 12, 18, 24, 30 and 36 months after. We expect
a gradual improvement on clinical outcome variables during the first 18 months
resulting in a 25% improvement at 18 months, compared with treatment as usual.
After this, we expect this clinical improvement to remain stable during the
next 18 months. At Arkin MBT can be offered to a total of 18 patients.
Patients will be analysed according to the intention to treat principle. Based
one experiences and literature (including the study by Bateman and Fonagy), the
proportion of patients who drop out within thefirst three month s of treatment
is approximately 20%. New patients will be recruited to fillup vacant MBT
places and followed up according to protocol. Therefore we expect to have a
total of 21patients in the analysis per condition in the Arkin sample. With a
sample of 21 patients per group, an effectsize of 0.9 on the BPDSI in an ANOVA
can be detected with a power of 81%.
With the participation of either Ingeest or DeViersprong we realize a
randomization of 36 patients to MBT(four groups on two locations), and 36
patients to the care as usual. With a sample of 36 patients pergroup,an effects
ize of 0.9 on the BPDSI in an ANOVA can be detected with a power of >90%.

Following MBT theory, mentalizing is the ability to understand oneself and
others by inferring the mental states that lie behind overt behaviour. Failure
to retain mentalizing, particularly in the midst of emotional interactions, is
understood to be a core problem in (borderline) personality disorder, resulting
in severe emotional fluctuations, impulsivity, and vulnerability to
interpersonal and social interactions. The object of MBT is to increase
mentalization capacity which should improve affect regulation and interpersonal
relationships
Care as usual is provided by an outpatient team composed of psychiatrists,
psychologists and mental health nurses. The team is experienced in the
treatment of patients with personality disorders. Treatment is mainly ambulant.
Day-treatment or hospitalization is only offered when necessary. The team aims
at delivering optimal care by tailoring the intensity of the intervention and
catering from a variety of interventions such as family interventions, VERS or
Lineham training, social skills training, cognitive psychotherapy,
psychodynamic psychotherapy, farmacotherapy, addiction treatment, inpatient
treatment etcetera

Burden: 6 moments of measurement (interview and selfrating scales) in 36 months
Risks: non