A mechanism-based group-psychotherapy approach to aggressive behavior (MAAP) in borderline personality disorder (BPD): a multicenter randomized controlled clinical trial

• Applicant: Professorin Dr. Sabine C. Herpertz
• Subject Area: Clinical Psychiatry, Psychotherapy, Child and Adolescent Psychiatry
• Term: since 2023
• Project identifier: Deutsche Forschungsgemeinschaft (DFG) - Project number 462340798

Borderline personality disorder (BPD) is a common and severe mental disorder with prevalence rates of about 1.7 % in the general population and up to 28% in psychiatric inpatients. Up to 80% of individuals with BPD have engaged in aggressive behaviors over the course of a year and more than 50% are occasionally or often involved in physical fights. Despite the high burden for people affected as well as their social surroundings, no specific cost-effective treatment options addressing aggressive behavior exist, up to now. To fill this research and treatment gap, we developed a short-term manualized Mechanism-based Anti-Aggression Psychotherapy (MAAP) for the group setting which specifically targets externally directed aggression in BPD using validated techniques from Dialectic-Behavior Therapy (DBT) and Mentalization-Based Therapy (MBT). Data from a DFG-funded pilot proof-of-concept study suggest that MAAP might be a promising therapy option for female and male patients with aggressive problems. Consequently, this study aims to investigate the efficacy of this novel 8-week group psychotherapy for “typical” BPD patients (with regard to generalizability of findings) showing aggressive behavior against others in a larger-scale multicenter (seven centers), cluster-randomized, observer blinded confirmatory trial against an active control group treatment of the same dosage, Non-Specific Supportive Psychotherapy (NSSP). All participating centers have high expertise in treating patients with BPD and safety will be given highest priority whether patients will participate in the experimental or control group. Following the hypothesis of a superiority of MAAP against NSSPD we plan to include N=186 patients with BPD and aggressive behaviors and have selected an interview-based measure (Overt Aggression Scale, OAS-M) to assess frequency and severity of overt aggressive behavior as primary outcome at 6-months follow-up and thereby have followed the reviewers´ suggestions. Secondary outcomes subsume ecological momentary assessment (EMA) as well as measurements related to quality of life and assumed mechanisms of change. We closely follow the design of the pilot study although we have changed some elements of the therapy program according to patients´ feedback in the pilot study and having received support from patients’ representatives. Superiority of the primary outcome measure in the MAAP arm over the NSSP arm will be tested by a linear mixed model of overt aggression score at follow-up as the dependent variable, pre-treatment overt aggression score as a covariate, center and treatment arm as fixed effects and therapy group as random effect, including different sensitivity analyses. In case of superiority the MAAP program can be implemented in mental health care services.

• DFG Programme: Clinical Trials
• Co-Investigators: Professorin Katja Bertsch, Ph.D.; Professorin Dr. Alexandra Philipsen