Journal of Personality Disorders, 22(3), 284–290, 2008

 2008 The Guilford Press

A PRELIMINARY, RANDOMIZED TRIAL

OF PSYCHOEDUCATION FOR WOMEN
WITH BORDERLINE PERSONALITY DISORDER
Mary C. Zanarini, EdD, and Frances R. Frankenburg, MD

The main objective of this study was to determine whether being taught
the latest information concerning borderline personality disorder (BPD)
leads to a decline in core BPD symptoms and an improvement in psy-
chosocial functioning. Fifty-five late adolescent women participated in
a rigorous diagnostic assessment and 50 met DIB-R and DSM-IV crite-
ria for BPD. All 50 were informed that they met criteria for BPD. Then
30 were randomized to a psychoeducation workshop that took place
within a week of diagnostic disclosure. The other 20 were assigned to a
waitlist and participated in the workshop at the end of this 12-week
study. The two primary outcome measures were readministered each
week of the trial: the Zanarini Rating Scale for DSM-IV Borderline Per-
sonality Disorder (ZAN-BPD) and the Sheehan Disability Scale (SDS).
Immediate psychoeducation concerning the BPD diagnosis was associ-
ated with a significantly greater decline in general impulsivity and the
storminess of close relationships. However, it did not result in signifi-
cantly improved psychosocial functioning. Taken together, the results
of this study suggest that informing patients about BPD soon after diag-
nostic disclosure may help to alleviate the severity of two of the core
elements of borderline psychopathology—general impulsivity and un-
stable relationships. They also suggest that such instruction may prove
to be a useful and cost-efficient form of pre-treatment.

Clinical experience suggests that many patients with borderline personal-

ity disorder (BPD) who are informed of their borderline diagnosis are not
given up-to-date information on BPD. The main reason for this seems to
be the time pressures facing clinicians. However because of this, patients
are deprived of the information they need to be informed consumers of
mental health services and to plan for their future in a reasonable manner.

From the Laboratory for the Study of Adult Development, McLean Hospital, and the Depart-
ment of Psychiatry, Harvard Medical School.
Presented at the 157th Annual Meeting of the American Psychiatric Association, New York,
New York, May 1–6, 2004.
Supported by a grant from Eli Lilly.
Address correspondence to Dr. Zanarini, McLean Hospital, 115 Mill Street, Belmont, Massa-
chusetts 02478; E-mail: zanarini@mclean.harvard.edu

284
PSYCHOEDUCATION FOR WOMEN WITH BPD 285

The current study addresses two main research questions. First, does
teaching newly diagnosed borderline patients about BPD have a beneficial
symptomatic effect (i.e., will key symptoms decline more for those taught
the latest information on BPD shortly after learning of their borderline di-
agnosis than for those who do not receive this instruction for several
months)? Second, does such instruction have a beneficial psychosocial ef-
fect (i.e., will social and vocational functioning improve more for those in
the immediate vs. those in the delayed instruction group)?

METHODS
Recruitment of women between the ages of 18 and 30 was accomplished
through advertising in the Boston area (i.e., using posters or internet list-
ings). These ads asked: Are you extremely moody? Are you often distrust-
ful of others? Do you frequently feel out of control? Are your relationships
very painful and difficult?
Subjects were initially screened by telephone to assess whether they met
the DSM-IV criteria for BPD using the borderline module of the Diagnostic
Interview for DSM-IV Personality Disorders (DIPD-IV; Zanarini, Franken-
burg, Chauncey, & Gunderson, 1987). A general psychiatric history was
also taken at the time of first telephone contact. Potential subjects were
excluded if they were currently in any type of psychiatric treatment.
Subjects were next invited to participate in face-to-face interviews. At
that time, the study procedures were fully explained and written informed
consent was obtained. Two semistructured diagnostic interviews were
then administered to each subject: (1) the Structured Clinical Interview for
DSM-IV Axis I Disorders (SCID I; Spitzer, Williams, Gibbon, & First, 1992)
and (2) the Revised Diagnostic Interview for Borderlines (DIB-R; Zanarini,
Gunderson, Frankenburg, & Chauncey, 1989). One observer-rated scale
and one self-report measure were also administered: the Zanarini Rating
Scale for DSM-IV Borderline Personality Disorder (ZAN-BPD; Zanarini et
al., 2003) and the Sheehan Disability Scale (SDS; Sheehan, Harnett-Shee-
han, & Rai, 1996). In addition, a 10-question paper-and-pencil test of
knowledge on various aspects of BPD was administered.
Subjects were included if they met both DIB-R and DSM-IV criteria for
BPD. They were excluded if they met current or lifetime criteria for schizo-
phrenia, schizoaffective disorder, or bipolar I disorder. They were also ex-
cluded if they met current criteria for substance dependence (except for
nicotine dependence).
All diagnostic information was carefully reviewed by one of us (MCZ),
who met with each subject and informed her of whether she met criteria
for BPD. Basic questions about the study were also answered.
All subjects then participated in a psychoeducation workshop detailing
the latest information on the following aspects of BPD: etiology, phenome-
nology, co-occurring disorders, treatment options, and longitudinal course.
This workshop was led jointly by two research assistants, who used a 63-
286 ZANARINI AND FRANKENBURG

slide PowerPoint presentation designed specifically for this study. Using a

3:2 ratio, subjects were either randomized to a workshop that took place
within a week of diagnostic disclosure or a waitlist. This latter group of
subjects took part in the workshop at the end of this twelve-week study.
Subjects were seen every week. Both the ZAN-BPD and the SDS were read-
ministered at each subsequent visit. Finally, the 10-question paper-and-
pencil test of knowledge on various aspects of BPD was readministered at
the end of the psychoeducation workshop.

DATA ANALYSIS

Between-group baseline demographic variables and clinical history vari-

ables were analyzed using chi-square analyses for categorical variables
and student’s t-test for continuous variables. Random effects regression
modeling methods were used to assess between-group differences on both
outcome measures using all available panel data (Greene, 2000). Baseline
value, treatment status, and time were the independent variables in these
modeling analyses of the study’s two primary outcome measures.

RESULTS
Fifty subjects were found to meet study criteria for BPD and five who were
interviewed did not. These 50 subjects were either randomized to immedi-
ate (N = 30) or delayed (N = 20) psychoeducation. No significant differences
were found at baseline on demographic characteristics, treatment histo-
ries, and lifetime co-occurring axis I disorders. The mean age of the 50
women in this study was 19.3 years (SD 1.4), 33 (86%) were white, and on
average, they were functioning in the lower half of the fair range of the
GAF (53.3; SD 1.9). In terms of prior psychiatric treatment, 25 (50%) had
been in psychotherapy, 10 (20%) had taken psychotropic medications, and
5 (10%) had been hospitalized for psychiatric reasons. In terms of lifetime
axis I disorders, 39 (78%) met criteria for a mood disorder (mostly major
depression), 20 (40%) met criteria for a substance use disorder, 14 (28%)
met criteria for an anxiety disorder, and 25 (50%) for an eating disorder.
All 50 subjects continued in the study for all 12 visits. Figure 1 shows
the mean total ZAN-BPD scores for the entire group of 50 subjects (as
there was no significant between-group difference in severity of borderline
symptoms over time (z-score and p-value for group membership: −0.414
and 0.679). However, the mean scores for the group taken as a whole de-
clined significantly over time, from a baseline high in the moderate range
(score of 10–18) to an endpoint score in the mild range (score of 1–9) of
the ZAN-BPD (z-score for time: −4.868; p-value for time: <0.001).
Figure 2 shows the mean SDS impairment ratings for vocational and
social functioning for the group taken as a whole (as there was no signifi-
cant between-group difference in vocational [z-score for group = 0.288, p-
value for group = 0.773] or social [z-score for group = −1.034, p-value for
PSYCHOEDUCATION FOR WOMEN WITH BPD 287

FIGURE 1. ZAN-BPD Scores Over Time for All Borderline Subjects

group = 0.301] functioning over time.) However, there was a trend for voca-
tional (z-score for time = −1.701, p-value for time = 0.089) but not social
(z-score for time = −1.207, p-value for time = 0.227) functioning to improve
over time for the group taken as a whole. As can be seen, borderline sub-
jects rated their impairment as marked (score >4) in both realms of func-
tioning at baseline. By the end of the study, however, their mean ratings
were in the moderate range (score of 4 or less).
In terms of knowledge about BPD, only three subjects (6%) correctly an-
swered six or more questions prior to participating in the psychoeducation
workshop. In contrast, 39 (78%) were able to answer 6 or more questions
correctly after their psychoeducation experience. The mean pre-workshop
score was 2.8 (SD = 1.8) and the post-workshop mean score was 7.0 (SD =
1.5).
Table 1 summarizes the immediate vs. waitlist groups mean difference
scores over the course of the study for the two BPD criteria assessed by
the ZAN-BPD that showed a significant between-group difference. (Data

FIGURE 2. Vocational and Social Impairment as Measured by the Sheehan Disability Scale
288 ZANARINI AND FRANKENBURG

TABLE 1. Random Effects Regression Modeling of Mean Difference Scores on ZAN-BPD

for Immediate and Waitlist Psychoeducation Groups of Women with Borderline
Baseline
Values Week 2 Week 3 Week 4 Week 5 Week 6 Week 7
Immediate Group (N = 30) (N = 30) (N = 30) (N = 30) (N = 30) (N = 30) (N = 30)
Two Forms of Impulsivity Mean 1.40 −0.27 −0.30 −0.30 −0.23 0.00 −0.10
Two Forms of Impulsivity SD 0.86 1.01 0.79 0.84 0.82 1.17 1.27
Stormy Relationships Mean 2.10 −0.67 −0.50 −0.70 −0.97 −0.63 −0.80
Stormy Relationships SD 0.84 0.96 0.97 1.06 0.76 1.00 0.92
Waitlist Group (N = 20) (N = 20) (N = 20) (N = 20) (N = 20) (N = 20) (N = 20)
Two Forms of Impulsivity Mean 1.40 −0.20 −0.10 0.15 0.40 0.25 0.35
Two Forms of Impulsivity SD 0.75 1.11 1.02 1.09 1.19 0.97 0.88
Stormy Relationships Mean 1.55 0.00 0.20 −0.05 0.00 0.05 −0.30
Stormy Relationships SD 1.05 1.03 1.32 1.19 1.30 1.28 1.75

on the other seven BPD criteria are available from the authors upon re-
quest.) As can be seen, declines in interpersonal storminess and general
impulsivity (not counting self-mutilation or suicide efforts) were found to
be significantly greater among those in the immediate treatment group
than the waitlist group. Interactions between treatment and time were
checked and found to be nonsignificant.

DISCUSSION
Two main findings have emerged from this study. The first is that learning
about BPD soon after being told one meets criteria for the disorder can
lead to a significantly greater reduction over the short-term in general im-
pulsivity and the storminess of relationships than receiving the same in-
struction three months later. This makes clinical sense as patients who
are knowledgeable about the borderline diagnosis may be better able to
control some of their more disruptive symptoms than patients who do not
yet possess this knowledge. It also makes sense that it was these two
symptoms that showed a between-group difference as it seems likely that
increased knowledge might be more useful in helping people control be-
havior than affects or cognitions.
Four forms of long-term psychosocial treatment for BPD have been
found to be efficacious for some of the symptoms of BPD, particularly
forms of impulsivity (Bateman & Fonagy, 1999; Clarkin, Levy, Lenzen-
weger, & Kernberg, 2007; Giesen-Bloo et al., 2006; Linehan, Armstrong,
Suarez, Almon, & Heard, 1991). However, most borderline patients are not
receiving such intensive or specialized treatments due to their cost and
complexity. In fact, many patients have to wait for extended periods of time
to receive any type of psychosocial treatment. Given this, psychoeduca-
tional programs such as the one described here may prove to be a useful
and cost efficient form of pre-treatment. Looked at another way, receiving
such instruction may both give patients the knowledge they need to plan
their futures and help them to control some of the more behavioral symp-
toms of BPD.
The second main finding is that this type of immediate instruction is not
PSYCHOEDUCATION FOR WOMEN WITH BPD 289

Random Effects
Week 8 Week 9 Week 10 Week 11 Week 12 Regression Modeling Z-score P-level
(N = 30) (N = 30) (N = 30) (N = 30) (N = 30) Two Forms of Impulsivitya
−0.20 −0.43 −0.53 −0.30 −0.43 Individual Baseline Score −6.846 <0.001
1.00 1.04 1.11 1.06 0.94 Treatment Group −2.251 0.024
−0.93 −0.90 −0.73 −0.77 −0.93 Time −1.250 0.211
0.83 1.24 1.01 0.90 0.94 Stormy Relationshipsb
(N = 20) (N = 20) (N = 20) (N = 20) (N = 20) Individual Baseline Score −8.364 <0.001
0.10 0.15 0.00 −0.20 0.05 Treatment Group −2.124 0.034
1.29 1.39 1.30 1.24 1.10 Time −2.203 0.028
−0.15 0.05 −0.25 −0.20 −0.05a Model χ2 = 53.50, p < 0.0001
1.18 1.61 1.21 1.36 1.43b Model χ2 = 96.75, p < 0.0001

as useful in helping patients to improve their psychosocial functioning.

While neither vocational nor social functioning improved significantly over
time, there was a trend for vocational functioning to become more adaptive
over the course of the study for those in both study groups. This lack of
an advantage for those who immediately received information about BPD
is not surprising because recent research has found that borderline pa-
tients are more likely to experience symptomatic improvement than im-
provement in the social and vocational realms over time (Skodol et al.,
2005).
The main limitation of this study is that the results are only generaliz-
able to young women with moderately severe BPD. Whether older women,
male patients, or those with severe BPD would respond in a similar man-
ner is open to question. Another limitation is that none of the subjects
were currently in treatment. This status approximates the status of many
patients being assessed for outpatient treatment or waiting for outpatient
treatment to begin. However, the results of this study may not generalize
to patients who are currently in treatment, particularly long-term treat-
ment. A third limitation is that we did not follow these patients for an
extended period of time and thus, do not know if these gains were sus-
tained, for example, at six months or a year.
Taken together, the results of this study suggest that informing newly
diagnosed patients of the latest information about BPD may provide the
added benefit of decreased symptom expression in two of the core ele-
ments of borderline psychopathology—general impulsivity and unstable
relationships. Because of this symptomatic decline, such instruction may
prove to be a useful and cost-efficient form of pre-treatment.

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