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Psychological therapies for people with borderline disorder
Abstract
Background:
Borderline personality disorder (BPD) is a relatively common personality disorder with a major impact on health services as those affected often present in crisis, often self-harming.
Objectives:
To evaluate the effects of psychological interventions for people with borderline personality disorder.
Search strategy:
We conducted a systematic search of 26 specialist and general bibliographic databases (December 2002) and searched relevant reference lists for further trials.
Selection criteria:
All relevant clinical randomised controlled trials involving psychological treatments for people with BPD. The definition of psychological treatments included behavioural, cognitive-behavioural, psychodynamic and psychoanalytic.
Data collection and analysis:
We independently selected, quality assessed and data extracted studies. For binary outcomes we calculated a standard estimation of the risk ratio (RR), its 95% confidence interval (CI), and where possible the number need to help/harm (NNT/H). For continuous outcomes, endpoint data were preferred to change data. Non-skewed data from valid scales were summated using a weighted mean difference (WMD).
Main results:
We identified seven studies involving 262 people, and five separate comparisons. Comparing dialectical behaviour therapy (DBT) with treatment as usual studies found no difference for the outcome of still meeting SCID-II criteria for the diagnosis of BPD by six months (n=28, 1 RCT, RR 0.69 CI 0.35 to 1.38) or admission to hospital in previous three months (n=28, 1 RCT, RR 0.77 CI 0.28 to 2.14). Self harm or parasuicide may decrease at 6 to 12 months (n=63, 1 RCT, RR 0.81 CI 0.66 to 0.98, NNT 12 CI 7 to 108). One study detected statistical difference in favour of people receiving DBT compared with those allocated to treatment as usual for average scores of suicidal ideation at 6 months (n=20, MD -15.30 CI -25.46 to -5.14). There was no difference for the outcome of leaving the study early (n=155, 3 RCTs, RR 0.74 CI 0.52 to 1.04). For the outcome of interviewer-assessed alcohol free days, skewed data are reported and tend to favour DBT. When a substance abuse focused DBT was compared with comprehensive validation therapy plus 12-step substance misuse programme no clear differences were found for service outcomes (n=23, 1 RCT, RR imprisoned 1.09 CI 0.64 to 1.87) or leaving the study early (n=23, 1 RCT, RR 7.58 CI 0.44 to 132.08). When dialectical behaviour therapy-oriented treatment is compared with client centred therapy no differences were found for service outcomes (n=24, 1 RCT, RR admitted 0.33 CI 0.08 to 1.33). However, fewer people in the DBT group displayed indicators of parasuicidal behaviour (n=24, RR 0.13 CI 0.02 to 0.85, NNT 2 CI 2 to 11). There were no differences for outcomes of anxiety and depression (n=24, 1 RCT, RR anxiety BAI >/=10 0.60 CI 0.32 to 1.12; RR depression HDRS >/=10 0.43 CI 0.14 to 1.28) but people who received DBT had less general psychiatric severity than those in the control (MD BPRS at 6 months -7.41 CI -13.72 to -1.10). Finally this one relevant study reports skewed data for suicidal ideation with considerably lower scores for people allocated to DBT. When psychoanalytically oriented partial hospitalization was compared with general psychiatric care the former tended to come off best. People who received treatment in a psychoanalytic orientated day hospital were less likely to be admitted into inpatient care when measured at different time points (e.g. n=44, RR admitted to inpatient 24 hour care >18 to 24 months 0.05 CI 0.00 to 0.77, NNT 3 CI 3 to 10) Fewer people in psychoanalytically oriented partial hospitalization needed day hospital intervention in the 18 months after discharge (n=44, 1 RCT, RR 0.04 CI 0.00 to 0.59, NNT 2 CI 2 to 8). More people in the control group took psychotropic medication by the 30 to 36 month follow-up, than those receiving psychoanalytic treatment (n=44, 1 RCT, RR 0.44 CI 0.25 to 0.80, NNT 3 CI 2 to 7). Anxiety and depression scores were generally lower in the psychoanalytically oriented partial hospitalization group (n=44, 1 RCT, RR >/=14 on BDI 0.52 CI 0.34 to 0.80, NNT 3 CI 3 to 6), as are global severity scores. People receiving psychoanalytic care in a day hospital had better social improvement in social adjustment using the SAS-SR at 6 to 12 months compared with people in general psychiatric care (MD -0.70 CI -1.08 to -0.32). Rates of attrition were the same (n=44, 1 RCT, RR leaving the study early 1.00 CI 0.23 to 4.42).
Authors' conclusions:
This review suggests that some of the problems frequently encountered by people with borderline personality disorder may be amenable to talking/behavioural treatments but all therapies remain experimental and the studies are too few and small to inspire full confidence in their results. These findings require replication in larger 'real-world' studies.
... There have been some reviews assessing the contributions of psychological treatments for borderline personality disorder that included mentalization-based therapy (Binks et al., 2006;Cristea et al., 2017;Stoffers et al., 2012). These reviews reported positive outcomes for MBT on BPD symptomatology; however, the reviews only included one (Binks et al., 2006) or two randomized control trials (RCTs) (Cristea et al., 2017;Stoffers et al., 2012)all of which were conducted by the developers of the therapy themselves. ...
... There have been some reviews assessing the contributions of psychological treatments for borderline personality disorder that included mentalization-based therapy (Binks et al., 2006;Cristea et al., 2017;Stoffers et al., 2012). These reviews reported positive outcomes for MBT on BPD symptomatology; however, the reviews only included one (Binks et al., 2006) or two randomized control trials (RCTs) (Cristea et al., 2017;Stoffers et al., 2012)all of which were conducted by the developers of the therapy themselves. Across these RCTs, effect sizes for MBT were either moderate or large; however, it has been shown that these effect sizes may be overestimated; results are likely to be influenced by both risk of bias and publication bias (Cristea et al., 2017). ...
... Fonagy was also the second author on another study included in this review (Rossouw & Fonagy, 2012). The limitation of author involvement previously identified for the reviews conducted by Binks et al. (2006), Cristea et al. (2017) and Stoffers et al. (2012) therefore remains. There was also some discrepancy between the number of participants included in the RCTs conducted by Bateman & Fonagy in 1999and, at follow-up, in 2001 In the reviewed studies, the effectiveness of MBT was compared to treatment programmes, such as structured clinical management or psychodynamic treatment, and was found to achieve either superior or equal results. ...
Objective
This review sought to systematically review evidence on the efficacy of mentalization‐based therapy (MBT) for the treatment of borderline personality disorder (BPD), in particular, in decreasing psychiatric symptoms associated with BPD and its comorbid disorders.
Method
Fourteen papers were included in the review which examined the effectiveness of MBT in the context of BPD; these included 11 original studies and three follow‐up papers.
Results
Mentalization‐based therapy was found to achieve either superior or equal reductions in psychiatric symptoms when compared with other treatments (supportive group therapy, treatment as usual/standard psychiatric care, structured clinical management, and specialized clinical management).
Discussion
Mentalization‐based therapy can achieve significant reductions in BPD symptom severity and the severity of comorbid disorders as well as increase quality of life. However, caution is required, as the need for better quality research such as randomized controlled trials is pressing. Research is also needed on the proposed mediators of MBT.
Practitioner points
• Mentalization‐based therapy (MBT) is increasingly being considered as a treatment for people with borderline personality disorder (BPD), and a systematic review was required to investigate its effectiveness.
• MBT was found to be equally as effective or superior to well‐established comparison treatments of BPD, however, the majority of studies was of unsatisfying quality.
• Little is known about the mechanisms of MBT.
• Further, better quality trials are needed to investigate its efficacy in treating BPD.
... There have been some reviews assessing the contributions of psychological treatments for borderline personality disorder that included mentalization-based therapy (Binks et al., 2006;Cristea et al., 2017;Stoffers et al., 2012). These reviews reported positive outcomes for MBT on BPD symptomatology; however, the reviews only included one (Binks et al., 2006) or two randomized control trials (RCTs) (Cristea et al., 2017;Stoffers et al., 2012)all of which were conducted by the developers of the therapy themselves. ...
... There have been some reviews assessing the contributions of psychological treatments for borderline personality disorder that included mentalization-based therapy (Binks et al., 2006;Cristea et al., 2017;Stoffers et al., 2012). These reviews reported positive outcomes for MBT on BPD symptomatology; however, the reviews only included one (Binks et al., 2006) or two randomized control trials (RCTs) (Cristea et al., 2017;Stoffers et al., 2012)all of which were conducted by the developers of the therapy themselves. Across these RCTs, effect sizes for MBT were either moderate or large; however, it has been shown that these effect sizes may be overestimated; results are likely to be influenced by both risk of bias and publication bias (Cristea et al., 2017). ...
... Fonagy was also the second author on another study included in this review (Rossouw & Fonagy, 2012). The limitation of author involvement previously identified for the reviews conducted by Binks et al. (2006), Cristea et al. (2017) and Stoffers et al. (2012) therefore remains. There was also some discrepancy between the number of participants included in the RCTs conducted by Bateman & Fonagy in 1999and, at follow-up, in 2001 In the reviewed studies, the effectiveness of MBT was compared to treatment programmes, such as structured clinical management or psychodynamic treatment, and was found to achieve either superior or equal results. ...
Introduction
This review sought to systematically review evidence on the efficacy of mentalization-based-therapy (MBT) for the treatment of Borderline Personality Disorder (BPD), in particular, in decreasing psychiatric symptoms associated with BPD and its comorbid disorders.
Methods
Fourteen papers were included in the review which examined the effectiveness of MBT in the context of BPD; these included 11 original studies and three follow-up papers.
Results
MBT was found to achieve either superior or equal reductions in psychiatric symptoms when compared with other treatments (supportive group therapy, treatment as usual/standard psychiatric care, structured clinical management and specialised clinical management).
Conclusion
MBT can achieve significant reductions in BPD symptom severity and the severity of comorbid disorders as well as increase quality of life. However, the need for better quality research, including more randomised controlled trials (RCTs), is clear. Research is also needed on the proposed mediators of MBT.
... Indeed, treatment of BPD is associated with highly elevated rates of burnout amongst clinicians and few mental health professionals have the knowledge to effectively treat these problems (Linehan, Cochran, Mar, Levensky, & Comtois, 2000). Luckily, several promising treatments have emerged and have been shown effective in treating BPD (Binks et al., 2006;Giesen-Bloo et al., 2006). ...
... Among the existing evidence-based treatments for BPD, DBT has generated the most empirical support thus far (Binks et al., 2006). However, significant portions of DBT patient populations do not show clinically significant improvement after one year of treatment (Rizvi, In such cases, the emotionally vulnerable person may seek help through extreme communication. ...
Dialectical Behavioral Therapy (DBT) is an evidence-based, long-term psychotherapy initially developed to treat Borderline Personality Disorder (BPD) patients and/or highly suicidal individuals. DBT involves four components: tailored individual therapy, phone coaching from the individual therapist, structured group skills training, and therapist supervision by participation in a "consultation team." While manualized, DBT is a multifaceted and flexibly applied treatment that balances interventions both for acceptance and maintenance (e.g., validating the patient in the present), and for change and progression (e.g., encouraging the patient to try on new, more healthy attitudes, emotions, and behaviors). The Dialectical Behavioral Therapy Clinic at Rutgers University (DBT-RU) is a research and training clinic that adapts the DBT Manual to provide short-term (6-months long), comprehensive DBT for community adults presenting with BPD and associated problems. The present project reports an example of the DBT-RU model in action, including the decision-making processes involved, by presenting the case of "Jane," for whom I was the therapist. At the beginning of therapy Jane was a 32-year-old, heterosexual, Caucasian, single mother of a 7-year-old son; and she worked as a medical technician. Her presenting problems met the full DSM-5 criteria for BPD. Her symptoms, following DSM-5 numbering, included: 1) frantic efforts to avoid abandonment; (2) recurrent unstable and intense relationships; (3) identity disturbance (in self and religious beliefs); (4) impulsivity; (6) affective instability; (7) chronic feelings of emptiness; and (8) inappropriate, intense anger. In addition, she reported past suicidal ideation that was "very strong." In line with Jane’s intense and challenging presenting problems, the process of therapy was complex with many starts and stops. However, over the course of therapy she showed important, substantial improvement, as reflected by both quantitative measures and qualitative indicators. To aid the reader in following the complex organization of this case study, an outline of it is presented in Appendix 1.
... Because patients with BPD are often prone to experiencing intense, difficult-to-regulate negative emotions and tendencies toward impulsive behavior, rates of suicidal behavior among those with the disorder have been reported to be as high as 78% [2], rates of self-harm as high as 91% [3], and rates of substance abuse as high as 50% [1,4]. Although treatment of BPD with psychotherapy has been shown to be fairly effective at reducing severe symptoms [5,6], early intervention could significantly improve the quality of life of those who would otherwise go on to maintain this debilitating and often life-threatening disorder [7,8]. ...
... Noting the reliance on retrospective, selfreported data in prior BPD protective factors research, we assessed moderating factors prospectively utilizing both observer and parent reports. We also sought to contribute to the literature on early childhood factors in BPD development by assessing risk and moderating factors in the preschool period (ages [3][4][5]. ...
Background:
Despite a growing literature detailing early childhood risk factors for borderline personality disorder (BPD), few studies have examined moderating factors that might mitigate or exacerbate the effects of those risk factors. The current study examined whether three preschool-age characteristics-impulsivity, emotional lability, and initiative-taking-moderated the relationship between known preschool-age risk factors and adolescent BPD symptoms.
Methods:
We performed multilevel modeling analyses in a sample (n = 151) from the Preschool Depression Study, a prospective longitudinal study with assessments from preschool through adolescence. Preschool risk factors included adverse childhood experiences, internalizing symptoms, and externalizing symptoms measured with parent clinical interviews. Preschool moderating factors were assessed via parent report and observational coding of temperament and behavior. The Borderline Personality Features Scale for Children measured BPD symptoms in adolescence.
Results:
We found that observed initiative-taking moderated the relationship between preschool internalizing symptoms and adolescent BPD symptoms (b = 0.57, p = .011) and moderated the relationship between preschool externalizing symptoms and adolescent BPD symptoms (b = 1.42, p = .013). Greater initiative-taking was associated with lower BPD risk for children with high internalizing or externalizing symptoms. Conversely, for children with low internalizing or externalizing symptoms, greater initiative-taking was associated with increased BPD risk.
Conclusions:
We identify a potential moderating factor in BPD development, offer novel targets for screening and intervention, and provide a framework for using early childhood observational assessments in BPD research. Our findings suggest the need for future research on early moderating factors in BPD development, which could inform early childhood interventions targeting those factors to mitigate the effects of potentially less malleable risk factors.
... To date there have been five published meta-analyses examining the treatment outcome for individual psychotherapies for BPD; 20,78,100-102 one published meta-analysis examining dropout; 103 one published meta-analysis examining outcome for group treatment of BPD; 104 and several meta-analyses of medication use. 100,101,[105][106][107][108] The first meta-analysis 100 included seven studies of 262 patients. Six of the studies were of DBT and one was for MBT. ...
... Regarding medications, the evidence for their efficacy from RCTs and meta-analyses suggests that the widespread use of medications in the treatment of BPD is not supported by the evidence. 101,105-108 Binks, et al. 100 examined ten studies of 554 patients, finding few and small differences between medications and placebo. They concluded that pharmacological treatment of people with BPD was not based on good evidence. ...
Treatment approaches for borderline personality disorder (BPD) derive from a range of traditions and theoretical orientations, oftentimes considered to be competing or mutually exclusive. In this chapter we describe the major psychotherapy approaches for treating BPD and examine the evidence from both randomized controlled trials and meta-analyses. We summarize the evidence for the efficacy various treatments for BPD, outline similarities and differences among these treatments, and provide a big-picture perspective by integrating research findings and distilling principles. We encourage researchers and clinicians to begin examining treatments more broadly, including how elements of various approaches may be combined or sequenced to better help patients. In this vein, strategies for adapting and integrating various treatments are discussed.
... Although DBT has a documented effect in reducing DSH in patients with BPD, knowledge of the trajectories of self-harm, and exactly when in the course of treatment DSH may finally cease, is still sparse. After conducting a systematic research on evaluating the effects of different psychological intervention for people with borderline personality disorder, Binks et al. (2006) concluded that self-harm or parasuicide may decrease at 6-12 months. In an adolescent population comparing DBT with individual and group supportive therapy (IGST), McCauley et al. (2018) found that 46.6% did no longer present self-harm after 6 months (treatment ending) of DBT treatment (vs. ...
... A study from van Goethem et al. (2015) found that parasuicidal behavior showed a highly variable course although overall decreased during DBT. This is in line with a study by Binks et al. (2006) which reported that self-harm and parasuicide FIGURE 2 | Cumulative percentage of patients that terminated self-harm behavior in the treatment period. decreased between 6 and 12 months into treatment. ...
The first aim of the study was to identify when deliberate self-harm (DSH) behavior ceased in patients with borderline symptoms undergoing dialectical behavioral treatment (DBT). The second aim was to compare patients who ceased their self-harm behavior early or late in the course of treatment, with regard to demographics, comorbidity, and symptom severity. The study used a naturalistic design and included 75 treatment completers at an outpatient DBT clinic. Of these 75 patients, 46 presented with self-harming behavior at pre-treatment. These 46 participants where split into two groups, based on median amount of time before ceasing self-harm behavior, termed early (up to 8 weeks) and late (8+ weeks) responders. Treatment duration varied from 16 to 160 weeks. Patients were assessed pre-and post-treatment using measures of depression, hopelessness, personality traits, quality of life, and global assessment of symptoms and functioning. The majority (93.5%) ceased their self-harming within the first year, and the average number of weeks was 15.5 (SD = 17.8). Twenty-five percent of patients ceased their DSH behavior during the first week of treatment. For the remaining patients, the cessation of DSH continued gradually across a 1 year period. We found no differences between early and late responders with respect to demographics, comorbidity, symptom severity, or treatment outcome. None of the patients committed suicide. The findings indicate that self-harming behavior decreases gradually across the first year after starting DBT.
... However, a range of psychological therapies have been developed that improve patient outcomes. 3,4 Evidencebased psychological treatments for people with personality disorder are intensive and usually involve attending group-based therapy and individual sessions over a 1-to 2-year period. 3 Limited availability of these treatments mean that many patients do not have access to them, and those that do often face long waiting times before they can start treatment. ...
... 3,4 Evidencebased psychological treatments for people with personality disorder are intensive and usually involve attending group-based therapy and individual sessions over a 1-to 2-year period. 3 Limited availability of these treatments mean that many patients do not have access to them, and those that do often face long waiting times before they can start treatment. 5 Even when these treatments are available, some patients, such as those with coexisting substance dependence, are excluded from them. ...
Background
National guidance cautions against low-intensity interventions for people with personality disorder, but evidence from trials is lacking.
Aims
To test the feasibility of conducting a randomised trial of a low-intensity intervention for people with personality disorder.
Method
Single-blind, feasibility trial (trial registration: ISRCTN14994755). We recruited people aged 18 or over with a clinical diagnosis of personality disorder from mental health services, excluding those with a coexisting organic or psychotic mental disorder. We randomly allocated participants via a remote system on a 1:1 ratio to six to ten sessions of Structured Psychological Support (SPS) or to treatment as usual. We assessed social functioning, mental health, health-related quality of life, satisfaction with care and resource use and costs at baseline and 24 weeks after randomisation.
Results
A total of 63 participants were randomly assigned to either SPS ( n = 33) or treatment as usual ( n = 30). Twenty-nine (88%) of those in the active arm of the trial received one or more session (median 7). Among 46 (73%) who were followed up at 24 weeks, social dysfunction was lower (−6.3, 95% CI −12.0 to −0.6, P = 0.03) and satisfaction with care was higher (6.5, 95% CI 2.5 to 10.4; P = 0.002) in those allocated to SPS. Statistically significant differences were not found in other outcomes. The cost of the intervention was low and total costs over 24 weeks were similar in both groups.
Conclusions
SPS may provide an effective low-intensity intervention for people with personality disorder and should be tested in fully powered clinical trials.
... The increase in RCTs has yielded a number of more recent studies that have been summarised by Binks et al. (2006) in a Cochrane review of seven studies. An additional meta-analytical study by Brazier et al. (2006) included another study and a further two that were deemed unsuitable by Binks et al. (2006). ...
... The increase in RCTs has yielded a number of more recent studies that have been summarised by Binks et al. (2006) in a Cochrane review of seven studies. An additional meta-analytical study by Brazier et al. (2006) included another study and a further two that were deemed unsuitable by Binks et al. (2006). Most of the studies included focused on DBT, with each of the meta-analyses concluding that DBT emerged only marginally better than treatment as usual (TAU). ...
The therapeutic uncertainty common in much of the early literature on borderline personality disorder (BPD) has given way to a growing research base with findings indicating the effectiveness of a number of psychological treatments. This article will review three major evidence-based treatments for BPD: dialectical behavior therapy, schema-focused therapy and mentalization-based treatment. While not a panacea, these treatments have provided, to differing degrees, a reasonable level of evidence indicating therapeutic effectiveness. The evidence base for each of these models is discussed as well as possible mechanisms of change. The article highlights similarities between the differing modalities as well as the features that distinguish the models. The article contends that increasing mentalization skills may be a common underlying factor in all treatments for individual with BPD. The authors conclude by discussing the difficulties and potential benefits of treatment integration.
... As a result, life stories of patients with PDs would show low levels of agency and communion. Although the effectiveness of psychotherapy for patients with PDs is well documented (10)(11)(12)(13), a better understanding of psychotherapeutic change is considered essential for the further development of treatments for PDs (14)(15)(16)(17). The therapeutic alliance is considered to be a decisive component of psychotherapy strongly connected to treatment outcome (18). ...
Introduction:
Studying written life stories of patients with personality disorders (PDs) may enhance knowledge of how they understand themselves, others and the world around them. Comparing the construction of their life stories before psychotherapy to their reconstruction after psychotherapy may provide insight in therapeutic changes in the understandings of their lives.
Methods:
As few studies addressed this topic, the current study explored changes in agency (i.e., perceived ability to affect change in life), and communion (i.e,, perceived connectedness to other persons) in written life stories of 34 patients with various PDs, before and after intensive psychotherapy treatment.
Results:
Life stories showed a positive increase in agency from pre- to posttreatment, in particular regarding internal agency, societal success, and occupational success. No significant changes were observed for communion as a whole. However, the perceived number and quality of close relationships revealed a significant positive increase.
Discussion:
The increased agency in the reconstruction of patients' life story after psychotherapy suggests that patients improved their perceived ability to affect change in their own lives. This can be seen as an important step in the treatment of PDs towards further recovery.
... 1,[14][15][16][17] On the other hand, there is substantial evidence that psychotherapy is beneficial for some clinically relevant outcomes in patients with BPD (eg, selfharm, suicidal ideation). 1,[18][19][20] However, provision of many evidence-based psychotherapy treatments requires specialist training, a team-based approach, and a significant time commitment from both patient and clinician, making them logistically challenging and expensive. This situation is gradually improving with the emergence of "common factors" psychological treatments 21 such as Good Psychiatric Management. ...
The use of electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS) in the treatment of people diagnosed with borderline personality disorder (BPD) highlights the need for systematic review of the evidence supporting this practice. A comprehensive literature search identified seven original clinical research studies investigating the use of brain stimulation therapies in people diagnosed with BPD. The lack of consistent study design, diagnostic methodology, treatment parameters, and outcome measures precluded analysis of aggregated study results. There were no ECT studies evaluating BPD symptom outcomes; however, studies of ECT in patients with comorbid BPD and depression suggested that depressive symptoms were less responsive to ECT compared with depression-only patients. The few studies available suggest that TMS may lead to clinically and statistically significant improvements in BPD symptoms and depressive symptoms. Similar overall improvements were reported despite the use of heterogeneous TMS treatment protocols, highlighting the importance of including a sham condition to investigate the contribution of the placebo effect to overall improvement. There is still no clear evidence supporting the use of ECT for treating people with BPD (with or without depression); therefore, the use of ECT in this population should be approached with caution. Although TMS shows early promise, the low numbers of participants in the few available studies suggest the urgent need for larger randomized controlled trials to provide an evidence base for this increasingly popular treatment.
... DBT decreases suicidality in chronic inpatients, however, its implementation is often limited by the patient's length of stay (162). DBT therapy usually lasts for 1 year (161). ...
The risk of suicide in psychiatric hospitals is 50 times higher than in the general population, despite patient safety being a priority for any hospital. However, to date, due to the complexity of assessing suicide risk, there has been no consensus on the suicide prevention measures that should be in place in hospitals. The aim of this work is: To provide an overview of the progress that has been made in the field of inpatient suicide prevention in recent years; discuss the problems that remain; and suggest potential future developments. As new clinical dimensions (notably anhedonia, psychological pain and hopelessness) develop, they should become new therapeutic targets. Team training (like the Gatekeeper Training Program) and the latest advances in suicide risk assessment (such as the Collaborative Assessment and Management of Suicidality) should be implemented in psychiatric wards. Suicide prevention plans (e.g., ASSIP, SAFE-T, etc.) represent easy-to-administer, low-cost interventions. The Mental Health Environment of Care Checklist has been proven effective to reduce suicide risk at hospitals. Furthermore, the types of psychotherapy recommended to reduce suicide risk are cognitive behavioral therapy (CBT) and dialectical behavioral therapy (DBT). There are several pharmacological treatments for suicide risk, such as lithium and clozapine, which have been shown to be effective in the long term, as well as ketamine and esketamine, which are more effective in the short term. Following some encouraging recent results, buprenorphine may also be proposed to patients with a suicide risk. Triple chronotherapy rapidly improves depressive symptoms over 9 weeks. Regarding brain stimulation techniques, rTMS has proven to be effective in alleviating multiple dimensions of suicidality.
... Sept des études portaient sur l'effet de la thérapiecomportementaledialectique (TCD) et une sur l'effet de la thérapiebasée sur la mentalisation (MBT). Les auteurs ontconclu que la thérapiecomportementaledialectique dans unecliniqueexterne et la thérapiebasée sur la mentalisation dans un hôpital de jour ontmontréuneréduction de l'automutilationcommel'une des nombreusesmesures de l'effet du traitement [59]. L'automutilations'inscrit dans plusieurs cadres nosographiques ; ainsi, il est primordial de faire le diagnostic des comorbidités dans le cadre d'unepriseen charge intégrale et globale. ...
Lautomutilationest un comportementassezfrequent chez la population psychiatrique. Cest un symptome qui a differentesfonctionsselon les comorbidites. Lobjectif de ce travail est de determiner le profilsociodemographique et clinique des patients avec automutilationainsi que les differents aspects de la priseen charge afin de dresser un profil de patient chez qui les automutilations constituent un risque de passage a lactesuicidaire. Nous avonsmeneune etude observationnelle descriptive chez des patients hospitalisesouvusen consultation de lhopitalpsychiatriqueuniversitaireArrazi de Saleayant deja fait uneautomutilation au cours de leur vie. Cette etude a recense 31 patients. Le groupe se compose majoritairementdhommes et lâgemoyenest de 27 ans. 22,6% des patients ontsubi un viol durantlenfance, 48,4% ontvecusoit la separation des parents ou le deces de lundeux. 67,7% ont deja etehospitaliseen milieu psychiatrique, 93,5% ont deja fait au moinsuneautomutilation dans le passe et 64,5% ont un antecedent de tentative de suicide. Lusageproblematique de substances psychoactivesestfrequemmentassocie aux automutilations a raison de 77,4%. Enfin, les diagnostics le plus souventassocies a lautomutilationsont la schizophrenie (48,4%), les troubles de la personnalite (19,4%) et lepisodedepressifcaracterise (16,1%). Lâgemoyen de debut des automutilationsest de 19 ans. Lautomutilationsurvientessentiellement dans le milieu familial. 58,1% des patients ontutiliseunearme blanche pour sautomutiler. 54,8 % de nos patients rapportent un apaisement apres lautomutilation, 35,5% regrettentleurgeste, 6,5% sontdegoutesalors que 3,2% sontindifferents. Le but de lautomutilation chez nos patients estavant tout dapaiser les tensions (45,2%), ensuite vient la raison de lautopunition (16,1%) et de lappel a laide (12,9%). Un antecedentdautomutilationestcorrele de façon significative a un antecedent de tentative de suicide. En conclusion,lautomutilationestrepandue et constitue un facteur de risque de suicide. Ainsi, une attention particuliere doit êtreaccordee a cette population pour un reperagerapide des sujets a risqueafin de prevenir tout passage a lactesuicidaire.
... 2 It is estimated that more than a fifth of inpatients on general adult wards, 3,4 more than 40% of women on Psychiatric Intensive Care Units, 5 and more than 60% of women treated on medium secure units have BPD. 6 While psychological treatments improve the mental health of people with BPD, 7 people with the most severe problems are less likely to engage in them. 8,9 No medication is licenced for the treatment of BPD, but despite this, people with severe BPD are often prescribed multiple medications. ...
Background
Data from case series suggest that clozapine may benefit inpatients with borderline personality disorder (BPD), but randomised trials have not been conducted.
Methods
Multicentre, double-blind, placebo-controlled trial. We aimed to recruit 222 inpatients with severe BPD aged 18 or over, who had failed to respond to other antipsychotic medications. We randomly allocated participants on a 1:1 ratio to receive up to 400 mg of clozapine per day or an inert placebo using a remote web-based randomisation service. The primary outcome was total score on the Zanarini Rating scale for Borderline Personality Disorder (ZAN-BPD) at 6 months. Secondary outcomes included self-harm, aggression, resource use and costs, side effects and adverse events. We used a modified intention to treat analysis (mITT) restricted to those who took one or more dose of trial medication, using a general linear model fitted at 6 months adjusted for baseline score, allocation group and site.
Results
The study closed early due to poor recruitment and the impact of the COVID-19 pandemic. Of 29 study participants, 24 (83%) were followed up at 6 months, of whom 21 (72%) were included in the mITT analysis. At 6 months, 11 (73%) participants assigned to clozapine and 6 (43%) of those assigned to placebo were still taking trial medication. Adjusted difference in mean total ZAN-BPD score at 6 months was -3.86 (95% Confidence Intervals = -10.04 to 2.32). There were 14 serious adverse events; 6 in the clozapine arm and 8 in the placebo arm of the trial. There was little difference in the cost of care between groups.
Interpretation
We recruited insufficient participants to test the primary hypothesis. The study findings highlight problems in conducting placebo-controlled trials of clozapine and in using clozapine for people with BPD, outside specialist inpatient mental health units.
Trial registration
ISRCTN18352058. https://doi.org/10.1186/ISRCTN18352058
... There have now been a number of meta-analytic reviews that have examined TFP in relation to other treatments [3,[25][26][27][28]. These studies have consistently found that there are no reliable differences in overall effect sizes between TFP treatments and other treatments, including DBT. ...
Purpose of Review
In this article, we describe the goals of transference-focused psychotherapy (TFP), its indications, underlying theory, and its broad structure and techniques. We summarize the current empirical support for TFP in regard to symptom and personality change. Lastly, we discuss recent developments and applications in TFP.
Recent Findings
TFP is a theory-based, manualized, empirically supported, outpatient psychotherapy designed specifically to treat patients with severe personality disorders, such as borderline and narcissistic personality disorders. Overall TFP focuses on consolidating identity, increasing emotion regulation, and improving relationships. In TFP, these improvements are accomplished by exploring and working through the patient’s fragmented and disparate experiences of the self and others, particularly through the relationship with the therapist. Compared with other empirically supported treatments for personality disorders, TFP has shown an equal improvement in depression, anxiety, functioning, and adjustment, and has led to a more consistent change in anger and aggression. Moreover, in three studies, TFP uniquely and consistently led to changes in attachment security and mentalizing capacity.
Summary
Although TFP manuals were first developed specifically for treating borderline personality disorder, recent research suggests that TFP has broader relevance for personality pathology more generally. Furthermore, future research is needed to explicate how TFP can be integrated with other treatments.
... Dialectical behavior therapy (DBT) has shown good clinical efficacy and is regarded as 1 of the most well-researched evidence-based treatments for BPD [5,[7][8][9]. The main focus of DBT treatment is the learning of a predefined set of behavioral skills that target lack of emotional, mental, interpersonal, and behavioral control [10]. ...
Background: Borderline personality disorder (BPD) is a disorder characterized by difficulties with regulating emotions and impulsive behavior. Long-term monitoring of progress during BPD psychotherapy constitutes a challenge using paper and pencil registration. Hence, a mobile app assessing emotions and progress in treatment may be useful.
Objective: The aim of this study was to examine the feasibility of using the mDiary app as an adjunct to dialectical behavior therapy (DBT) for the treatment of BPD.
Methods: A total of 9 focus group interviews were conducted and analyzed according to the grounded theory approach. Furthermore, the usability of the mDiary app was examined using the System Usability Scale (SUS). The app was implemented in a standard DBT program as an adjunct to DBT. In total, 16 patients (age range 19-41 years) and 23 therapists (age range 25-64 years) from 5 Danish public outpatient psychiatric treatment facilities participated in the study.
Results: Overall, patients were satisfied with the mDiary app, as it was “easy to use” and “always there.” Inside-out innovation, meaning new work tasks generated during implementation and communication of modifications needed in the app, was found to influence the perceived usability negatively among the interviewed therapists. The patients rated the usability as high (mean SUS score 81.2, SD 9.9), whereas therapists rated the mDiary app at an average level (mean 68.3, SD 14.3). Older age of the users correlated with lower usability ratings on the SUS score (Pearson r=−0.60).
Conclusions: The mDiary app was considered as an acceptable and relevant way of registering DBT diary data for both patients and therapists generating increased long-term overview. Older users were overall more reluctant to accept this new technology in clinical practice. Time to align expectations among involved parties needs to be set aside when implementing this new approach to patient monitoring. Here, the focus should be on the realistic use of resources and expected impact on present clinical work.
... 8 For more complicated patients, several different, manualized therapies have been delivered in group and individual formats to good effect, including dialectical behavioral therapy, mentalization-based therapy, and transference-focused psychotherapy. 34,35 Inpatient psychiatric hospitals can be helpful for stabilization of acutely suicidal patients, but this approach is generally considered only as a last resort, especially in view of the concern that it can actually exacerbate symptoms (reviewed in 36 ). No treatment for BPD targets a specific biological mechanism. ...
Learning objectives
After participating in this activity, learners should be better able to:
• Assess medication management in patients with borderline personality disorder (BPD)
• Evaluate the role of deprescribing as an active intervention in patients with BPD treated with polypharmacy
Abstract
Psychopharmacology in borderline personality disorder (BPD) is complicated by comorbid disorders, substance use, sensitivity to side effects, risk of self-harm through medication misuse, and intense but transient symptoms. Patients’ relationships with medications may range from tenuous to highly enmeshed, and may profoundly influence the response to treatment. For these reasons, awareness of current evidence and flexible approaches are particularly relevant to prescribing in BPD. In this narrative review, we illustrate the current status of medication management in BPD by focusing on polypharmacy. We use a single vignette to explore the limitations of prescribing multiple medications and the factors contributing to polypharmacy. With the same vignette, and using the framework of deprescribing, we describe how medication regimens can be reduced to a necessary minimum. Deprescribing, originally developed in geriatric medicine, is an active intervention that involves a risk-benefit analysis for each medication, keeping in mind the patient’s medical and psychiatric status and his or her preferences and values. Deprescribing lends itself well to use in psychiatry and especially in BPD because of its emphasis on the patient’s preferences and on repeated conversations to revisit and update decisions. In addition to elaborating on the deprescribing framework, we provide recommendations for conducting these critical discussions about medications in BPD, with particular attention to the patient’s relationship to the medication. Finally, we summarize our recommendations and strategies for implementing flexible and responsive medication management for patients with BPD. We suggest areas of future research, including testing the efficacy of targeted intermittent medication treatments.
... Dialectical behavior therapy (DBT) has shown good clinical efficacy and is regarded as 1 of the most well-researched evidence-based treatments for BPD [5,[7][8][9]. The main focus of DBT treatment is the learning of a predefined set of behavioral skills that target lack of emotional, mental, interpersonal, and behavioral control [10]. ...
BACKGROUND
Background: Borderline personality disorder (BPD) is a debilitating disease characterized by difficulties with regulating emotions and impulsive behavior. Monitoring progress in BPD constitutes a challenge for health care professionals and patients alike, especially regarding the long-term overview. A mobile application accessible to patients at all times, allowing monitoring of symptoms, which can be shared with their therapist, may facilitate treatment progress and has, not yet been developed and implemented in clinical practice.
OBJECTIVE
Objectives: In collaboration with the Danish app-monitoring company Monsenso, we developed and evaluated the usability of a BPD-specific mobile application aimed at monitoring progress in dialectic behavior therapy (DBT), using a user-centered design and the involvement of the end users (patients and therapists).
METHODS
Methods: The intervention consisted of a scheduled 56-week out-patient intervention with DBT using the app as self-monitoring emotions and regulation skills. Sixteen patients (age: 19-41) and 23 therapists (age: 25-64) participated in the study. Focus group interviews were conducted and analyzed according to a grounded theory approach. System usability questionnaires (SUS) were administered as well.
RESULTS
Results: The patients were over all satisfied with the solution and rated usability high (Mean SUS score 81.25, SD 9.92). The patients rated the app as useful, because it was easy to use and “always there”. Sixteen therapists rated the app-solution at an average level (Mean 68.38, SD 14.36), while the 6 therapists involved in the first basic development were less satisfied with the app than later adopters (Mean 42.5, SD 16.58) and found it below average. Increasing age of the users coincided with a less favourable perception of usability. A complementary process to outside-in innovation was identified as inside out-innovation. This has to be taken in to account when implementing and developing a tech-solution at the same time. In the present study, sources of treatment instability introduced while developing were: learning to use the app, adaption needed in the work procedures, getting the solution to work technically and fitting the solution to the needs of the most important work tasks.
CONCLUSIONS
Conclusions: The Monsenso app is a useful and acceptable way of registering DBT diary cards, tracking app acquisition and is now implementable without undue hassles with high patient usability and acceptable therapist usability. The app is sufficiently ready to investigate in effectiveness studies. In order to ensure successful implementation of similar projects in the future, it is important to be aware that co-occurring development and implementation is likely associated with frustrations among therapists.
... This can be concluded from clinical guidelines, meta-analyses, and systematic or critical literature reviews 1 . Other treatments, such as pharmacological interventions, have received less empirical support 1,2 . ...
Mixed features personality disorders (PDs) are highly prevalent and associated with significant burden of disease. Despite that, it has been an overlooked diagnostic category with respect to clinical research. This study aims to review empirical evidence about psychotherapy delivery available for these patients. We present a systematic review of clinical trials investigating the outcomes of psychotherapeutic interventions in adults with a primary diagnosis of mixed features PDs. Data were obtained from Medline/PubMed, Embase and PsycINFO. Seven studies met inclusion criteria; in one of them the whole sample was of this diagnostic group; two studies analysed psychotherapeutic intervention outcomes in this population, among other types of PDs, yet drawing specific conclusions on mixed features PDs patients; remaining studies addressed patient samples with different PDs types, mixed features included, where specific findings in this group of patients were not described-nonetheless, they included representative numbers of subjects with the diagnosis of interest. Available studies suggest that mixed features personality pathology per se does not seem to be an impediment to benefit from psychotherapeutic treatment, and improvement in different areas of life is possible for patients undergoing psychotherapy. The extant literature is marked by multiple challenges and inconsistencies across studies. Silva S et al. / Arch Clin Psychiatry. 2018;45(6):161-6
... En un estudio reciente realizado por la Co- chrane (Binks, C. A. et al., 2006b) y centrados en terapias psicológicas dirigidas al TLP, los au- tores también concluyen que algunos de los problemas encontrados frecuentemente por las personas con TLP pueden ser receptivos a las terapias psicológicas actuales, pero todas ellas siguen siendo experimentales y los estu- dios son demasiado escasos y pequeños para inspirar una total confianza en los resultados. Insisten en la necesidad de estudios de mayor tamaño y realizados en el mundo «real». ...
INTRODUCCIÓN
Los Trastornos de Personalidad (TPs) constituyen un grupo de pacientes que genera gran preocupación entre los profesionales sanitarios por la complejidad de su clínica, la respuesta frecuentemente insatisfactoria a los tratamientos y la carencia de propuestas claras sobre intervenciones terapéuticas idóneas. Ello genera la necesidad de examinar la trascendencia del problema en la CAV, así como de establecer una serie de recomendaciones que guíen a la autoridad sanitaria a la hora de diseñar una oferta asistencial adecuada para estas personas.
OBJETIVOS
• Conocer la demanda de atención sanitaria directamente relacionada con los Trastornos de Personalidad en la red pública de la CAPV.
• Analizar las técnicas y esquemas organizativos empleados en la red y en otros sistemas sanitarios para atender dichos trastornos.
• Elaborar una serie de propuestas sobre la atención a Trastornos de Personalidad, para su eventual puesta en marcha en la CAPV, con el fin de mejorar la atención actual, teniendo en cuenta la calidad de las evidencias que la sustentan y la aplicabilidad del
esquema organizativo en nuestro sistema sanitario, que incluya una reflexión sobre los costes.
MATERIAL Y MÉTODOS
• Análisis de registros sanitarios disponibles en la red de salud mental del País Vasco, complementados por un examen más detallado de los datos de cada centro d
onde desarrollan su tarea los investigadores.
• Recogida de información sobre la práctica asistencial real en nuestro medio a los pacientes con TP a través de fuentes de alta calidad.
• Recogida de información sobre esquemas organizativos en este campo, tanto de nuestro entorno nacional como de aquellos dispositivos extranjeros de presti
gio.
• Revisión sistemática de la literatura científica sobre la atención a Trastornos de Personalidad y modelos organizativos.
• Análisis de los datos obtenidos, debate y elaboración de un informe con recomendaciones concretas.
RESULTADOS Y DISCUSIÓN
Los TP son frecuentes en nuestros dispositivos. Con frecuencia pasan desapercibidos para los planificadores por un infradiagnóstico unido a un infrarregistro.
Los profesionales los consideran difíciles de tratar y les otorgan un pronóstico sombrío, en contradicción con los datos de evolución más optimistas de la literatura. Carecemos de protocolos estructurados para el abordaje de los TP en nuestras unidades. Nos falta formación tanto sobre la patología en sí como de las posibles intervenciones terapéuticas. Las unidades de referencia a nivel nacional o internacional suelen caracterizarse por una estructura sólida, una terapéutica multicomponente con intervenciones integradas sobre todo de base dinámica o cognitivo-conductual, aplicadas en encuadres individuales y grupales, tanto a nivel ambulatorio intensivo como de hospitalización parcial.
Las evidencias halladas en la literatura son escasas y difíciles de interpretar por la complejidad metodológica que acompaña a la investigación en PT que se añade
a las dificultades propias de trabajar con TPs. Existe un consenso amplio que considera la psicoterapia como el elemento central del tratamiento de los TP, combinada con una intervención farmacológica dirigida a agrupaciones de síntomas. Las técnicas cognitivo-conductuales y dinámicas son las más utilizadas. Los antidepresivos en general y los ISRS en particular, han mostrado mayor potencial en el tratamiento de los TPs. Respecto a la duración de los tratamientos, tiende a considerarse la necesidad de duraciones largas, superiores a un año. El encuadre preferido en los programas existentes es el ambulatorio intensivo o bien la hospitalización parcial.
RECOMENDACIONES Y CONCLUSIONES
Se plantean una serie de niveles de mejoras en el abordaje a los TP de complejidad creciente que pueden implantarse sucesiva o simultáneamente en la Red de SM d
el País Vasco.
1. Programa de Formación en TP. Red SM
2. Unidad de Formación e Investigación
3. Unidad Asistencial Piloto. Énfasis en intervenciones grupales. Uso preferente de Técnicas dinámicas. Formación de profesionales en técnicas cognitivo-conductuales. Evaluación exhaustiva de resultados
4. Difusión de Unidades Asistenciales
5. Unidad de Hospitalización. Programa residencial
Optamos por proponer comenzar el desarrollo de este plan a partir del nivel 3, con la creación de una Unidad Asistencial Piloto, que se haga cargo además de los niveles previos 1 y 2.
... Evidence-based psychological treatments for people with personality disorder are intensive. They typically combine individual and group-based therapy delivered over a 12-18-month period [6,7]. Most people with personality disorder do not have access to these intensive interventions and even when they are available as many as half of those who are referred do not engage with them [8,9]. ...
Background
Previous research has demonstrated the clinical effectiveness of long-term psychological treatment for people with some types of personality disorder. However, the high intensity and cost of these interventions limit their availability. Lower-intensity interventions are increasingly being offered to people with personality disorder, but their clinical and cost effectiveness have not been properly tested in experimental studies. We therefore set out to develop a low intensity intervention for people with personality disorder and to test the feasibility of conducting a randomized controlled trial to compare the clinical effectiveness of this intervention with that of treatment as usual (TAU).
Methods
A two-arm, parallel-group, single-blind, randomized controlled trial of Psychological Support for Personality (PSP) versus TAU for people aged over 18 years, who are using secondary care mental health services and have personality disorder. We will exclude people with co-existing organic or psychotic mental disorders (dementia, bipolar affective disorder, delusional disorder, schizophrenia, schizoaffective disorder, or schizotypal disorder), those with cognitive or language difficulties that would preclude them from providing informed consent or compromise participation in study procedures, and those who are already receiving psychological treatment for personality disorder. Participants will be randomized via a remote system in a ratio of PSP to TAU of 1:1. Randomization will be stratified according to the referring team and gender of the participant.
A single follow-up assessment will be conducted by masked researchers 24 weeks after randomization to assess mental health (using the Warwick and Edinburgh Well-Being Schedule), social functioning (using the Work and Social Adjustment Scale), health-related quality of life (EQ-5D-5 L), incidence of suicidal behavior, satisfaction with care (Client Satisfaction Questionnaire), and resource use and costs using a modified version of the Adult Service Use Schedule. In addition to this, each participant will be asked to complete the patient version of the Clinical Global Impression Scale.
Feasibility and acceptability will primarily be judged by study recruitment rate and engagement and retention in treatment. The analysis will focus principally on descriptive data on the rate of recruitment, characteristics of participants, attrition, adherence to therapy, and follow-up. We will explore the distribution of study outcomes to investigate assumptions of normality in order to plan the analysis and sample size of a future definitive trial.
Discussion
Most people with personality disorder do not currently receive evidence-based interventions. While a number of high intensity psychological treatments have been shown to be effective, there is an urgent need to develop effective low intensity approaches to help people unable to use existing treatments. PSP is a low intensity intervention for individuals, which was developed following extensive consultation with users and providers of services for people with personality disorder. This study aims to examine the feasibility of a randomized trial of PSP compared to TAU for people with personality disorder.
Trial registration
ISRCTN Registry, ISRCTN14994755. Registered on 18 July 2017.
... 10 BPD is also a stronger predictor of MDD than other personality disorders such as avoidant and paranoid disorders. 11 Patients with MDD and comorbid BPD have dramatically lower rates of depression remission (30% by the first year) than patients with only MDD (80%), 12 and they do not respond as well to antidepressants such as selective serotonin reuptake inhibitors 13,14 and tricyclic antidepressant medication. 15 Patients with BPD tend to over-endorse their depressive symptoms, 16 and these depressive symptoms typically do not improve without first addressing the underlying personality disorder. ...
Objective:
Previous research suggests that electroconvulsive therapy (ECT)-the criterion standard for the treatment of severe depression-is not as effective when the patient has comorbid borderline personality disorder (BPD). The ECT outcomes of patients with and without BPD were compared in a retrospective chart review to test this claim.
Methods:
We enrolled 137 patients with a diagnosis of major depressive disorder who completed the McLean Screening Instrument for Borderline Personality Disorder. Twenty-nine patients had positive screening scores for BPD. The difference in Patient Health Questionnaire (PHQ-9) scores before and after ECT was compared between patients with and without BPD. Follow-up PHQ-9 scores determined after treatment were collected and analyzed.
Results:
Electroconvulsive therapy equally improved symptoms of depression as measured by PHQ-9 score in both patients who screened positive and patients who screened negative for BPD. No difference in the increase in PHQ-9 scores between these 2 groups was noted 1 month after treatment (P = 0.19).
Conclusions:
These data showed that a positive BPD screen does not necessarily predict a poorer response to ECT, nor does it predict greater symptom recurrence after ECT. This does not suggest that ECT is necessarily an appropriate treatment for major depressive disorder in patients with a comorbid BPD, given the limitations of screening instruments.
... Among the psychosocial treatments showing efficacy for BPD [20][21][22][23], dialectical behaviour therapy (DBT), a comprehensive cognitive behavioural treatment, has accrued the most empirical support [24]. DBT involves weekly hour-long individual therapy, weekly group skills training (typically 2-2.5 h), between-session telephone consultation as needed to coach the patient in the use of behavioural skills (typically by phone or other communication media), and weekly therapist consultation team meetings designed to support, motivate, and enhance the skills of therapists [25]. ...
Background:
Although Dialectical Behaviour Therapy (DBT) is an evidence-based psychosocial treatment for borderline personality disorder (BPD), the demand for it exceeds available resources. The commonly researched 12-month version of DBT is lengthy; this can pose a barrier to its adoption in many health care settings. Further, there are no data on the optimal length of psychotherapy for BPD. The aim of this study is to examine the clinical and cost-effectiveness of 6 versus 12 months of DBT for chronically suicidal individuals with BPD. A second aim of this study is to determine which patients are as likely to benefit from shorter treatment as from longer treatment.
Methods/design:
Powered for non-inferiority testing, this two-site single-blind trial involves the random assignment of 240 patients diagnosed with BPD to 6 or 12 months of standard DBT. The primary outcome is the frequency of suicidal or non-suicidal self-injurious episodes. Secondary outcomes include healthcare utilization, psychiatric and emotional symptoms, general and social functioning, and health status. Cost-effectiveness outcomes will include the cost of providing each treatment as well as health care and societal costs (e.g., missed work days and lost productivity). Assessments are scheduled at pretreatment and at 3-month intervals until 24 months.
Discussion:
This is the first study to directly examine the dose-effect of psychotherapy for chronically suicidal individuals diagnosed with BPD. Examining both clinical and cost effectiveness in 6 versus 12 months of DBT will produce answers to the question of how much treatment is good enough. Information from this study will help to guide decisions about the allocation of scarce treatment resources and recommendations about the benefits of briefer treatment.
Trial registration:
NCT02387736 . Registered February 20, 2015.
... Substantial skew has been found in economic and cost indicators (Barber & Thompson, 2000;Hlatky, Boothroyd, & Johnstone, 2002) and measures of quality of life (Arostegui, Nunez-Anton, & Quintana, 2007) and social functioning (Tyrer et al., 2005) in clinical trial data. Skew is the norm in measures of depression (Rutter & Miglioretti, 2003;Zimmerman, Chelminski, & Posternak, 2004), mania (Picardi et al., 2008) and suicidal ideation (Binks et al., 2006). Experimental psychopathology research typically measures clinical constructs in analogue populations, and these too often have heavily skewed distributions (Rutter & Miglioretti, 2003;Tyrer et al., 2005;Zimmerman et al., 2004). ...
Paper describing the utility and application of various robust methods in R
... 11 Many people who have this diagnosis report that they are dissatisfied with the treatment they receive, 12,13 and mental health practitioners often find it difficult to work with people with this condition. 14 Although psychological treatments, such as dialectical behaviour therapy and mentalisation-based therapy, have been shown to improve the mental health of people with BPD, 15 most people with this disorder do not have access to specialist psychological treatment services. Among those who do, many do not engage with psychological treatment, and as many as half of those who do engage drop out before the treatment has been completed. ...
Background
No drug treatments are currently licensed for the treatment of borderline personality disorder (BPD). Despite this, people with this condition are frequently prescribed psychotropic medications and often with considerable polypharmacy. Preliminary studies have indicated that mood stabilisers may be of benefit to people with BPD.
Objective
To examine the clinical effectiveness and cost-effectiveness of lamotrigine for people with BPD.
Design
A two-arm, double-blind, placebo-controlled individually randomised trial of lamotrigine versus placebo. Participants were randomised via an independent and remote web-based service using permuted blocks and stratified by study centre, the severity of personality disorder and the extent of hypomanic symptoms.
Setting
Secondary care NHS mental health services in six centres in England.
Participants
Potential participants had to be aged ≥ 18 years, meet diagnostic criteria for BPD and provide written informed consent. We excluded people with coexisting psychosis or bipolar affective disorder, those already taking a mood stabiliser, those who spoke insufficient English to complete the baseline assessment and women who were pregnant or contemplating becoming pregnant.
Interventions
Up to 200 mg of lamotrigine per day or an inert placebo. Women taking combined oral contraceptives were prescribed up to 400 mg of trial medication per day.
Main outcome measures
Outcomes were assessed at 12, 24 and 52 weeks after randomisation. The primary outcome was the total score on the Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD) at 52 weeks. The secondary outcomes were depressive symptoms, deliberate self-harm, social functioning, health-related quality of life, resource use and costs, side effects of treatment and adverse events. Higher scores on all measures indicate poorer outcomes.
Results
Between July 2013 and October 2015 we randomised 276 participants, of whom 195 (70.6%) were followed up 52 weeks later. At 52 weeks, 49 (36%) of those participants prescribed lamotrigine and 58 (42%) of those prescribed placebo were taking it. At 52 weeks, the mean total ZAN-BPD score was 11.3 [standard deviation (SD) 6.6] among those participants randomised to lamotrigine and 11.5 (SD 7.7) among those participants randomised to placebo (adjusted mean difference 0.1, 95% CI –1.8 to 2.0; p = 0.91). No statistically significant differences in secondary outcomes were seen at any time. Adjusted costs of direct care for those prescribed lamotrigine were similar to those prescribed placebo.
Limitations
Levels of adherence in this pragmatic trial were low, but greater adherence was not associated with better mental health.
Conclusions
The addition of lamotrigine to the usual care of people with BPD was not found to be clinically effective or provide a cost-effective use of resources.
Future work
Future research into the treatment of BPD should focus on improving the evidence base for the clinical effectiveness and cost-effectiveness of non-pharmacological treatments to help policy-makers make better decisions about investing in specialist treatment services.
Trial registration
Current Controlled Trials ISRCTN90916365.
Funding
Funding for this trial was provided by the Health Technology Assessment programme of the National Institute for Health Research (NIHR) and will be published in full in Health Technology Assessment ; Vol. 22, No. 17. See the NIHR Journals Library website for further project information. The Imperial Biomedical Research Centre Facility, which is funded by NIHR, also provided support that has contributed to the research results reported within this paper. Part of Richard Morriss’ salary during the project was paid by NIHR Collaboration for Leadership in Applied Health Research and Care East Midlands.
... Studies have found that hopelessness is a strong predictor of suicide. People who feel hopeless may talk about "unbearable" feelings, predict a bleak future, and state that they have nothing to look forward to [14,15]. ...
... Patients often require intensive psychiatric care and 20% of psychiatric hospitalizations. However, after helping as many of them are improving over time and are eventually able to lead productive lives [2]. ...
... PDs are highly prevalent both in community and clinical samples, with rates of 15% (Grant et al., 2004) and 45% (Zimmerman, Rothschild, & Chelminski, 2005), respectively. Today, psychotherapy is the treatment of choice for PDs (e.g., Binks et al., 2006;Clarkin, Levy, Lenzenweger, & Kernberg, 2007), and the efficacy of several cognitive-behavioral (Koons et al., 2001;Linehan et al., 2006) as well as psychodynamic treatments (Bateman & Fonagy, 1999Clarkin et al., 2007;Fonagy, 2015) for PD pathology has been shown. These findings have led to increased optimism about the treatability of PDs (Fonagy & Bateman, 2006;Levy & Scott, 2007;Linehan et al., 2006). ...
Today, psychotherapy is the treatment of choice for patients with a personality disorder (PD). PD patients are however difficult to engage into treatment and little is known about the factors that lead to dropout. The aim of this study was to increase our understanding of dropout in PD patients. In particular, and based on earlier studies, we aimed to identify baseline patient factors predicting dropout from a psychodynamic hospitalization-based treatment program. Results in a sample of 129 well-screened PD patients showed (a) a dropout rate of 34%, which is in line with earlier studies; (b) univariate analysis indicated that a lower educational level, the presence of Cluster A PD, especially schizoid PD, the total number of Axis II disorders, and the total number of Axis I disorders were predictive of dropout; and (c) when these variables were entered in a stepwise logistic regression analysis, the only significant predictor of dropout was the number of Axis II diagnoses. Dropout from a hospitalization-based psychodynamic treatment program was thus associated with a higher number of Axis II diagnoses (odds ratio = 1.73, 95% confidence interval [1.16, 2.57]). These findings suggest that the more serious one’s personality pathology is at the start of treatment, the higher the chance patients will drop out from our treatment program. Implications for the psychosocial treatment of PD patients are formulated.
... Although it has been previously noted that, given the heterogeneity of the disorder, it is unlikely that any so-called "one size fits all" treatment could be identified [5], this heterogeneity has been insufficiently taken into account in existing evidence-based treatments [6,7]. Empirical evidence for a variety of treatments for BPD, such as Transference-Focused Psychotherapy; Systems Training for Emotional Predictability and Problem Solving, Dialectical Behavior Therapy, Schema-Focused Therapy, and Mentalization-Based Treatment is accumulating [8][9][10]. However, interpretation of treatment outcome in these studies is hampered by the fact that there may be substantial differences in outcome for different types of BPD patients. ...
Background
The borderline personality disorder (BPD) population is notably heterogeneous, and this has potentially important implications for intervention. Identifying distinct subtypes of patients may represent a first step in identifying which treatments work best for which individuals.
Methods
A cluster-analysis on dimensional personality disorder (PD) features, as assessed with the SCID-II, was performed on a sample of carefully screened BPD patients (N = 187) referred for mentalization-based treatment. The optimal cluster solution was determined using multiple indices of fit. The validity of the clusters was explored by investigating their relationship with borderline pathology, symptom severity, interpersonal problems, quality of life, personality functioning, attachment, and trauma history, in addition to demographic and clinical features.
Results
A three-cluster solution was retained, which identified three clusters of BPD patients with distinct profiles. The largest cluster (n = 145) consisted of patients characterized by “core BPD” features, without marked elevations on other PD dimensions. A second “Extravert/externalizing” cluster of patients (n = 27) was characterized by high levels of histrionic, narcissistic, and antisocial features. A third, smaller “Schizotypal/paranoid” cluster (n = 15) consisted of patients with marked schizotypal and paranoid features. Patients in these clusters showed theoretically meaningful differences in terms of demographic and clinical features.
Conclusions
Three meaningful subtypes of BPD patients were identified with distinct profiles. Differences were small, even when controlling for severity of PD pathology, suggesting a strong common factor underlying BPD. These results may represent a stepping stone toward research with larger samples aimed at replicating the findings and investigating differential trajectories of change, treatment outcomes, and treatment approaches for these subtypes.
Trial registration
The study was retrospectively registered 16 April 2010 in the Nederlands Trial Register, no. NTR2292.
... Substantial skew has been found in economic and cost indicators (Barber & Thompson, 2000;Hlatky, Boothroyd, & Johnstone, 2002) and measures of quality of life (Arostegui, Nunez-Anton, & Quintana, 2007) and social functioning (Tyrer et al., 2005) in clinical trial data. Skew is the norm in measures of depression (Rutter & Miglioretti, 2003;Zimmerman, Chelminski, & Posternak, 2004), mania (Picardi et al., 2008) and suicidal ideation (Binks et al., 2006). ...
This paper reviews and offers tutorials on robust statistical methods relevant to clinical and experimental psychopathology researchers. We review the assumptions of one of the most commonly applied models in this journal (the general linear model, GLM) and the effects of violating them. We then present evidence that psychological data are more likely than not to violate these assumptions. Next, we overview some methods for correcting for violations of model assumptions. The final part of the paper presents 8 tutorials of robust statistical methods using R that cover a range of variants of the GLM (t-tests, ANOVA, multiple regression, multilevel models, latent growth models). We conclude with recommendations that set the expectations for what methods researchers submitting to the journal should apply and what they should report.
... The primary outcome measure was CGI [Guy, 1976]; specifically, severity of illness (CGI-S). CGI is a commonly used scale for measuring the effect of pharmacological intervention in various studies on personality disorders [Frankenburg and Zanarini, 1993;Binks et al. 2006]. CGI scores were ascertained before starting PP and during treatment with PP in the most recent 6 months. ...
Background:
High-security hospital patients are often complex in presentation and are characterized by treatment resistance, medication nonadherence and history of violence. Paliperidone is licensed both as an oral and depot antipsychotic medication in the treatment of schizophrenia. Clinical trials have shown that paliperidone depot is well tolerated with similar efficacy to risperidone depot but with additional practical advantages. Whilst data exist for the effectiveness of paliperidone palmitate (PP), there are no studies involving patients in forensic settings or those with comorbid personality disorder. Our aim was to evaluate the effectiveness of PP on violence, aggression and personality disorder symptoms.
Methods:
This project was a retrospective service evaluation involving 11 patients, carried out in a high-security hospital. A combination of patient records and interviews with the treating consultant psychiatrist were used to ascertain a Clinical Global Impression (CGI) score, the effect of PP on specific personality disorder symptom domains (cognitive-perceptual, impulsive-behavioural dyscontrol and affective dysregulation) and incidents of violence and aggression. Engagement with occupational and psychological therapies was also evaluated. Metabolic parameters were reviewed.
Results:
A total of 6 out of 11 patients continued on PP, most of whom had schizophrenia and dissocial personality disorder with histories of violence. All showed improvement in the CGI score with associated benefits in the three personality symptom domains. Overall, two patients demonstrated a reduction in the risk of violence. There was improvement in engagement with occupational therapy and psychological work. No significant effects on metabolic parameters were noted although hyperprolactinaemia, albeit asymptomatic, was consistently recorded.
Conclusions:
This pragmatic service evaluation of a small but complex patient group demonstrated, for the first time, that PP was effective in reducing violence as well as improving personality pathology across all dimensions: a finding which could have significant implications for management of such high-security patients.
The chapter deals with psychodynamic therapeutic approaches to treating patients with problems in violence and aggression. Within psychodynamic therapies, two approaches can be differentiated: One is the more classic insight‐oriented approach and the other aims more to enhance personality functioning. After a description of the common principles of psychodynamic treatment, recommendations for adaptation when treating violent patients are discussed. A systematic review shows promising results for psychodynamic individual and group therapies as well as integrated therapeutic approaches.
There is a lack of evidence to support the use of Dialectical Behaviour Therapy (DBT) for people with intellectual disabilities (ID) living in the community with no history of forensic involvement. This study evaluates a DBT pilot programme for those with ID within a community setting. Four participants took part over a period of six months. The research focuses on ways in which a DBT programme can be adapted for this population and discusses the suitability of outcome measures used to evaluate the intervention (Cognitive and Affective Mindfulness Scale-Revised, Difficulties in Emotional Regulation Scale and Health of the Nation Outcome Scales for People with Learning Disabilities). All four participants completed the pilot programme. Results were not found to be significant. However, there is evidence of small improvement on the HoNOS-LD measure. The findings support the need for larger scale studies and outcome measures appropriate for use for those with ID.
Differential response to the Systems Training for Emotional Predictability and Problem Solving (STEPPS) program was compared in subgroups identified through latent class analysis (LCA). STEPPS is an evidence-based group treatment program for patients with borderline personality disorder (BPD). A reanalysis of data was conducted using data from a 20-week randomized controlled trial and 1-year follow-up. Subjects (n = 164) with DSM-IV BPD were assessed for comorbid Axis I and II disorders and selected clinical variables. Severity was assessed using the Zanarini Rating Scale for BPD (ZAN-BPD) and the Borderline Evaluation of Severity Over Time (BEST). Three- and four-class models were identified with the four-class model having the better fit. The latter included a high severity (HS) class (26%), an affective instability/substance abuse (AISA) class (16%), an empty/dissociation/identity disturbance (EDID) class (27%), and a low severity (LS) class (30%). High impulsiveness predicted membership in the HS class. Improvement was determined using a linear mixed-effects model. Those most likely to benefit were those in the HS group characterized by high symptom severity, Axis I and II comorbidity, problem relationships, abandonment fears, and intense anger. This work should help further efforts to match patients with treatments based on sociodemographic, diagnostic, and other illness characteristics.
Mental Health, Diabetes and Endocrinology examines the main areas of clinical overlap between endocrinology and mental health to address key clinical conundrums. Drawing on the most recent developments from literature and clinical practice, this book gives specific attention to the main areas where clinical conundrums and treatment challenges arise across endocrinology, psychiatry, psychology and primary care. Common challenges in this area include depression which can impact on the person's ability to self-care and to adhere to treatment with consequences for their morbidity and mortality; 'diabulaemia' associated with high mortality rates; obesity and associated mental disorders; cognitive impairment and mental capacity; anti-psychotic medications and their endocrine sequelae; and specific setting-related considerations. Mental Health, Diabetes and Endocrinology is a useful resource for the overlapping conditions across these specialities, and provides clinically-focussed evidence-based resources for all health care professionals who encounter these issues.
The best evidence for effective treatment of personality disorder supports the use of specialized forms of psychotherapy. However, these forms of treatment are generally unavailable in health care systems. This may be partly due to the expense of routinely offering long‐term therapies. There is evidence that psychotherapy for personality disorder is cost‐effective. One way to address this problem is to treat most patients more briefly.
Background
Over the decades, a variety of psychological interventions for borderline personality disorder (BPD) have been developed. This review updates and replaces an earlier review (Stoffers‐Winterling 2012).
Objectives
To assess the beneficial and harmful effects of psychological therapies for people with BPD.
Search methods
In March 2019, we searched CENTRAL, MEDLINE, Embase, 14 other databases and four trials registers. We contacted researchers working in the field to ask for additional data from published and unpublished trials, and handsearched relevant journals. We did not restrict the search by year of publication, language or type of publication.
Selection criteria
Randomised controlled trials comparing different psychotherapeutic interventions with treatment‐as‐usual (TAU; which included various kinds of psychotherapy), waiting list, no treatment or active treatments in samples of all ages, in any setting, with a formal diagnosis of BPD. The primary outcomes were BPD symptom severity, self‐harm, suicide‐related outcomes, and psychosocial functioning. There were 11 secondary outcomes, including individual BPD symptoms, as well as attrition and adverse effects.
Data collection and analysis
At least two review authors independently selected trials, extracted data, assessed risk of bias using Cochrane's 'Risk of bias' tool and assessed the certainty of the evidence using the GRADE approach. We performed data analysis using Review Manager 5 and quantified the statistical reliability of the data using Trial Sequential Analysis.
Main results
We included 75 randomised controlled trials (4507 participants), predominantly involving females with mean ages ranging from 14.8 to 45.7 years. More than 16 different kinds of psychotherapy were included, mostly dialectical behaviour therapy (DBT) and mentalisation‐based treatment (MBT). The comparator interventions included treatment‐as‐usual (TAU), waiting list, and other active treatments. Treatment duration ranged from one to 36 months.
Psychotherapy versus TAU
Psychotherapy reduced BPD symptom severity, compared to TAU; standardised mean difference (SMD) −0.52, 95% confidence interval (CI) −0.70 to −0.33; 22 trials, 1244 participants; moderate‐quality evidence. This corresponds to a mean difference (MD) of −3.6 (95% CI −4.4 to −2.08) on the Zanarini Rating Scale for BPD (range 0 to 36), a clinically relevant reduction in BPD symptom severity (minimal clinical relevant difference (MIREDIF) on this scale is −3.0 points).
Psychotherapy may be more effective at reducing self‐harm compared to TAU (SMD −0.32, 95% CI −0.49 to −0.14; 13 trials, 616 participants; low‐quality evidence), corresponding to a MD of −0.82 (95% CI −1.25 to 0.35) on the Deliberate Self‐Harm Inventory Scale (range 0 to 34). The MIREDIF of −1.25 points was not reached.
Suicide‐related outcomes improved compared to TAU (SMD −0.34, 95% CI −0.57 to −0.11; 13 trials, 666 participants; low‐quality evidence), corresponding to a MD of −0.11 (95% CI −0.19 to −0.034) on the Suicidal Attempt Self Injury Interview. The MIREDIF of −0.17 points was not reached.
Compared to TAU, psychotherapy may result in an improvement in psychosocial functioning (SMD −0.45, 95% CI −0.68 to −0.22; 22 trials, 1314 participants; low‐quality evidence), corresponding to a MD of −2.8 (95% CI −4.25 to −1.38), on the Global Assessment of Functioning Scale (range 0 to 100). The MIREDIF of −4.0 points was not reached.
Our additional Trial Sequential Analysis on all primary outcomes reaching significance found that the required information size was reached in all cases.
A subgroup analysis comparing the different types of psychotherapy compared to TAU showed no clear evidence of a difference for BPD severity and psychosocial functioning.
Psychotherapy may reduce depressive symptoms compared to TAU but the evidence is very uncertain (SMD −0.39, 95% CI −0.61 to −0.17; 22 trials, 1568 participants; very low‐quality evidence), corresponding to a MD of −2.45 points on the Hamilton Depression Scale (range 0 to 50). The MIREDIF of −3.0 points was not reached.
BPD‐specific psychotherapy did not reduce attrition compared with TAU. Adverse effects were unclear due to too few data.
Psychotherapy versus waiting list or no treatment
Greater improvements in BPD symptom severity (SMD −0.49, 95% CI −0.93 to −0.05; 3 trials, 161 participants), psychosocial functioning (SMD −0.56, 95% CI −1.01 to −0.11; 5 trials, 219 participants), and depression (SMD −1.28, 95% CI −2.21 to −0.34, 6 trials, 239 participants) were observed in participants receiving psychotherapy versus waiting list or no treatment (all low‐quality evidence). No evidence of a difference was found for self‐harm and suicide‐related outcomes.
Individual treatment approaches
DBT and MBT have the highest numbers of primary trials, with DBT as subject of one‐third of all included trials, followed by MBT with seven RCTs.
Compared to TAU, DBT was more effective at reducing BPD severity (SMD −0.60, 95% CI −1.05 to −0.14; 3 trials, 149 participants), self‐harm (SMD −0.28, 95% CI −0.48 to −0.07; 7 trials, 376 participants) and improving psychosocial functioning (SMD −0.36, 95% CI −0.69 to −0.03; 6 trials, 225 participants). MBT appears to be more effective than TAU at reducing self‐harm (RR 0.62, 95% CI 0.49 to 0.80; 3 trials, 252 participants), suicidality (RR 0.10, 95% CI 0.04, 0.30, 3 trials, 218 participants) and depression (SMD −0.58, 95% CI −1.22 to 0.05, 4 trials, 333 participants). All findings are based on low‐quality evidence. For secondary outcomes see review text.
Authors' conclusions
Our assessments showed beneficial effects on all primary outcomes in favour of BPD‐tailored psychotherapy compared with TAU. However, only the outcome of BPD severity reached the MIREDIF‐defined cut‐off for a clinically meaningful improvement. Subgroup analyses found no evidence of a difference in effect estimates between the different types of therapies (compared to TAU) .
The pooled analysis of psychotherapy versus waiting list or no treatment found significant improvement on BPD severity, psychosocial functioning and depression at end of treatment, but these findings were based on low‐quality evidence, and the true magnitude of these effects is uncertain. No clear evidence of difference was found for self‐harm and suicide‐related outcomes.
However, compared to TAU, we observed effects in favour of DBT for BPD severity, self‐harm and psychosocial functioning and, for MBT, on self‐harm and suicidality at end of treatment, but these were all based on low‐quality evidence. Therefore, we are unsure whether these effects would alter with the addition of more data.
Background
Diagnosing borderline personality disorder in adolescence is controversial. Early and appropriate treatment for adolescents showing traits of borderline personality disorder is urgently needed.
Objective
However, while some studies on the effectiveness and efficacy of psychodynamic therapy in adults with borderline personality disorder exist, research on adolescents is scarce.
Methods
In a randomized controlled trial in an inpatient setting, we demonstrated the effectiveness of the psychoanalytic-interactional method (PiM) in adolescents diagnosed with borderline personality disorder or structural deficits (Salzer et al., 2013; Salzer et al., 2014).
Results
PiM is a useful method in both inpatient and outpatient treatment and fits the specific requirements of adolescent treatment.
Background
Borderline personality disorder (BPD) is characterized by severe emotion dysregulation that is often complicated by comorbid diagnoses, deliberate self-harm, and chronic suicidal ideation. Unfortunately, current care pathways for individuals with BPD are strained by limited resources, inadequate training, and an overuse of emergency departments and crisis teams. Such barriers result in delayed access to effective treatment, which increases risk of deterioration, disability, and morbidity. A first step toward addressing these limitations of the current care pathway is to understand key stakeholders’ lived experiences in this pathway and their perspectives on potential solutions.
Objective
The purpose of this paper is to present a protocol for a study that explores the lived experiences of the current care pathway from the perspectives of patients with BPD, as well as their caregivers and clinicians.
Methods
A qualitative approach is most appropriate for the exploratory nature of the research objective. Accordingly, 3 to 6 patients with a diagnosis of BPD, 3 caregivers of individuals with BPD, and 3 clinicians of patients diagnosed with BPD will be invited to participate in individual, semistructured interviews that focus on service experiences.
Results
It is anticipated that results will yield insight into the lived experiences of patients with BPD, caregivers, and clinicians and provide a better understanding of the perceived gaps in services and potential solutions. Results are expected to be available in 12 months.
Conclusions
This paper describes a protocol for a qualitative study that seeks to understand the lived experiences and perspectives of key stakeholders (patients, caregivers, and clinicians) on the current care pathway for BPD. Results will provide a basis for future research in this area and will have the potential to inform training, practice, and policy.
International Registered Report Identifier (IRRID)
DERR1-10.2196/14885
Background
Patient self-monitoring via mobile phones during psychotherapy can enhance and provide an overview of psychotherapeutic progress by graphically displaying current and previous symptom scores, providing feedback to the patient, delivering psychoeducative material, and providing timely data to the therapist or treatment team.
Objective
This study will aim to assess the effects of using a mobile phone to self-monitor symptoms and acquire coping skills instead of using pen and paper during psychotherapy in patients with borderline personality disorder (BPD). Dialectical behavior therapy will be performed to treat BPD. The primary outcome is the mean time needed to learn coping skills directed at emotion regulation; the secondary outcome is changes in the BPD symptom score as measured by the Zanarini Rating Scale for Borderline Personality Disorder.
Methods
This study is a pragmatic, multicenter randomized controlled trial. Participants were recruited through five public general psychiatric outpatient treatment facilities in Denmark. Patients are randomly assigned, on a 1:1 basis, to either the mobile phone condition (using the Monsenso mDiary mobile app) or pen-and-paper condition. Patients will complete several self-report questionnaires on symptom severity; assessments by trained raters on BPD severity will be performed as well. Survival analysis with a shared frailty model will be used to assess the primary outcome.
Results
Recruitment began in June 2017 and was completed in February 2019 after 80 participants were recruited. The study ended in February 2020. It is expected that the benefits of mobile phone–based self-report compared to the pen-and-paper method will be demonstrated for skill learning speed and registration compliance. To our knowledge, this is the first trial exploring the impact of cloud-based mobile registration in BPD treatment.
Conclusions
This trial will report on the effectiveness of mobile phone–based self-monitoring during psychiatric treatment. It has the potential to contribute to evidence-based clinical practice since apps are already in use clinically.
Trial Registration
ClinicalTrials.gov NCT03191565; https://clinicaltrials.gov/ct2/show/NCT03191565
International Registered Report Identifier (IRRID)
DERR1-10.2196/17737
Step 5 of the EBP process is to finalize the treatment plan with the client and to formally document it in the client’s record. Step 5 builds on the collaborative exploration of relevant and potentially effective treatments done in Step 4. Step 6 of the EBP process is to implement the treatment, including monitoring and evaluation of the client’s progress. This chapter explores several issues related to finalizing the treatment plan. Clinical expertise is often required to ensure the treatment plan is feasible. Further, differences between the research designs most often found in systematic reviews and prioritized in the EBM/EBP hierarchy of evidence are compared and contrasted with research designs most often used in evaluating individual client progress. Several approaches to qualitative and quantitative clinical practice evaluation are also described and critically examined.
Step 3 of EBP centers on evaluating research quality and relevance. This chapter explores sampling, measures, definitions of treatments, and the use of the correct statistical tests in EBP research evaluation. Level of measure, sampling distributions, and different types of statistics are addressed. Treatment manuals are described and illustrated. All these components of research work in tandem to yield valid and rigorous results in quantitative clinical research. Of particular interest is how relevant research methods are to the unique client. This may be important for racially, ethnically, and/or gender nonconforming clients and for immigrant clients. This chapter examines these research methods issues in depth.
La Terapia Dialéctica Conductual (TDC) es un tratamiento desarrollado para pacientes con Trastorno Límite de la Personalidad (TLP). En la TDC se combinan técnicas de terapia de la conducta con principios de aceptación de la realidad derivados del Zen y de la filosofía dialéctica. La TDC es una terapia multi-modal que incluye 4 componentes: terapia individual, entrenamiento grupal en habilidades, soporte telefónico y un grupo de consulta para los terapeutas. Como lo demuestran distintos ensayos clínicos controlados y aleatorizados, la TDC es hoy en día el único tratamiento para el TLP que ha sido suficientemente investigado como para considerarse basado en la evidencia. La TDC también ha sido adaptada para el tratamiento de otras patologías vinculadas a la disregulación emocional, lo que ha contribuido a ampliar su aplicación a otras poblaciones clínicas. En este sentido, el entrenamiento en habilidades también se aplica como componente único de tratamiento, acumulando cada vez más evidencia en relación a su eficacia. En el presente artículo se exponen los principios básicos de la terapia y se realiza una revisión de sus aplicaciones clínicas y así como de la evidencia empírica disponible hasta el momento.
Findings from randomized controlled trials and meta-analyses suggest that there are several efficacious treatments for borderline personality disorder, including those based on cognitive behavior theories and psychodynamic theories. In addition, there are generalist and adjunctive approaches. These treatments and the corresponding evidence associated with each are described. It is concluded randomized controlled trials and meta-analyses suggest little to no difference between any active specialty treatments for borderline personality disorder; there are no differences between dialectical behavior therapy and non–dialectical behavior therapy treatments or between cognitive behavior–based and psychodynamic theory–based treatments. Thus, clinicians are justified in using any of these efficacious treatments.
We examined which items on the Borderline Evaluation of Severity Over Time and the Zanarini Rating Scale for Borderline Personality Disorder improved during participation in Systems Training for Emotional Predictability and Problem Solving (STEPPS). Data on 193 subjects from two independent sources were included: (1) a randomized controlled trial at an academic medical centre and (2) uncontrolled data from Iowa's correctional system. STEPPS effect size was estimated by contrasting effect size for those in the randomized controlled trial assigned to STEPPS + treatment as usual to effect size for those assigned to treatment as usual alone. Items from the Borderline Evaluation of Severity Over Time scale showing the greatest improvement assessed affective instability, 'taking steps to avoid/prevent problems', 'choosing to use a positive activity', identity disturbance and abandonment fears. The Zanarini Rating Scale for Borderline Personality Disorder items showing the greatest improvement assessed mood instability, chronic feelings of emptiness and identity disturbance. STEPPS effect size was significant for the Borderline Evaluation of Severity Over Time items rating paranoia and 'taking steps to avoid/prevent problems' and the Zanarini Rating Scale for Borderline Personality Disorder items assessing paranoia, impulsivity, chronic emptiness and unstable relationships. This, and future work, could eventually help in matching patients to particular treatment programmes that target their preponderant symptoms. © 2018 John Wiley & Sons, Ltd.
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:
To assess the beneficial and harmful effects of psychological therapies for people with borderline personality disorder (BPD).
This chapter describes the origins, structure and applications of dialectical behaviour therapy (DBT) and the evidence base for its efficacy across adult patient populations. A review of current literature, prospective directions and contraindications for DBT in the treatment of pathological gambling (PG), and a case study are included. Despite strong evidence for the efficacy of DBT for other addictions, disorders with a high comorbidity with PG, and commonly co-occurring features such as emotion dysregulation, there has been limited research in the application of this therapy to the PG population. Research is needed to delineate the groups for which DBT treatment may be effective. The theoretical links outlined suggest a cautiously hopeful outlook for the use of this intervention for a subgroup of pathological gamblers (PGs), particularly for those who are less responsive to traditional CBT.
Group schema therapy (GST) has been proposed as a novel long-term treatment programme for borderline and cluster C personality disorders. We implemented a short-term GST programme (12–15 sessions, based on the manual by Farrell and Shaw (2012), including both cognitive / behavioural and experiential interventions for in-patients (n=9) with either borderline or cluster C personality disorders (and axis I co-morbidities) treated in a (sub)acute psychiatric in-patient setting. We evaluated pre- and post-treatment self-report of maladaptive and adaptive schema modes (using the SMI) and early maladaptive schemas (YSQ-3), as well as overall symptom severity (brief symptom check list, BSCL-53-S), patient satisfaction (ZUF-8) and group climate and coherence (GCQ-S). We found significant reduction of symptoms, and trend-level improvement for schema mode activation, but not maladaptive schemas. Effect sizes of Cohen's d=0.857 for symptoms and d=0.693 for maladaptive schema mode reduction were, however, lower than previous GST trials in in-patient settings with a longer treatment phase and outpatient GST trials using the Farrell and Shaw-model, indicating importance of duration in ST treatment. Our findings in this uncontrolled study provide first evidence that GST (based on the Farrell and Shaw model) can be implemented and adapted for use in short-term in-patient (sub)acute settings.
Our objective was to investigate, in a naturalistic, prospective study, the follow-up status of patients with borderline personality disorder (BPD) treated with a combination of day treatment and subsequent outpatient group psychotherapy (G-group, n=12) and compare their status with that of patients with BPD treated in the same day hospital but without subsequent outpatient group therapy (Non-G-group, n=31). At follow-up an average of 34 months after discharge from the day hospital, the G-group patients had a moderate impairment in global health (HSRS), a low level of symptoms (GSI), a low rate of rehospitalization and suicide attempts, and a high rate of remission from substance use disorders. Compared with the Non-G-group, the G-group patients had a significantly higher HSRS and a significantly lower GSI at follow-up. In multivariate analyses controlling for background and treatment variables, number of months in work last year before admission and outpatient group therapy predicted a better HSRS at fol...
The present study is based on a large population of borderline and other patients intensively treated on an inpatient unit specialized for long-term psychotherapy. This paper concerns global outcome data on 205 patients with borderline personality disorder as defined by DSM-III (APA, 1980), of whom 188 (91.7%) were traced. The comparison group consists of 99 DSM-III-defined schizophrenics, of whom 95 (96%) were traced.
In most randomised trials each subject is individually assigned at random to an intervention group. The intervention is applied directly to the subject and observations are made on each individual to determine the outcome of the intervention. Sometimes subjects cannot be allocated independently, or they may interact with one another during the treatment period.
In trials of population screening, for example, screening centres may be set up in some districts and not in others. This may be necessary because widespread publicity is needed to encourage subjects to come for screening, or because members of the screening group might pass on information to neighbours who have been allocated to the control arm (no screening), leading them to demand screening.
In the Swedish two county trial of breast cancer screening the county of Kopparberg was divided into seven geographical areas.1 2 Each was then subdivided into three units, …
As a consequence of adverse childhood experiences, offenders can develop mental health problems consistent with a diagnosis of borderline personality disorder (BPD). This is characterised by difficulties with distress tolerance, emotional and behavioural regulation, and interpersonal skills, that often manifests as recurrent suicidal ideation and self-harm. The dynamic interaction between the prison environment, offender psychopathology and individual coping styles further elevates this risk for suicide and self-harm. There are few treatment programs with proven efficacy in managing borderline characteristics with the exception of dialectical behaviour therapy (DBT) developed by Marsha Linehan (1993a) for clinical populations. However, the development, implementation and evaluation of forensic-based DBT programs is in its infancy. The RUSH (Real Understanding of Self-Help) Program is a recent Australian DBT adaptation targeting vulnerable offenders exhibiting borderline characteristics. This paper provides an in-depth exploration of RUSH, highlighting the modifications made to the original DBT framework. Therapeutic obstacles associated with implementing RUSH in a correctional environment are discussed, together with successful strategies to overcome these difficulties. Finally, examination of quantitative and qualitative outcomes suggests that RUSH is a promising, holistic offender rehabilitation program targeting BPD characteristics and related problem areas.
Service usage of 24 patients with a personality disorder was established for one year pre-treatment and one year post-treatment via a prospective survey of the patients, their original referrer and their general practitioner. The average annual cost of psychiatric and prison services (calculated from extra-contractual referrals (ECR) tariffs and Home Office data) was Σ13 966 pre-treatment compared to Σ1308 post-treatment, representing a cost-offset of Σ12 658 per patient per year. The average cost of the specialist admission was Σ25 641. Thus the cost to the Nation for treating these personality disordered patients in a tertiary treatment resource would be recouped within two years and represent a saving thereafter.
ABSTRACT Given that borderline personality disorder (BPD) is increasingly managed by community mental health teams (CMHTs), an exploration of the effectiveness of the cognitive-analytic model (Ryle 1997a) was undertaken in this context. A young man with a primary diagnosis of BPD was offered a course of cognitive-analytic therapy (CAT) by a member of the CMHT. Therapy was only partially successful, due apparently to the severity of the disorder but also, critically, to the absence of a shared understanding of the disorder by team members as well as other agencies involved. However, the CAT model, involving explicit reformulation, helped educate key members of the team about the disorder and the part they might play in it and to contain the splitting and anxiety provoked by such a patient. In addition, CAT created a reasonably robust therapeutic alliance, with more regular contact and no re-admission during the period of therapy. An extended‘contextual’ reformulation can also offer a means of understanding the difficulties encountered in working with such patients, classically described by Main in‘The ailment’ (1957), and provide the conceptual containment required to work with such‘difficult’ patients.
A comparison of the social role performance of acutely depressed women with a matched non-symptomatic normal group, using a semi-structured interview, indicates that depressed women are significantly more impaired in all roles. The degree of the depressive's impairment in intimate interpersonal relations provides a significant context for understanding symptom formation and treatment processes.
The development of a 21-item self-report inventory for measuring the severity of anxiety in psychiatric populations is described. The initial item pool of 86 items was drawn from three preexisting scales: the Anxiety Checklist, the Physician’s Desk Reference Checklist, and the Situational Anxiety Checklist. A series of analyses was used to reduce the item pool. The resulting Beck Anxiety Inventory (BAI) is a 21-item scale that showed high internal consistency (α = .92) and test—retest reliability over 1 week, r (81) = .75. The BAI discriminated anxious diagnostic groups (panic disorder, generalized anxiety disorder, etc.) from nonanxious diagnostic groups (major depression, dysthymic disorder, etc). In addition, the BAI was moderately correlated with the revised Hamilton Anxiety Rating Scale, r (150) = .51, and was only mildly correlated with the revised Hamilton Depression Rating Scale, r (153) = .25.
Objective: Funnel plots (plots of effect estimates against sample size) may be useful to detect bias in meta-analyses that were later contradicted by large trials. We examined whether a simple test of asymmetry of funnel plots predicts discordance of results when meta-analyses are compared to large trials, and we assessed the prevalence of bias in published meta-analyses. Design: Medline search to identify pairs consisting of a meta-analysis and a single large trial (concordance of results was assumed if effects were in the same direction and the meta-analytic estimate was within 30
Describes the rationale, development, and validation of the Scale for Suicide Ideation, a 19-item clinical research instrument designed to quantify and assess suicidal intention. In a sample with 90 hospitalized Ss, the scale was found to have high internal consistency and moderately high correlations with clinical ratings of suicidal risk and self-administered measures of self-harm. Furthermore, it was sensitive to changes in levels of depression and hopelessness (Beck Depression Inventory and Hopelessness Scale, respectively) over time. Its construct validity was supported by 2 studies by different investigators testing the relationship between hopelessness, depression, and suicidal ideation and by a study demonstrating a significant relationship between high level of suicidal ideation and "dichotomous" attitudes about life and related concepts on a semantic differential test. Factor analysis yielded 3 meaningful factors: Active Suicidal Desire, Specific Plans for Suicide, and Passive Suicidal Desire. (29 ref)
• Current emphasis on early case finding, outpatient care, and on longitudinal studies of asymptomatic patients has focused attention on the community adjustment of psychiatric patients. Thus, simple and inexpensive methods such as self-report scales, which allow the routine assessment of patient adjustment, are potentially useful.
The derivation and testing of such a method, the Social Adjustment Scale Self-Report, is described. This scale covers the patient's role performance, interpersonal relationships, friction, feelings and satisfaction in work, and social and leisure activities with the extended family, as a spouse, parent, and member of a family unit. Self-report results based on 76 depressed outpatients were comparable to those obtained from relatives as well as by a rater who interviewed the patient directly.
This study evaluated the effectiveness of well-defined outpatient psychotherapy for patients with borderline personality disorder.
Thirty patients with borderline personality disorder diagnosed according to the DSM-III criteria were given twice weekly outpatient psychotherapy for 12 months by trainee therapists who were closely supervised. The treatment approach was based on a psychology of self (this term being used in its broad sense), and strong efforts were made to ensure that all therapists adhered to the treatment model. Outcome measures included frequency of use of drugs (both prescribed and illegal), number of visits to medical professionals, number of episodes of violence and self-harm, time away from work, number of hospital admissions, time spent as an inpatient, score on a self-report index of symptoms, and number of DSM-III criteria (weighted for frequency, severity, and duration) fulfilled.
The subjects showed statistically significant improvement from the initial assessment to the end of the year of follow-up on every measure. Moreover, 30% of the subjects no longer fulfilled the DSM-III criteria for borderline personality disorder. This improvement had persisted 1 year after the cessation of therapy.
The results suggest that a specific form of psychotherapy is of benefit for patients with borderline personality disorder.
A randomized clinical trial was conducted to evaluate the effectiveness of a cognitive-behavioral therapy, ie, dialectical behavior therapy, for the treatment of chronically parasuicidal women who met criteria for borderline personality disorder. The treatment lasted 1 year, with assessment every 4 months. The control condition was "treatment as usual" in the community. At most assessment points and during the entire year, the subjects who received dialectical behavior therapy had fewer incidences of parasuicide and less medically severe parasuicides, were more likely to stay in individual therapy, and had fewer inpatient psychiatric days. There were no between-group differences on measures of depression, hopelessness, suicide ideation, or reasons for living although scores on all four measures decreased throughout the year.
We constructed a set of circumplex scales for the Inventory of Interpersonal Problems (IIP; Horowitz, Rosenberg, Baer, Ureno, & Villasenor, 1988). Initial scale construction used all 127 items from this instrument in two samples of university undergraduates (n = 197; n = 273). Cross-sample stability of item locations plotted against the first two principal components was high. A final set of eight 8-item circumplex scales was derived from the combined sample (n = 470) and cross-validated in a third university sample (n = 974). Finally, we examined the structural convergence of the IIP circumplex scales with an established measure of interpersonal dispositions, the Revised Interpersonal Adjective Scales (IAS-R; Wiggins, Trapnell, & Phillips, 1988). Although both circumplex instruments were derived independently, they shared a common Circular space. Implications of these results are discussed with reference to current research methods for the study of interpersonal behavior.
There are very few studies on the changes in patients with borderline personality disorder (BPD) treated with psychodynamic psychotherapy, around the world, and as far as we know, this is the first report in Mexico on this subject. The main features of this disorder appear at 18 years of age (75% females; 25% males) and are frequent crises characterized by impulsivity (physical figths, substance abuse, suicide or selfmutilating behavior), affective instability (episodes of depression, anxiety and anger) and alterations in identity (sudden changes in values, vocational or laboral goals) that consume a lot of health resources and contribute to many failures in academic and work performance. Its treatment always needs some form of individual or group psychotherapy, with medication at times. In most of the clinical settings this disorder is considered as untractable or to take years to produce beneficial modifications. According to the epidemiological studies of several countries, this disorder appears in 1.1 to 4.6% in the general population, in 10% of the patients in ambulatory mental health centers, in 20% of the hospitalized psychiatric patients and in 30 to 60% of the patients with personality disorders. In a clinical psychiatric population in the Central Military Hospital (Mexico City) the prevalence was 35.7%. This paper reports changes observed in the psychopathology of borderline personality disorder treated by therapists trained in the Kernberg's manualized psychodynamic psychotherapy, delivered in two weekly 45 minutes sessions, videorecorded and supervised once a week by experts. As for the therapists that participated in the study, four were psychoanalysts with a mean experience of 12 years (D.E. = 1.15) and 10 psychotherapists with a mean experience of 4.67 years (D.E. = 4.23). The experience of both groups of therapists was significately different (U = 7.5, p<.002). Nineteen patients were treated: four males and 15 females who met the DSM IV borderline personality disorder criteria. Measurements of the psychopathology and global functioning were made at the beginning of the treatment, and every 24 sessions during a two years period, using the Clarkin's Dimensional Scale of the DSM IV Borderline Personality Disorder, and the DSM IV Global Assessment of Functioning. The results were: a) Eleven patients no longer met the DSM IV borderline personality disorder criteria at the 72nd session measurement, b) there was a positive change in the severity of the psychopathology in all criteria along time, c) the impulsivity criteria disappeared at the 24th session evaluation; affective instability criteria almost disappeared at the 48th session evaluation, while identity alterations criteria had only minimal changes even in those patients that remained in treatment for almost two years, d) the gaining in the Global Assessment of Functioning from the beginning to the 72nd session measurement was 70% and, f) there were no significative differences between the type of therapist and the improvement of the patient in the measurements. These results should be replicated and contrasted with randomized and comparative studies between this type of therapy and supportive psychotherapy, cognitive-behavioral therapy, interpersonal therapy, group therapy and medication in patients of other social classes treated by residents in psychiatry and clinical psychologists before making available this therapy to a wider patients population.
A randomized, controlled trial was conducted on 110 subjects who scored positive on the Diagnostic Interview for Borderlines to assess the merits of an experimental, time-limited group treatment for borderline personality disorder (BPD) in comparison with the control condition, individual dynamic psychotherapy. Seventy-nine subjects received treatment. Analyses at 12- and 24-month follow-ups on 84% of the treated subjects (N = 66), demonstrated no statistically significant differences in outcome on the major dependent variables. Outpatient referrals to the study complied with the treatments at twice the rate of inpatient referrals. The total study cohort showed significant improvements on all major outcomes at follow-up. The cost effectiveness of the group approach, in tandem with its potential for application in a range of community services by multidisciplinary practitioners, speaks to the promise of this treatment as an innovative service approach for BPD.
The author discusses the treatment needs of the young, self-destructive, unstable borderline client. A practice approach reformulated on the basis of recent research findings on borderline developmental history and course of illness is presented. This approach employs strategies derived from trauma recovery and brief treatment to address self-destructiveness and high rates of attrition in this clinic population as well as the demands of managed mental health care for briefer, more effective treatment. Pragmatic goals and structured, focused interventions for initial contacts or the early stage of treatment are outlined and illustrated.
Background:
A randomized clinical trial was conducted to evaluate whether the superior performance of dialectical behavior therapy (DBT), a psychosocial treatment for borderline personality disorder, compared with treatment-as-usual in the community, is maintained during a 1-year posttreatment follow-up.
Methods:
We analyzed 39 women who met criteria for borderline personality disorder, defined by Gunderson's Diagnostic Interview for Borderline Personality Disorder and DSM-III-R criteria, and who had a history of parasuicidal behavior. Subjects were randomly assigned either to 1 year of DBT, a cognitive behavioral therapy that combines individual psychotherapy with group behavioral skills training, or to treatment-as-usual, which may or may not have included individual psychotherapy. Efficacy was measured on parasuicidal behavior (Parasuicide History Interview), psychiatric inpatient days (Treatment History Interview), anger (State-Trait Anger Scale), global functioning (Global Assessment Scale), and social adjustment (Social Adjustment Scale—Interview and Social Adjustment Scale—Self-Report). Subjects were assessed at 6 and 12 months into the follow-up year.
Results:
Comparison of the two conditions revealed that throughout the follow-up year, DBT subjects had significantly higher Global Assessment Scale scores. During the initial 6 months of the follow-up, DBT subjects had significantly less parasuicidal behavior, less anger, and better self-reported social adjustment. During the final 6 months, DBT subjects had significantly fewer psychiatric inpatient days and better interviewer-rated social adjustment. Conclusion: In general, the superiority of DBT over treatmentas-usual, found in previous studies at the completion of 1 year of treatment, was retained during a 1-year follow-up.
The difficulties inherent in obtaining consistent and adequate diagnoses for the purposes of research and therapy have been pointed out by a number of authors. Pasamanick12 in a recent article viewed the low interclinician agreement on diagnosis as an indictment of the present state of psychiatry and called for "the development of objective, measurable and verifiable criteria of classification based not on personal or parochial considerations, but on behavioral and other objectively measurable manifestations."Attempts by other investigators to subject clinical observations and judgments to objective measurement have resulted in a wide variety of psychiatric rating scales.4,15 These have been well summarized in a review article by Lorr11 on "Rating Scales and Check Lists for the Evaluation of Psychopathology." In the area of psychological testing, a variety of paper-and-pencil tests have been devised for the purpose of measuring specific
To comprehend the results of a randomized controlled trial (RCT), readers
must understand its design, conduct, analysis, and interpretation. That goal
can be achieved only through complete transparency from authors. Despite several
decades of educational efforts, the reporting of RCTs needs improvement. Investigators
and editors developed the original CONSORT (Consolidated Standards of Reporting
Trials) statement to help authors improve reporting by using a checklist and
flow diagram. The revised CONSORT statement presented in this article incorporates
new evidence and addresses some criticisms of the original statement.The checklist items pertain to the content of the Title, Abstract, Introduction,
Methods, Results, and Comment. The revised checklist includes 22 items selected
because empirical evidence indicates that not reporting the information is
associated with biased estimates of treatment effect or because the information
is essential to judge the reliability or relevance of the findings. We intended
the flow diagram to depict the passage of participants through an RCT. The
revised flow diagram depicts information from 4 stages of a trial (enrollment,
intervention allocation, follow-up, and analysis). The diagram explicitly
includes the number of participants, according to each intervention group,
included in the primary data analysis. Inclusion of these numbers allows the
reader to judge whether the authors have performed an intention-to-treat analysis.In sum, the CONSORT statement is intended to improve the reporting of
an RCT, enabling readers to understand a trial's conduct and to assess the
validity of its results.
In this article the authors describe the three-year combined group and individual therapy project for patients suffering from severe borderline personality disorder. The project attempted through careful supervision and regular whole-team meetings to integrate the research findings of attachment theory into the practice of both group and individual therapy. Material from the group sessions follows a description of the project's organization and the relevant attachment theory.
Es werden langfristige Veränderungen der borderlinespezifischen Symptomatik bei 14 Patienten mit der Diagnose Borderline-Persönlichkeitsstörung (Kriterien nach Kernberg u. Rorschach-Test) verglichen mit denen von 13 Patienten mit der Diagnose Schizophrenie und 16 mit der Diagnose Depression (jeweils ICD-9-Kriterien). Die Borderline-Symptomatik wird mit Hilfe des Diagnostischen Interviews für Borderliner (DIB) vor der Behandlung und 4 Jahre später zum Zeitpunkt der Katamnese erhoben. Die Behandlung für die Borderline-Patienten besteht jeweils aus der Teilnahme an einer ambulanten klientenzentrierten Gruppenpsychotherapie (2mal wöchentlich, ca. 100 Sitzungen insgesamt), die Behandlung der Kontrollgruppenpatienten folgt dem klinischen Standard.
Die Borderline-Symptomatik reduziert sich bei allen Patienten, am eindruckvollsten jedoch bei den Borderline-Patienten selbst: Von ursprünglich 14 Borderline-Patienten erfüllten 4 Jahre später nur noch 2 die DIB-Kriterien einer Borderline-Persönlichkeitsstörung. Allerdings gibt es deutliche Unterschiede bezüglich der Bereiche, in denen sich die Borderline-Symptomatik reduziert: Die Veränderungen sind am stärksten im Bereich „Impulskontrollverluste” und im Hinblick auf das Auftreten von psychotischen Episoden und am geringsten im Bereich „zwischenmenschliche Beziehungen”.
Long-Term Changes of Borderline Symptomatics of Patients After Client-Centred Group Psychotherapy:
In a follow-up study the long-term changes of borderline symptomatic of 14 patients with the diagnosis borderline personality disorder (criteria by Kernberg and Rorschach test) are compared with 13 patients with diagnosis schizophrenia and 16 patients with diagnosis depression (each case according to ICD-9 criteria). The Diagnostic Interview for Borderline Patients (DIB) is evaluated to comprehend the structure and kinds of borderline symptoms before and 4 years after treatment. Borderline patients are treated in a setting of client-centred group psychotherapy (twice a week, approximately 100 sessions). The treatment of the patients joining the control group is based on clinical standard.
As a result all patients reduced the borderline-like symptoms. However, the most significant changes can be seen in the borderline group. 2 out of 14 borderline patients still fulfill the DIB Criteria of borderline personality disorder. Nevertheless, there are differences in the reduction of specific categories of borderline symptoms. The greatest changes are in the categories „loss of impulse control” and „psychotic episodes”, whereas there are only slight improvements in the category „interpersonal relationships”.
Reviews the research to date on the course of personality disorders (PDs). All the studies that included some systematic research on the course of any of the PDs were located. A few older studies were not included because of diagnostic limitations. There was some difficulty directly comparing earlier studies that used idiosyncratic diagnoses. Studies that antedate Diagnostic and Statistical Manual of Mental Disorders-III (DSM-III) are described separately. 26 empirical studies are reviewed. The major methodological points and substantive findings are discussed across studies. Borderline PD was the most commonly studied Axis II disorder. Most studies used a prospective cohort design with either an Axis I or an Axis II comparison group. Regardless of diagnosis and length of follow-up, all longitudinal studies demonstrate that most Ss with PDs still have significant symptoms and impairment in social functioning on follow-up. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
As we have noted before, many statistical methods of analysis assume that the data have a normal distribution.1 When the data do not they can often be transformed to make them more normal.2 Readers of published papers may wish to be reassured that the authors have carried out an appropriate analysis. When authors present data in the form of a histogram or scatter diagram then readers can see at a glance whether the distributional assumption is met. If, however, only summary statistics are presented—as is often the case—this is much more difficult. If the summary statistics …
The aim of this article is to illustrate: (i) the advantages of a psychodynamically informed management of patients with a borderline personality organisation who require inpatient treatment; and (ii) the principles of a 'therapeutic community' approach in practice.
The 18-month residential therapeutic community treatment of a patient presenting with a history of brief psychotic episodes is described. An attempt is made to analyse the relationships between treatment variables and the patient's clinical progress over the treatment period.
By the end of treatment significant improvement in the patient's clinical state had occurred. Evidence is presented to support the conclusion that the treatment was an important factor in this outcome.
Clinical management based upon a psychodynamic understanding of the borderline patient's presentation is likely to best fit the individual patient's needs. Such a treatment approach, as embodied in a well-functioning therapeutic community, may help create the possibility of a 'new beginning' for the patient.
Borderline personality disorder is a severe form of Axis II pathology characterized by disturbed interpersonal relationships. Widely regarded as being very difficult to treat, problematic family interactions are thought to be central to the etiology and maintenance of the disorder. Recently, empirical research has suggested that higher family levels of emotional overinvolvement might be associated with borderline clients doing better clinically and staying out of the hospital. This article describes a family-based approach to the treatment of borderline personality disorder based on the expressed emotion construct. © 1998 John Wiley & Sons, Inc.
The family therapy of twenty-four cases of adolescents diagnosed as having borderline personality disorder is described. In comparison to matched psychiatric controls, the families of these adolescents were more angry and irritable and had higher rates of sexual abuse and sibling psychopathology. Relationship difficulties, in particular oscillating attachments, were frequently seen in therapy, which was more tumultuous with frequent impulsive acts of self-harm.
Deliberate self-harm (DSH) presents a significant health problem, especially as treatments have not been particularly successful in reducing repetition. Dialectical behaviour therapy (DBT; Linehan, 1993) is one approach that has reported some success in reducing self-harm rates in borderline personality disorder patients, who self-harm frequently, though it remains largely untested outside its original setting. The present study aimed to assess the effectiveness of DBT in self-harming women in an institutional setting in the United King-dom where self-harm is common. Female patients at Rampton Hospital who were displaying self-harming behaviour and met criteria for borderline personality disorder (N = 10) particip-ated in the full one-year treatment package of DBT. Patients were assessed on self-harm rates and on a number of psychological variables, pre-, during-and post-therapy, including a 6-month follow-up. There was a significant reduction in DSH during therapy, which was maintained at 6-month follow-up. This was paralleled by a reduction in dissociative experi-ences and an increase in survival and coping beliefs, alongside improvements in depression, suicide ideation, and impulsiveness. The findings are preliminary but the results suggest that DBT might provide an effective treatment for severe self-harm in institutional settings, and also highlight some of the psychological mechanisms that might mediate these improve-ments in self-harming behaviour.
Recent findings suggest that personality fragmentation may be a core component of borderline personality disorder (BPD) and that successful treatment of BPD may depend on the extent to which this is addressed. Cognitive analytic therapy (CAT) can increase integration by strengthening awareness, and hence control, of the dissociative processes maintaining fragmentation. This pilot study aimed to conduct a systematic evaluation of the impact of CAT on BPD severity and personality integration. A patient series within-subject design was used. Five BPD participants completed a series of assessments to evaluate the impact of therapy on BPD severity, fragmentation, dissociation, symptomatology and interpersonal adjustment before, during and following 16-session CAT. By follow-up, CAT had produced reductions in the severity of BPD for all five participants, and three participants showed significant changes in their levels of personality fragmentation. Improvements in comorbid disturbance were less consistent, however. Although the small number of participants involved limits these findings, they have theoretical and clinical interest. They generally support the suggestion that integration should be enhanced with BPD patients, and suggest that CAT may be a useful method to achieve this goal.
A randomized clinical trial was conducted to evaluate whether Dialectical Behavior Therapy (DBT), an effective cognitive-behavioral treatment for suicidal individuals with borderline personality disorder (BPD), would also be effective for drug-dependent women with BPD when compared with treatment-as-usual (TAU) in the community. Subjects were randomly assigned to either DBT or TAU for a year of treatment. Subjects were assessed at 4, 8, and 12 months, and at a 16-month follow-up. Subjects assigned to DBT had significantly greater reductions in drug abuse measured both by structured interviews and urinalyses throughout the treatment year and at follow-up than did subjects assigned to TAU. DBT also maintained subjects in treatment better than did TAU, and subjects assigned to DBT had significantly greater gains in global and social adjustment at follow-up than did those assigned to TAU. DBT has been shown to be more effective than treatment-as-usual in treating drug abuse in this study, providing more support for DBT as an effective treatment for severely dysfunctional BPD patients across a range of presenting problems.