Effect of simpler, adapted psychotherapy models compared with specialized models in the treatment of personality disorders: an umbrella review
Systematic review
|Published
On commission from the Norwegian Directorate of Health, we conducted an umbrella review (a review of systematic reviews) on the effect of simpler, adapted psychotherapy models compared with specialised ones in the treatment of personality disorders.
Key message
Personality disorders are primarily treated with psychotherapy (talk therapy). Various therapeutic models have been developed for this purpose, differing in specialisation, structure, and resource needs. They can be categorised into simpler, adapted psychotherapy models and more specialised psychotherapy models.
On commission from the Norwegian Directorate of Health, we conducted an umbrella review (a review of systematic reviews) on the effect of simpler, adapted psychotherapy models compared with specialised ones in the treatment of personality disorders.
We conducted systematic literature searches in six databases after systematic reviews published 2015 to 2025. Two project members independently assessed the titles and abstracts and subsequently selected full texts according to our predefined inclusion criteria. We evaluated the methodological quality of the most recent relevant reviews using the AMSTAR-2 checklist.
We included 71 systematic reviews, and based our results on the most relevant and recent one of high methodological quality according to AMSTAR-2:
- The results comprised only four primary studies.
- Outcomes included condition severity, symptom burden, self-harm, suicidal behaviour, personality functioning, quality of life and functioning level.
- The evidence base has methodological weaknesses, leading to low/very low confidence in the results.
The results show that we cannot draw clear conclusions as to whether simpler, adapted psychotherapy models as defined in in this umbrella review differ in effect from specialised psychotherapy models in the treatment of personality disorders.
Summary
Introduction
The Norwegian Directorate of Health is preparing national guidelines for the detection, assessment and treatment of personality disorders. For this work, it is important to understand the effect of simpler, adapted psychotherapy models compared with specialised psychotherapy models for the treatment of people with personality disorders. These psychotherapy models represent various approaches with varying degrees of specialisation, structure and resource requirements. Simpler, adapted psychotherapy models are, for example, Structured Clinical Management. Specialised psychotherapy models are, for example, Dialectical Behaviour Therapy, Schema-focused Therapy and Mentalisation-based therapy.
Objective
The purpose of this work was to contribute updated, high-quality research evidence to the evidence base that will inform the national guideline for the treatment of personality disorders. On commission by the Norwegian Directorate of Health, we conducted an umbrella review of systematic reviews published between 2015 and 2025 that investigated the effect of simpler, adapted psychotherapy models compared with specialised psychotherapy models for the treatment of people with personality disorders.
Method
We used established methods for umbrella reviews and followed our project plan, with a few changes, with pre-specified inclusion criteria. Relevant publications were systematic reviews published between 2015 and 2025 that evaluated the effects of simpler and adapted psychotherapy models compared with specialised psychotherapy models for the treatment of personality disorders. Relevant outcomes included severity of the condition, symptoms/symptom burden, self-harm, suicidal ideation and behaviour, personality functioning, and level of functioning.
We conducted systematic searches in August 2025 in MEDLINE (OVID), EMBASE (OVID) APA PsycINFO (OVID), Cochrane Library (Wiley), Epistemonikos, and Web of Science (Clarivate). Two of us independently screened the title and abstract, and then the full text of publications that were included at the title and abstract level. We also reviewed the reference lists of relevant umbrella reviews from the last five years identified in the search.
The included reviews were sorted by how many relevant studies they had included, then the three reviews with the highest number of relevant studies were assessed using the AMSTAR-2 checklist. One systematic review was assessed as having high methodological quality, one as moderate and one as critically low methodological quality. We report results from the systematic review with high methodological quality. That was also the one with the highest number of included studies.
For parts of the data extraction, we used AI-based tools. All extracted information was then manually checked by a project member. We extracted information as reported in the systematic reviews and have presented this descriptively in our report. Results were extracted from the most recent reviews of high methodological quality that covered our research question. We used the GRADE approach (confidence in the results) to assess our confidence in the effect estimates. We examined the overlap of relevant primary studies across all included reviews. Beyond this, we did not conduct any independent analyses.
Results
The search yielded 1575 unique references, of which we included 71 systematic reviews published from 2015 to 2025. None focused exclusively on comparing simpler, adapted psychotherapy models with specialised models for treating personality disorders. Nevertheless, 21 reviews contained at least one primary study that was relevant to our research question. Two of the three most recent systematic reviews, with search year 2022, were assessed to have high and moderate methodological quality and were used as a basis for evaluating the effect of the relevant interventions.
Summarised on Good Psychiatric Management (GPM) compared with Dialectical Behavior Therapy (DBT):
- GPM, compared with DBT, possibly results in a slightly greater symptom reduction for depression compared with DBT in people with BPD after 36 months.
- GPM possibly results in little or no difference compared with DBT in severity of BPD, interpersonal functioning, symptom distress, non-suicidal self-injuries or suicidal episodes.
- There is a lack of evidence on the effect of GPM compared with DBT on quality of life, as well as on the occurrence of adverse events, serious adverse events, and treatment dropout due to adverse events.
Summarised on STEPPS (Systems training for emotional predictability and problem solving) compared with Dialectical Behavior Therapy (DBT):
- It is uncertain if there is a difference in effect between STEPPS and DBT on the severity of BPD, symptoms of anxiety and depression, dissociation experiences, suicide risk or quality of life.
- There is a lack of evidence on the effect of STEPPS, compared with DBT, on self-injuries, adverse events, serious adverse events, or if participants withdrew due to adverse events.
Summarised on Structured Clinical Management (SCM) compared with Mentalization-Based Treatment (MBT):
- It is uncertain whether there is a difference in effect between SCM and MBT on overall symptom burden, symptoms of depression, severe self-harm, suicide attempts, personality functioning, a six-month period without suicide attempts, or severe self-harm or hospitalisations among people with BPD.
- There is a lack of evidence on the effect of SCM, compared with MBT, on severity of BPD, symptoms measured as anxiety, quality of life, adverse events, serious adverse events or if participants withdrew due to adverse events.
Discussion
The evidence base is too weak to draw conclusions about the effects of simpler, adapted psychotherapeutic models compared with specialised models for the treatment of personality disorders as included in our PICO. The available evidence consists of few and small primary studies, and there is substantial heterogeneity in the results.
Our main conclusion is therefore that there is a lack of robust evidence, largely due to the absence of larger, well-conducted randomized controlled trials. For each of the interventions assessed, additional high-quality studies are needed to draw conclusions with high or moderate confidence in the results.
The evidence base from high methodological quality systematic reviews was last updated in 2022, when the literature searches were conducted.
Conclusion
The evidence, based on a few small studies that have inherent methodological limitations, substantially reduces our confidence in the validity of the results. Consequently, the effects of simpler, adapted psychotherapy models compared with specialised models for the treatment of personality disorders, as they were specified in our inclusion criteria, remain uncertain.