Dialectical Behavior Therapy vs Schema Therapy for Borderline Personality Disorder

Key Takeaways

• No statistically significant difference was observed between dialectical behavior therapy and schema therapy on the primary outcome.
• No significant between-group differences were reported on secondary outcomes, while both groups improved substantially over time.
• Dropout was similar between groups, and the abstract did not describe adverse events or other safety outcomes.

In the BOOTS randomized clinical trial, borderline personality disorder severity declined markedly over 3 years in 204 adults receiving outpatient care, with no statistically significant difference between dialectical behavior therapy and schema therapy on the primary outcome. Both psychotherapies were associated with substantial improvement across repeated assessments during follow-up, and neither was shown to be superior on the main measure of borderline personality disorder severity.

The 3-year multicenter superiority randomized clinical trial was conducted in 9 Dutch outpatient centers across the Netherlands. Adults aged 18 to 65 years with borderline personality disorder were enrolled, and 204 participants were randomized overall. Assessors were blinded to treatment allocation, and computerized covariate-adaptive randomization accounted for sex and baseline borderline personality disorder severity. Of the enrolled sample, 95 participants were assigned to dialectical behavior therapy and 109 to schema therapy; mean age was 32.21 years, and 84.3% were female. Both treatments were delivered over 2 years in a combined group-individual format.

The primary outcome was the rate of change in DSM-5 borderline personality disorder severity from baseline to 1-year posttreatment follow-up, 3 years after baseline, measured by the BPDSI-5 total score. At 36-month follow-up, the estimated mean difference between groups was −1.09 on the BPDSI-5, with Cohen d of 0.15 (95% CI, −0.17 to 0.47). The primary comparison also yielded P=.27 and r=0.09, consistent with no statistically significant difference between treatments. No significant differences were observed on secondary outcomes covering DSM-5 BPD criteria, general symptom severity, functioning, quality of life, well-being, and sleep problems.

Treatment dropout did not differ significantly between groups, although attrition increased over time in both study arms during the 2-year treatment period. Dropout in the dialectical behavior therapy group was 34% at 1 year and 52% at 2 years. Corresponding rates in the schema therapy group were 29% at 1 year and 46% at 2 years.

The authors concluded that neither therapy was shown to be superior in this superiority trial and called for future research on equivalence and treatment matching.