Dialectical Behavior Therapy vs Schema Therapy for Patients With Borderline Personality Disorder

JAMA Psychiatry, vol. 83, pp. 669

Abstract

Importance: Head-to-head comparisons of evidence-based treatments for borderline personality disorder (BPD), including dialectical behavior therapy (DBT) and schema therapy (ST), remain scarce, despite their widely recognized relevance. Objective: To compare the effectiveness of DBT and ST in a multicenter trial among outpatients with BPD. Design, Setting, and Participants: This 3-year multicenter superiority randomized clinical trial (RCT), part of the BOOTS (Borderline Optimal Treatment Selection) project, was conducted between January 2019 and April 2025. The trial was conducted in 9 Dutch outpatient centers among individuals aged 18 to 65 years with BPD. Assessments were administered by assessors blinded to treatment allocation. Interventions: Participants were randomized to DBT or ST via computerized covariate-adaptive randomization accounting for sex and BPD severity. Both treatments were delivered over 2 years in a combined group-individual format. Main Outcomes and Measures: The primary outcome was the rate of change in DSM-5 BPD severity from baseline to 1-year posttreatment follow-up (3 years after baseline), assessed by the Borderline Personality Disorder Severity Index, fifth version (BPDSI-5) total score. Secondary outcomes included DSM-5 BPD criteria, general symptom severity, functioning, quality of life, well-being, sleep problems, and treatment dropout. Results: Of 204 participants (172 female [84.3%]; mean [SD] age, 32.21 [9.57] years), 95 (46.6%) received DBT and 109 (53.4%) received ST. Intention-to-treat analysis revealed no significant difference between DBT and ST in reducing BPD severity (P = .27, r = 0.09), with large improvements in both treatments. At 36-month follow-up, the estimated mean difference was -1.09 on the BPDSI-5 (Cohen d = 0.15; 95% CI, -0.17 to 0.47). No significant differences between treatments were observed on any secondary outcome, with marked improvements over time in both treatments. Dropout did not differ significantly (DBT: 34% at 1 year, 52% at 2 years; ST: 29% at 1 year, 46% at 2 years). Conclusions and Relevance: This multicenter RCT found no significant differences in effectiveness between DBT and ST for outpatients with BPD, with substantial improvements across outcomes. Future research is warranted to assess equivalence and to determine which treatment works best for whom and why. Trial Registration: https://onderzoekmetmensen.nl Identifier: NL-OMON49443.

Authors 14

1. Carlijn J. M. Wibbelink

   University of Amsterdam

   Affiliation as printed

   Department of Clinical Psychology, University of Amsterdam, Amsterdam, the Netherlands

2. Jan Henk Kamphuis

   University of Amsterdam

   Affiliation as printed

   Department of Clinical Psychology, University of Amsterdam, Amsterdam, the Netherlands

3. Roland Sinnaeve

   KU Leuven

   Affiliation as printed

   Department of Neurosciences, Mind Body Research, Katholieke Universiteit Leuven, Leuven, Belgium

4. Raoul P. P. P. Grasman

   University of Amsterdam

   Affiliation as printed

   Department of Psychological Methods, University of Amsterdam, Amsterdam, the Netherlands

5. Jet Alberts
   Affiliation as printed

   Nederlands Psychoanalytisch Instituut Amsterdam, Amsterdam, the Netherlands

6. Marieke Alkema Aachen Now with GGZ Rivierduinen

   Antes · GGZ Rivierduinen

   Affiliation as printed

   Department of Addiction and Personality, Antes Mental Health Care, Rotterdam, the Netherlands

   Now with GGZ Rivierduinen, Zoetermeer, the Netherlands

7. Eliane C.P. Dek

   PsyQ

   Affiliation as printed

   PsyQ Personality Disorders Rotterdam-Kralingen, Rotterdam, the Netherlands

8. Monique Hupkes

   GGZ Noord-Holland-Noord

   Affiliation as printed

   GGZ Noord-Holland-Noord, Heerhugowaard, the Netherlands

9. Chrissy James

   GGZ inGeest

   Affiliation as printed

   GGZ inGeest, Amsterdam, the Netherlands

10. Annemieke M. Koppeschaar

    PsyQ

    Affiliation as printed

    Now with PsyQ Online, Den Haag, the Netherlands

    PsyQ Amsterdam, Amsterdam, the Netherlands

11. Maria Ploegmakers

    Pro Persona

    Affiliation as printed

    Pro Persona, Tiel, the Netherlands

12. Rachel J. Schuur Aachen GGZ Rivierduinen

    GGZ Rivierduinen

    Affiliation as printed

    GGZ Rivierduinen, Leiden, the Netherlands

13. Marieke van Vliet

    Pro Persona

    Affiliation as printed

    Pro Persona, Ede, the Netherlands

14. Arnoud R. Arntz

    University of Amsterdam

    Affiliation as printed

    Academic Center for Trauma and Personality, Amsterdam, the Netherlands

    Department of Clinical Psychology, University of Amsterdam, Amsterdam, the Netherlands