Guided internet-based cognitive behavioral therapy for insomnia in patients with borderline personality disorder: Study protocol for a randomized controlled trial

Abstract

Borderline personality disorder (BPD) is a highly disabling psychiatric disorder with emotion dysregulation at its core, resulting in affective instability, impulsivity and sometimes self-harming or suicidal behavior. Sleep is increasingly recognized to play a crucial role in emotion regulation. BPD patients often suffer from (severe) insomnia, potentially aggravating symptoms and preventing recovery from BPD. Yet, the effects of insomnia treatments have not been investigated in context of BPD. Guided internet-based cognitive behavioral therapy for insomnia (iCBT-I; i-Sleep) has been proven effective in improving both insomnia and affective symptoms. In this randomized controlled trial among 96 patients with a DSM-5 diagnosis of BPD (or other personality disorder with ≥4 BPD traits) and insomnia symptoms, we will test the effectiveness of iCBT-I before regular BPD treatment starts, during the waitlist period, on BPD symptoms. Patients in the control group monitor their sleep through a sleep diary during the waitlist period and also receive standard BPD treatment after that. Using linear mixed models we will test the hypothesis that the iCBT-I group improves more than the control group on BPD symptoms (primary outcome), insomnia severity, additional subjective and objective sleep variables, emotion regulation, comorbid anxiety and depression complaints, and quality of life. These effects are thought to arise from a direct effect of improved sleep on emotion regulation and a synergistic effect on the consolidation and internalization of the BPD treatment effect. To our knowledge, this is the first trial assessing effectiveness of CBT-I in patients with BPD (traits). The accessibility of the studied intervention greatly facilitates clinical implication in case of positive results.

Keywords: Borderline personality disorder; Cognitive behavioral therapy for insomnia; Insomnia; Internet intervention; Randomized controlled trial; Sleep.

Fig. 1

Flowchart of study procedures. Note. BPD: borderline personality disorder; BPDSI: Borderline Personality Disorder Severity Index; iCBT-I: internet-based cognitive behavioral therapy for insomnia; SCID-5-P: Structured Clinical Interview for DSM-5 Personality Disorders; STEPPS: Systems Training for Emotional Predictability and Problem Solving.

Fig. 2

Schedule of enrolment, interventions, and assessments. Note. T1 and T2 are 2 months and 8 months after baseline respectively. Use of medication and treatment is additionally assessed between T1 and T2; at 4 months and 6 months.