Cognitive Behavioral Therapy-Based Interventions for Borderline Personality Disorder and Mood Disorders

  • Karen L. Jacob
  • Ana M. Rodriguez-Villa


Cognitive Behavioral Therapy (CBT) is a well-established treatment approach for treating patients suffering from a range of emotional problems including a number of mood and anxiety disorders. The basic treatment approach highlights the importance of increasing patients’ structured self-awareness in order to help them identify maladaptive cognitive processes and behavioral patterns that influence emotional distress. CBT promotes patients use of skills-based interventions that challenge thoughts and support intentional shifts in behavior in order to decrease distress. Given CBT’s effectiveness in treating a range of emotional disorders, it has been applied to the treatment of more complicated clinical profiles, such as patients suffering from characterological disorders like borderline personality disorder (BPD). Both Schema-Focused Therapy (SFT) as well as Dialectical Behavioral Therapy (DBT) are evidence-based intensive psychotherapeutic treatments derived from CBT but adapted to treat patients with BPD. Less intensive applications of CBT for BPD have proven to be effective and are more practical in generalist clinical settings. We will outline the limitations associated with more specialized forms of treatment and further propose a return to the basics of CBT using the Flexible CBT model in order to treat patients with complicated clinical profiles seeking treatment in a typical clinical setting.


Bipolar Disorder Cognitive Behavioral Therapy Borderline Personality Disorder Dialetical Behavioral Therapy Borderline Personality Disorder 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Zimmerman M, Coryell W. The reliability of personality disorder diagnoses in a nonpatient sample. J Pers Disord. 1989;3:53–7.CrossRefGoogle Scholar
  2. 2.
    Swartz M, Blazer D, George L, Winfield I. Estimating the prevalence of borderline personality disorder in the community. J Pers Disord. 1990;4(3):257–72.CrossRefGoogle Scholar
  3. 3.
    Torgersen S, Kringlen S, Cramer V. The prevalence of personality disorder in a community sample. Arch Gen Psychiatry. 2001;58:590–6.PubMedCrossRefGoogle Scholar
  4. 4.
    Kass F, Skodol A, Charles E, Spitzer R, Williams J. Scaled ratings of DSM-III personality disorders. Am J Psychiatry. 1985;142:627–30.PubMedGoogle Scholar
  5. 5.
    Gunderson JG. Borderline personality disorder: a clinical guide. Washington, DC: American Psychiatric Publishing; 2001.Google Scholar
  6. 6.
    Zanarini MC, Frankenburg FR, Reich DB, Fitzmaurice G. Attainment and stability of sustained symptomatic remission and recovery among patients with borderline personality disorder and axis II comparison subjects: a 16-year prospective follow-up study. Am J Psychiatry. 2012;169:476–83.PubMedCrossRefPubMedCentralGoogle Scholar
  7. 7.
    Gunderson JG, Stout RL, McGlashan TH, Shea MT, Morey LC, Grilo CM, et al. Ten-year course of borderline personality disorder: psychopathology and function from the Collaborative Longitudinal Personality Disorders Study. Arch Gen Psychiatry. 2011;68:827–37.PubMedCrossRefPubMedCentralGoogle Scholar
  8. 8.
    Linehan MM. Cognitive behavioral treatment of borderline personality disorder. New York: Guilford; 1993.Google Scholar
  9. 9.
    Linehan MM. Skills training manual for treating borderline personality disorder. New York: Guildford; 1993.Google Scholar
  10. 10.
    Koons CR, Robins CJ, Bishop GK, et al. Efficacy of dialectical behavioral therapy in women veterans with borderline personality disorder: a randomized controlled trial. Behav Ther. 2001;32:371–90.CrossRefGoogle Scholar
  11. 11.
    Verheul R, Van Den Bosch LM, Koeter MW, et al. Dialectical behavior therapy for women with borderline personality disorder: 12-month, randomized clinical trial in the Netherlands. Br J Psychiatry. 2003;182:135–40.PubMedCrossRefGoogle Scholar
  12. 12.
    Bohus M, Haaf B, Simms T, Limberger MF, Schmahl C, Unckel C, et al. Effectiveness of inpatient dialectical behavioral therapy for borderline personality disorder: a controlled trial. Behav Res Ther. 2004;42:487–99.PubMedCrossRefGoogle Scholar
  13. 13.
    Giesen-Bloo J, van Dyck R, Spinhoven P, van Tilburg W, Dirksen C, van Asselt T, et al. Outpatient psychotherapy for borderline personality disorder: randomized trial of schema-focused therapy vs transference-focused psychotherapy. Arch Gen Psychiatry. 2006;63(6):649–58.PubMedCrossRefGoogle Scholar
  14. 14.
    Young JE, Klosko JS, Weishaar ME. Schema therapy: a practitioner’s guide. New York: The Guilford Press; 2003.Google Scholar
  15. 15.
    Clarkin JF, Levy KN, Lenzenweger MF, Kernberg OF. Evaluating three treatments for borderline personality disorder: a multiwave study. Am J Psychiatry. 2007;164(6):922–8.PubMedCrossRefGoogle Scholar
  16. 16.
    Clarkin JF, Yeomans F, Kerberg OF. Psychotherapy of borderline personality: focusing on object relations. Washington, DC: American Psychiatric Publishing, Inc; 2006.Google Scholar
  17. 17.
    Bateman A, Fonagy P. Effectiveness of partial hospitalization in the treatment of borderline personality disorder: a randomized controlled trial. Am J Psychiatry. 1999;156:1563–9.PubMedGoogle Scholar
  18. 18.
    Bateman A, Fonagy P. Treatment of borderline personality disorder with psychoanalytically oriented partial hospitalization: an eighteen month follow-up. Am J Psychiatry. 2001;158:36–42.PubMedCrossRefGoogle Scholar
  19. 19.
    Chambless DL, Ollendick TH. Empirically supported psychological interventions: controversies and evidence. Annu Rev Psychol. 2001;52:685–716.PubMedCrossRefGoogle Scholar
  20. 20.
    Linehan MM, Comtois KA, Murray AM, Brown MZ, Gallop RJ, Heard HL, et al. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry. 2006;63(7):757–66.PubMedCrossRefGoogle Scholar
  21. 21.
    Harned MS, Chapman AL, Dexter-Mazza ET, Murray A, Comtois KA, Linehan MM. Treating co-occurring Axis I disorders in recurrently suicidal women with borderline personality disorder: a 2-year randomized trial of dialectical behavior therapy versus community treatment by experts. J Counsult Clin Psychol. 2008;76(6):1068–75.CrossRefGoogle Scholar
  22. 22.
    McMain SF, Guimond T, Streiner DL, Cardish RJ, Links PS. Dialectical behavior therapy compared with general psychiatric management for borderline personality disorder: clinical outcomes and functioning over a 2-year follow-up. Am J Psychiatry. 2012;169(6):650–61.PubMedCrossRefGoogle Scholar
  23. 23.
    Beck JS. Cognitive behavioral therapy: basics and beyond. 2nd ed. New York: Guilford Press; 2011.Google Scholar
  24. 24.
    Davidson K, Norrie J, Tyrer P, Gumley A, Tata P, Murray H, et al. The effectiveness of cognitive behavior therapy for borderline personality disorder: results from the borderline personality disorder study of cognitive therapy (BOSCOT) trial. J Pers Disord. 2006;20(5):450–65.PubMedCrossRefPubMedCentralGoogle Scholar
  25. 25.
    Davidson KM, Tran CF. Impact of treatment intensity on suicidal behavior and depression in borderline personality disorder: a critical review. J Pers Disord. 2014;28(2):181–97.PubMedCrossRefGoogle Scholar
  26. 26.
    Neuhaus EC. Fixed values and a flexible partial hospital program model. Harv Rev Psychiatry. 2006;14:1–14.PubMedCrossRefGoogle Scholar
  27. 27.
    Ellis A. Rational psychotherapy. J Gen Psychol. 1958;59:35–49. Reprinted: New York: Institute for Rational-Emotive Therapy.PubMedCrossRefGoogle Scholar
  28. 28.
    Beck AT. Cognitive therapy and the emotional disorders. New York: International Universities Press; 1976.Google Scholar
  29. 29.
    Beck AT, Rush AJ, Shaw BF, Emery G. Cognitive therapy for depression. New York: Guilford Press; 1979.Google Scholar
  30. 30.
    Beck AT, Steer RA, Brown GK. Manual for the beck depression inventory-II. San Antonio: Psychological Corporation; 1996.Google Scholar
  31. 31.
    Segal ZV. Appraisal of the self-schema construct in cognitive models of depression. Psychol Bull. 1988;103:147–62.PubMedCrossRefGoogle Scholar
  32. 32.
    McGinn LK, Young JE. Schema-focused therapy. In: Salkovskis PM, editor. Frontiers of cognitive therapy. New York: Guilford Press; 1996. p. 182–207.Google Scholar
  33. 33.
    Young J, Klosko J. Schema therapy. In: Oldham JM, Skodol AE, Bender DS, editors. The American Psychiatric Publishing textbook of personality disorders. 1st ed. Arlington: American Psychiatric Publishing; 2005. p. 289–306.Google Scholar
  34. 34.
    Spinhoven P, Bockting CL, Kremers IP, Schene AH, Mark J, Williams G. The endorsement of dysfunctional attitudes is associated with an impaired retrieval of specific autobiographical memories to matching cues. Memory. 2007;15:324–38.PubMedCrossRefPubMedCentralGoogle Scholar
  35. 35.
    Kabat-Zinn J. Wherever you go, there you are: mindfulness meditation in everyday life. New York: Hyperion; 1994.Google Scholar
  36. 36.
    Lynch TR, Chapman AL, Rosenthal MZ, Kuo JR, Linehan MM. Mechanisms of change in dialectical behavior therapy: theoretical and empirical observations. J Clin Psychiatry. 2006;62:459–80.Google Scholar
  37. 37.
    Van Dijk S, Jeffrey J, Katz MR. A randomized, controlled, pilot study of dialectical behavior therapy skills in a psychoeducational group for individuals with bipolar disorder. J Affect Disord. 2013;145(3):386–93.PubMedCrossRefGoogle Scholar
  38. 38.
    Deckersbach T, Hölzel BK, Eisner LR, Stange JP, Peckham AD, Dougherty DD, et al. Mindfulness-based cognitive therapy for nonremitted patients with bipolar disorder. CNS Neurosci Ther. 2012;18(2):133–41.PubMedCrossRefPubMedCentralGoogle Scholar
  39. 39.
    Vollestad J, Nielsen MB, Nielsen GH. Mindfulness- and acceptance-based interventions for anxiety disorders: a systematic review and meta-analysis. Br J Clin Psychol. 2012;51(3):239–60.PubMedCrossRefGoogle Scholar
  40. 40.
    Hofe EA, Bui E, Marques L, Morris LK, Robinaugh DJ, Worthington JJ, et al. Randomized controlled trial of mindfulness meditation for generalized anxiety disorder: effects of anxiety and stress reactivity. J Clin Psychiatry. 2013;74(8):786–92.CrossRefGoogle Scholar
  41. 41.
    Kristeller JL, Baer RA, Quillian-Wolever R. Mindfulness-based approaches to eating disorders. In: Baer RA, editor. Mindfulness-based treatment approaches: clinician’s guide to evidence base and applications. Amsterdam/Boston: Elsevier, Academic Press; 2006.Google Scholar
  42. 42.
    Wanden-Berghe RG, Sanz-Valero J, Wanden-Berghe C. The application of mindfulness to eating disorders treatment: a systematic review. Eat Disord. 2011;19(1):34–48.PubMedCrossRefGoogle Scholar
  43. 43.
    Chiesa A, Serretti A. Are Mindfulness-Based Interventions Effective for Substance Use Disorders? A Systematic Review of the Evidence. Subst Use Misuse. 2014;49(5):492–512.PubMedCrossRefGoogle Scholar
  44. 44.
    McMain SF, Links PS, Gnam WH, Guimond T, Cardish RJ, Korman L, et al. A randomized trial of dialectical behavior therapy versus general psychiatric management for borderline personality disorder. Am J Psychiatry. 2009;166(12):1365–74.PubMedCrossRefGoogle Scholar
  45. 45.
    Bateman A, Fonagy P. Randomized controlled trial of outpatient mentalization-based treatment versus structured clinical management for borderline personality disorder. Am J Psychiatry. 2009;166(12):1355–64.PubMedCrossRefGoogle Scholar
  46. 46.
    Chambless DL. Beware the dodo bird: the dangers of overgeneralization. Clin Psychol Sci Pract. 2002;9(1):13–6.CrossRefGoogle Scholar
  47. 47.
    Task Force on Promotion and Dissemination of Psychological Procedures. Division of Clinical Psychology, American Psychological Association. Training in and dissemination of empirically validated psychological treatments: reports and recommendations. Clin Psychol. 1995;48:3–23.Google Scholar
  48. 48.
    Chambless DL. Identification of empirically supported psychological interventions. Clin Res Dig Suppl Bull. 1996;14(6):1–2.Google Scholar
  49. 49.
    Weinberger J. Common factors aren’t so common: the common factor dilemma. Clin Psychol Sci Pract. 1995;2(1):45–69.CrossRefGoogle Scholar
  50. 50.
    Driessen ED, Hollon SD. Cognitive behavioral therapy for mood disorders: efficacy, moderators and mediators. Psychiatr Clin North Am. 2010;33(3):537–55.PubMedCrossRefPubMedCentralGoogle Scholar
  51. 51.
    Lam DH, Watkins ER, Hayward P, et al. A randomized controlled study of cognitive therapy for relapse prevention for bipolar affective disorder. Arch Gen Psychiatry. 2005;162(2):145–52.Google Scholar
  52. 52.
    Lam DH, Hayward P, Watkins ER, et al. Relapse prevention in patients with bipolar disorder: cognitive therapy outcome after 2 years. Am J Psychiatry. 2006;67(2):324–29.Google Scholar
  53. 53.
    Hollon SD, Thase ME, Markowitz JC. Treatment and prevention of depression. Psychol Sci Public Interest. 2002;3.Google Scholar
  54. 54.
    Markar HR, Mander AJ. Efficacy of lithium prophylaxis in clinical practice. Br J Psychiatry. 1989;155:496–500.PubMedCrossRefGoogle Scholar
  55. 55.
    Zaretsky AE, Sakina R, Sagar VP. How well do psychosocial interventions work in biopolar disorder? Can J Psychiatry. 2007;52:14–21.PubMedGoogle Scholar
  56. 56.
    McHugh RK, Whitton SW, Peckham AD, Welge JA, Otto MW. Patient preference for psychological vs pharmacologic treatment of psychiatric disorders: a meta-analytic review. J Clin Psychiatry. 2013;74(6):595–602.PubMedCrossRefPubMedCentralGoogle Scholar
  57. 57.
    Skodol AE, Stout RL, McGlashan TH, Grilo CM, Gunderson JG, Shea MT, et al. Co-occurrence of mood and personality disorders: a report from the collaborative longitudinal personality disorders study (CLPS). Depress Anxiety. 1999;10(4):175–82.PubMedCrossRefGoogle Scholar
  58. 58.
    Frank E, Kupfer DJ, Thase ME, Mallinger AG, Swartz HA, Fagiolini AM, et al. Two-year outcomes for interpersonal and social rhythm therapy in individuals with bipolar I disorder. Arch Gen Psychiatry. 2005;62(9):996–1004.PubMedCrossRefGoogle Scholar
  59. 59.
    Goodwin FK, Jamison K. Manic-depressive illness: bipolar disorders and recurrent depression. 2nd ed. New York: Oxford University Press; 2007.Google Scholar
  60. 60.
    Lauder SD, Berk M, Castle DJ, Dodd S, Berk L. The role of psychotherapy in bipolar disorder. Med J Aust. 2010;193(4):S31–5.PubMedGoogle Scholar
  61. 61.
    Hubble MA, Duncan BL, Miller SD. Introduction. In: Hubble MA, Duncan BL, Miller SD, editors. The heart and soul of change: what works in therapy. Washington, DC: American Psychological Association; 1999. p. 1–19.CrossRefGoogle Scholar
  62. 62.
    Persons JB. The case formulation approach to cognitive-behavioral therapy. New York: The Guilford Press; 2008.Google Scholar
  63. 63.
    Christopher MS, Jacob KL, Neuhaus EC, Neary TJ, Fiola LA. Cognitive and behavioral changes related to symptom improvement among patients with a mood disorder receiving intensive cognitive-behavioral therapy. J Psychiatr Pract. 2009;15(2):95–102.PubMedCrossRefGoogle Scholar
  64. 64.
    Neuhaus EC. The flexible CBT approach. (Online Textbook). Lincoln: TRi Behavioral, LLC; 2008. Scholar
  65. 65.
    Doss BD. Changing the way we study change in psychotherapy. Clin Psychol Sci Pract. 2004;11:368–86.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  1. 1.Department of PsychiatryMcLean Hospital, Gunderson ResidenceBelmontUSA
  2. 2.Department of PsychiatryMcLean HospitalBelmontUSA

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