Although there is general consensus that only prolonged and intensive psychotherapy can provide real recovery from Borderline Personality Disorder (BPD), almost nothing is known about the relative effectiveness of different approaches. The present study compared the (cost-)effectiveness of two psychotherapies for BPD aiming at a fundamental change: a modern psychodynamic approach (Transference-Focused Psychotherapy, TFP) and schema-focused cognitive therapy (SFT).

In a multicenter trial 86 patients were randomised to either TFP or SFT and treated for max. 3 years. In Maastricht, patients also participated in fundamental studies on emotion regulation (attentional bias, fMRI, peripheral nervous system responses).

TFP had more (early) drop-outs than SFT. SFT was about twice as effective as TFP in terms of recovery from BPD. This effect could not be explained by differences in drop-outs. SFT was superior to TFP on all other measures. On cost-effectiveness ratios, SFT was superior with respect to recovery, and equivalent when quality-of-life was considered. Functional MRI and other indices indicated that recovery from BPD was associated with normalizing of emotion regulation.

The results indicate that it is possible to successfully and cost-effectively treat these difficult patients by prolonged psychotherapeutic treatment. Assessment of attentional bias and amygdala/hipocampal responses to threat cues indicates that ‘symptomatic’ cure is accompanied by normalizing of these processes, suggesting a deep and fundamental change. Moreover, results of a 1-year follow-up indicate that recovery continues.