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Malas O, Gómez-Domenech A. Effect of Dialectical Behavior Therapy on Negative Affect, and Symptoms of Depression and Anxiety in Individuals with Borderline Personality Disorder during COVID-19 Pandemic. J Clin Med 2024; 13:2603. [PMID: 38731131 PMCID: PMC11084774 DOI: 10.3390/jcm13092603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 04/24/2024] [Accepted: 04/27/2024] [Indexed: 05/13/2024] Open
Abstract
Background: This study investigated the effectiveness of dialectical behavior therapy (DBT) in patients with borderline personality disorder (BPD) during the COVID-19 pandemic, assessing negative affect, depression, and anxiety levels as indicators of health. Methods: A total of 287 participants were recruited, including BPD patients at different stages of treatment and the general population without a diagnosis of BPD. Questionnaires were used to assess the fear of COVID-19 and the referenced health indicators. Results: No differences were observed between groups in levels of fear of COVID-19, but there were differences in the health indicators studied. BPD patients in long-term treatment showed levels of negative affect similar to those of the general population, while those in early treatment stages exhibited significantly higher levels. However, no significant improvements were observed in levels of depression and anxiety in the long-term treatment group compared to those who underwent the initial treatment phase. Conclusions: These findings underscore the importance of effectively intervening in BPD, especially in stress-inducing situations such as the pandemic, and suggest the need to explore complementary approaches to addressing depression and anxiety in this clinical context.
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Affiliation(s)
- Olga Malas
- Department of Psychology, Sociology and Social Work, University of Lleida, 25001 Lleida, Spain
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Euler S, Babl A, Dommann E, Stalujanis E, Labrish C, Kramer U, McMain S. Maladaptive defense mechanisms moderate treatment outcome in 6 months versus 12 months dialectical-behavior therapy for borderline personality disorder. Psychother Res 2024:1-17. [PMID: 38648578 DOI: 10.1080/10503307.2024.2334053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 03/18/2024] [Indexed: 04/25/2024] Open
Abstract
OBJECTIVE We investigated whether defense mechanisms in patients with borderline personality disorder (BPD) predict treatment response of dialectical behavior therapy (DBT) and whether they moderate outcome in different treatment lengths. METHOD We analyzed a subsample of 60 outpatients with BPD, randomized into either 6 (n = 30) or 12 (n = 30) months of DBT. The average level of defensive adaptiveness, assessed with observer-rated overall defensive functioning (ODF) and "immature" (i.e., maladaptive) defenses were used as predictors and moderators of self-reported frequency of self-harm. We conducted a Generalized Linear Mixed Model (GLMM). RESULTS A lower ODF at treatment onset predicted smaller reductions in self-harm, irrespective of treatment length (IRR = 0.92, 95% CI = [0.86, 0.99], p = .020). Lower order "immature" ("major image distorting") defenses showed significantly smaller (IRR = 1.13, 95% CI = [1.06, 1.21], p < .001) and higher order "immature" ("minor image distorting") defenses showed significantly larger (IRR = .91, 95% CI = [.85, .97], p = .006) reductions in self harm in the 6-month but not in the 12-month treatment. CONCLUSION Even though the results have to be regarded as preliminary due to the small sample size, findings might indicate that patients with BPD and lower average defensive adaptiveness may benefit from individualized treatment plans including specific interventions targeting defense function.
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Affiliation(s)
- Sebastian Euler
- Department of Consultation Psychiatry and Psychosomatics, University Hospital of Zürich, Zürich, Switzerland
| | - Anna Babl
- Department of Clinical Psychology, Leiden University, Leiden, Netherlands
| | - Eliane Dommann
- Clinical Psychology and Psychotherapy Department, University of Bern, Bern, Switzerland
| | - Esther Stalujanis
- Department of Consultation Psychiatry and Psychosomatics, University Hospital of Zürich, Zürich, Switzerland
| | - Cathy Labrish
- Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
| | - Ueli Kramer
- Department of Psychiatry, Institute of Psychotherapy, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Shelley McMain
- Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
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Bozzatello P, Blua C, Marin G, Rocca P, Bellino S. Group interpersonal psychotherapy (IPT-G) for borderline personality disorder: A randomized controlled study. J Psychiatr Res 2023; 168:157-164. [PMID: 37913742 DOI: 10.1016/j.jpsychires.2023.10.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 10/12/2023] [Accepted: 10/25/2023] [Indexed: 11/03/2023]
Abstract
Recent evidence supported the notion that add-on group therapy should be provided to individuals with borderline personality disorder (BPD) who already undergo individual psychotherapy. The present 20 week-study was aimed to evaluate the efficacy of the adjunction of group interpersonal psychotherapy (IPT-G) to individual interpersonal psychotherapy adapted for BPD - revised (IPT-BPD-R) in comparison with individual IPT-BPD-R alone in a group of BPD patients. In addition, demographical and clinical characteristics that can be considered predictors of response to add-on group therapy were investigated. Forty-six patients were randomly assigned to 1) IPT-BPD-R plus IPT-G or to 2) IPT-BPD-R in the waiting list for IPT-G. Patients were assessed at baseline and after 20 weeks with: the Clinical Global Impression Scale, Severity item (CGI-S); the Social Occupational Functioning Assessment Scale (SOFAS); the Satisfaction Profile (SAT-P); the Borderline Personality Disorder Severity Index (BPDSI); the Modified Overt Aggression Scale (MOAS); the Childhood Trauma Questionnaire - Short Form (CTQ-SF); the Inventory of Interpersonal Problems (IIP-32); and the Reading the Mind in the Eyes Test (RMET). Statistical analyses included: ANOVA for repeated measures to compare score changes of the rating scales within groups (trial duration) and between groups (treatment modalities), and multiple regression analysis to identify which clinical factors are significantly and independently related to the difference of BPDSI score between baseline and week 20 (Δ BPDSI). The significance level was P ≤ 0.05. Both significant within-subjects effects (duration) and between-subjects effects (treatment modalities) were found for the following rating scales: MOAS; BPDSI items "feelings of emptiness", "outbursts of anger," and "affective instability"; RMET; SAT-P items "work" and "sleep, food, free time"; and IIP-32 scale "domineering/controlling". At the multiple regression analysis BPDSI item "impulsivity", RMET, and the subscale "socially inhibited" of the IIP-32 were significantly and independently related to Δ BPDSI score. In conclusion, the add-on of IPT-G produced higher improvement in core BPD symptoms, social cognition, a dysfunctional interpersonal style, and subjective quality of life. Subjects who were less impulsive, less socially inhibited, and with higher abilities in social cognition obtained greater benefits from the adjunction of group therapy. CLINICAL TRIALS REGISTRATION NUMBER: ACTRN12623000002684, Australian New Zealand Clinical Trials Registry (ANZCTR).
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Affiliation(s)
- Paola Bozzatello
- Department of Neuroscience, University of Turin, Via Cherasco 15, 10126, Turin, Italy.
| | - Cecilia Blua
- Department of Neuroscience, University of Turin, Via Cherasco 15, 10126, Turin, Italy.
| | - Giacomo Marin
- Department of Neuroscience, University of Turin, Via Cherasco 15, 10126, Turin, Italy.
| | - Paola Rocca
- Department of Neuroscience, University of Turin, Via Cherasco 15, 10126, Turin, Italy.
| | - Silvio Bellino
- Department of Neuroscience, University of Turin, Via Cherasco 15, 10126, Turin, Italy.
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Kramer U, Temes CM, Frankenburg FR, Glass IV, Zanarini MC. Course and predictors of social security disability insurance in patients with borderline personality disorder over 24 years of prospective follow-up. Borderline Personal Disord Emot Dysregul 2023; 10:30. [PMID: 37807072 PMCID: PMC10561411 DOI: 10.1186/s40479-023-00236-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 09/06/2023] [Indexed: 10/10/2023] Open
Abstract
BACKGROUND The utilization of Social Security Disability Insurance (SSDI) is frequent in patients with borderline personality disorder (BPD) and may represent a meaningful marker of a patient's symptom severity, poor psychosocial functioning, and/or inner suffering. Over 24 years of prospective follow-up, the present study aims to describe the course of SSDI and assess the role of clinically relevant predictors. METHODS A total of 290 inpatients with BPD were interviewed at baseline and 12 consecutive follow-up waves, each separated by two years, after index hospitalization. Included were also 72 inpatients with other personality disorders. Surviving patients were reinterviewed. A series of interviews and self-report measures were used to assess psychosocial functioning and treatment history, axis I and II disorders, and childhood/adult adversity. RESULTS Results show that rates of SSDI utilization were relatively stable over 24 years of follow-up (on average, 47.2% of the patients with BPD were on SSDI). Patients with BPD were three times more likely to be on SSDI than patients with other PDs. Patients with BPD displayed flexibility in their usage of SSDI. By 24 years, 46% of patients remitted, out of which 85% experienced recurrence and 50% of the patients had a new onset over time. In multivariate analyses, four variables were found to predict SSDI status in patients with BPD over time. These variables were: age 26 or older, lower IQ, severity of non-sexual childhood abuse, and presence of PTSD. CONCLUSIONS The results of this study suggest that a combination of a demographic factors, childhood adversity, natural endowment, and comorbidity are significant predictors of receiving SSDI over time. On a group level, there is a relative stability of SSDI usage over time, but on the individual level, the present study found a high fluctuation in receiving SSDI over 24 months of prospective follow-up.
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Affiliation(s)
- Ueli Kramer
- Department of Psychiatry, Institute of Psychotherapy and General Psychiatry Service, University of Lausanne, Place Chauderon 18, CH-1003, Lausanne, Switzerland.
| | | | - Frances R Frankenburg
- Edith Nourse Rogers VA Medical Center, Boston University School of Medicine, Boston, USA
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Katakis P, Schlief M, Barnett P, Rains LS, Rowe S, Pilling S, Johnson S. Effectiveness of outpatient and community treatments for people with a diagnosis of 'personality disorder': systematic review and meta-analysis. BMC Psychiatry 2023; 23:57. [PMID: 36681805 PMCID: PMC9862782 DOI: 10.1186/s12888-022-04483-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 12/19/2022] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Quality of care and access to effective interventions have been widely criticised as limited for people diagnosed with 'personality disorder' or who have comparable needs (described in some recent papers as "Complex Emotional Needs" (CEN). It is important to identify effective interventions and the optimal context and mode of delivery for people with CEN. We aimed to investigate the effectiveness of psychosocial interventions delivered in community and outpatient settings in treating symptoms associated with 'personality disorder', and the moderating effects of treatment-related variables. METHODS We systematically searched MEDLINE, EMBASE, PsycINFO, CINAHL, HMIC, ASSIA for articles published in English, from inception to November 23, 2020. We included randomized controlled trials examining interventions provided in community or outpatient settings for CEN. The primary outcome was 'personality disorder' symptoms, while secondary outcomes included anxiety symptoms, depressive symptoms, and global psychiatric symptoms. Random-effects meta-analysis was conducted for each outcome, and meta-regression analysis was performed to assess the moderating effects of treatment characteristics. The quality of the studies and the degree of publication bias was assessed. RESULTS We included 54 trials (n = 3716 participants) in the meta-analysis. We found a large effect size (g = 0.78, 95% CI: 0.56 to 1.01, p < 0.0001) favoring interventions for 'borderline personality disorder' (BPD) symptoms over Treatment as Usual or Waitlist (TAU/WL), and the efficacy was maintained at follow-up (g = 1.01, 95% CI: 0.37 to 1.65, p = 0.002). Interventions effectively reduced anxiety symptoms (g = 0.58, 95% CI: 0.21 to 0.95, p = 0.002), depressive symptoms (g = 0.57, 95% CI: 0.32 to 0.83, p < 0.0001), and global psychiatric symptoms (g = 0.50, 95% CI: 0.35 to 0.66, p < 0.0001) compared to TAU/WL. The intervention types were equally effective in treating all symptom categories assessed. Treatment duration and treatment intensity did not moderate the effectiveness of the interventions for any outcome. CONCLUSIONS People with a 'personality disorder' diagnosis benefited from psychological and psychosocial interventions delivered in community or outpatient settings, with all therapeutic approaches showing similar effectiveness. Mental health services should provide people with CEN with specialised treatments in accordance with the availability and the patients' preferences.
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Affiliation(s)
- Panos Katakis
- Division of Psychiatry, University College London, London, UK.
| | - Merle Schlief
- NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, UK
| | - Phoebe Barnett
- NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, UK
- Centre for Outcomes Research and Effectiveness, Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Luke Sheridan Rains
- NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, UK
| | - Sarah Rowe
- Division of Psychiatry, University College London, London, UK
| | - Steve Pilling
- Centre for Outcomes Research and Effectiveness, Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
- National Collaborating Centre for Mental Health, Royal College of Psychiatrists, London, UK
- Camden and Islington NHS Foundation Trust, London, UK
| | - Sonia Johnson
- NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, UK
- Camden and Islington NHS Foundation Trust, London, UK
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Bailey G, Halamová J, Vráblová V. Clients' Facial Expressions of Self-Compassion, Self-Criticism, and Self-Protection in Emotion-Focused Therapy Videos. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:1129. [PMID: 36673885 PMCID: PMC9859613 DOI: 10.3390/ijerph20021129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 12/31/2022] [Indexed: 06/17/2023]
Abstract
Clients' facial expressions allow psychotherapists to gather more information about clients' emotional processing. This study aims to examine and investigate the facial Action Units (AUs) of self-compassion, self-criticism, and self-protection within real Emotion-Focused Therapy (EFT) sessions. For this purpose, we used the facial analysis software iMotions. Twelve video sessions were selected for the analysis based on specific criteria. For self-compassion, the following AUs were significant: AUs 4 (brow furrow), 15 (lip corner depressor), and the AU12_smile (lip corner puller). For self-criticism, iMotions identified the AUs 2 (outer brow raise), AU1 (inner brow raise), AU7 (lid tighten), AU12_smirk (unilateral lip corner puller), and AU43 (eye closure). Self-protection was combined using the occurrence of AUs 1 and 4 and AU12_smirk. Moreover, the findings support the significance of discerning self-compassion and self-protection as two different concepts.
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Affiliation(s)
| | - Júlia Halamová
- Institute of Applied Psychology, Faculty of Social and Economic Sciences, Comenius University in Bratislava, Mlynské luhy 4, 821 05 Bratislava, Slovakia
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Stoffers-Winterling JM, Storebø OJ, Simonsen E, Sedoc Jørgensen M, Pereira Ribeiro J, Kongerslev MT, Lieb K. Perspectives on Dialectical Behavior Therapy and Mentalization-Based Therapy for Borderline Personality Disorder: Same, Different, Complementary? Psychol Res Behav Manag 2022; 15:3179-3189. [PMID: 36329713 PMCID: PMC9624210 DOI: 10.2147/prbm.s342257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 09/11/2022] [Indexed: 11/16/2022] Open
Abstract
Current evidence suggests that individuals with borderline personality disorder (BPD) are likely to benefit from specialized, or BPD-specific, treatments. Dialectical behavior therapy (DBT) and mentalization-based treatment (MBT) are currently the most intensively researched BPD treatments. Reviewing the current research, this paper highlights similarities and differences between the two treatments, and discusses possible ways they could complement each other. As the effectiveness of specialized treatments for BPD in general has been determined with some certainty, research now tends towards individualized approaches, identifying predictors of optimal treatment response. However, it is still to be settled who might profit from a combination of or sequential treatment with DBT and MBT.
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Affiliation(s)
- Jutta M Stoffers-Winterling
- Department of Psychiatry and Psychotherapy, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Ole Jakob Storebø
- Psychiatric Research Unit, Psychiatry Region Zealand, Slagelse, Denmark,Department of Psychology, University of Southern Denmark, Odense, Denmark,Correspondence: Ole Jakob Storebø, Psychiatric Research Unit, Psychiatry Region Zealand, Fælledvej 6, Slagelse, 4200, Denmark, Tel +45 24965917, Email
| | - Erik Simonsen
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark,Mental Health Services East, Psychiatry Region Zealand, Roskilde, Denmark
| | | | - Johanne Pereira Ribeiro
- Psychiatric Research Unit, Psychiatry Region Zealand, Slagelse, Denmark,Department of Psychology, University of Southern Denmark, Odense, Denmark
| | - Mickey T Kongerslev
- Psychiatric Research Unit, Psychiatry Region Zealand, Slagelse, Denmark,Department of Psychology, University of Southern Denmark, Odense, Denmark,Mental Health Services East, Psychiatry Region Zealand, Roskilde, Denmark
| | - Klaus Lieb
- Department of Psychiatry and Psychotherapy, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
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Ledden S, Rains LS, Schlief M, Barnett P, Ching BCF, Hallam B, Günak MM, Steare T, Parker J, Labovitch S, Oram S, Pilling S, Johnson S. Current state of the evidence on community treatments for people with complex emotional needs: a scoping review. BMC Psychiatry 2022; 22:589. [PMID: 36064337 PMCID: PMC9442944 DOI: 10.1186/s12888-022-04171-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 07/18/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Improving the quality of care in community settings for people with 'Complex Emotional Needs' (CEN-our preferred working term for services for people with a "personality disorder" diagnosis or comparable needs) is recognised internationally as a priority. Plans to improve care should be rooted as far as possible in evidence. We aimed to take stock of the current state of such evidence, and identify significant gaps through a scoping review of published investigations of outcomes of community-based psychosocial interventions designed for CEN. METHODS We conducted a scoping review with systematic searches. We searched six bibliographic databases, including forward and backward citation searching, and reference searching of relevant systematic reviews. We included studies using quantitative methods to test for effects on any clinical, social, and functioning outcomes from community-based interventions for people with CEN. The final search was conducted in November 2020. RESULTS We included 226 papers in all (210 studies). Little relevant literature was published before 2000. Since then, publications per year and sample sizes have gradually increased, but most studies are relatively small, including many pilot or uncontrolled studies. Most studies focus on symptom and self-harm outcomes of various forms of specialist psychotherapy: most result in outcomes better than from inactive controls and similar to other specialist psychotherapies. We found large evidence gaps. Adaptation and testing of therapies for significant groups (e.g. people with comorbid psychosis, bipolar disorder, post-traumatic stress disorder, or substance misuse; older and younger groups; parents) have for the most part only reached a feasibility testing stage. We found little evidence regarding interventions to improve social aspects of people's lives, peer support, or ways of designing effective services. CONCLUSIONS Compared with other longer term mental health problems that significantly impair functioning, the evidence base on how to provide high quality care for people with CEN is very limited. There is good evidence that people with CEN can be helped when specialist therapies are available and when they are able to engage with them. However, a much more methodologically robust and substantial literature addressing a much wider range of research questions is urgently needed to optimise treatment and support across this group.
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Affiliation(s)
- Sarah Ledden
- Division of Psychiatry, University College London, London, UK
| | - Luke Sheridan Rains
- NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, UK
| | - Merle Schlief
- NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, UK.
| | - Phoebe Barnett
- NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, UK
- Centre for Outcomes Research and Effectiveness, Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Brian Chi Fung Ching
- NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, UK
| | - Brendan Hallam
- Division of Psychiatry, University College London, London, UK
- Research Department of Primary Care & Population Health, University College London, London, UK
| | - Mia Maria Günak
- NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, UK
- Department of Psychology, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Thomas Steare
- NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, UK
| | - Jennie Parker
- NIHR Mental Health Policy Research Unit Co-Production Group, University College London, London, UK
| | - Sarah Labovitch
- NIHR Mental Health Policy Research Unit Co-Production Group, University College London, London, UK
- West London NHS Trust, London, UK
| | - Sian Oram
- NIHR Mental Health Policy Research Unit, Department of Health Service and Population Research, King's College London, London, UK
| | - Steve Pilling
- Centre for Outcomes Research and Effectiveness, Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
- National Collaborating Centre for Mental Health, Royal College of Psychiatrists, London, UK
- Camden and Islington NHS Foundation Trust, London, UK
| | - Sonia Johnson
- NIHR Mental Health Policy Research Unit, Division of Psychiatry, University College London, London, UK
- Camden and Islington NHS Foundation Trust, London, UK
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Stoffers-Winterling JM, Storebø OJ, Kongerslev MT, Faltinsen E, Todorovac A, Sedoc Jørgensen M, Sales CP, Edemann Callesen H, Pereira Ribeiro J, Völlm BA, Lieb K, Simonsen E. Psychotherapies for borderline personality disorder: a focused systematic review and meta-analysis. Br J Psychiatry 2022; 221:538-552. [PMID: 35088687 DOI: 10.1192/bjp.2021.204] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND A recently updated Cochrane review supports the efficacy of psychotherapy for borderline personality disorder (BPD). AIMS To evaluate the effects of standalone and add-on psychotherapeutic treatments more concisely. METHOD We applied the same methods as the 2020 Cochrane review, but focused on adult samples and comparisons of active treatments and unspecific control conditions. Standalone treatments (i.e. necessarily including individual psychotherapy as either the sole or one of several treatment components) and add-on interventions (i.e. complementing any ongoing individual BPD treatment) were analysed separately. Primary outcomes were BPD severity, self-harm, suicide-related outcomes and psychosocial functioning. Secondary outcomes were remaining BPD diagnostic criteria, depression and attrition. RESULTS Thirty-one randomised controlled trials totalling 1870 participants were identified. Among standalone treatments, statistically significant effects of low overall certainty were observed for dialectical behaviour therapy (self-harm: standardised mean difference (SMD) -0.54, P = 0.006; psychosocial functioning: SMD -0.51, P = 0.01) and mentalisation-based treatment (self-harm: risk ratio 0.51, P < 0.0007; suicide-related outcomes: risk ratio 0.10, P < 0.0001). For adjunctive interventions, moderate-quality evidence of beneficial effects was observed for DBT skills training (BPD severity: SMD -0.66, P = 0.002; psychosocial functioning: SMD -0.45, P = 0.002), and statistically significant low-certainty evidence was observed for the emotion regulation group (BPD severity: mean difference -8.49, P < 0.00001), manual-assisted cognitive therapy (self-harm: mean difference -3.03, P = 0.03; suicide-related outcomes: SMD -0.96, P = 0.005) and the systems training for emotional predictability and problem-solving (BPD severity: SMD -0.48, P = 0.002). CONCLUSIONS There is reasonable evidence to conclude that psychotherapeutic interventions are helpful for individuals with BPD. Replication studies are needed to enhance the certainty of findings.
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Affiliation(s)
| | - Ole Jakob Storebø
- Mental Health Services, Region Zealand Psychiatry, Denmark; and Department of Psychology, University of Southern Denmark, Denmark
| | - Mickey T Kongerslev
- Mental Health Services, Region Zealand Psychiatry, Denmark; and Department of Psychology, University of Southern Denmark, Denmark
| | - Erlend Faltinsen
- Mental Health Services, Region Zealand Psychiatry, Denmark; Centre for Evidence-Based Medicine Odense (CEBMO), University of Southern Denmark, Denmark; and Cochrane Denmark, Department of Clinical Research, University of Southern Denmark, Denmark
| | - Adan Todorovac
- Mental Health Services, Region Zealand Psychiatry, Denmark
| | | | - Christian P Sales
- Research & Innovation Department, Nottinghamshire Healthcare NHS Foundation Trust, UK
| | | | | | - Birgit A Völlm
- Department of Forensic Psychiatry, Rostock University Medical Centre, Germany
| | - Klaus Lieb
- Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Germany
| | - Erik Simonsen
- Mental Health Services, Region Zealand Psychiatry, Denmark; and Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
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Ciesinski NK, Sorgi-Wilson KM, Cheung JC, Chen EY, McCloskey MS. The effect of dialectical behavior therapy on anger and aggressive behavior: A systematic review with meta-analysis. Behav Res Ther 2022; 154:104122. [DOI: 10.1016/j.brat.2022.104122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 05/02/2022] [Accepted: 05/13/2022] [Indexed: 11/25/2022]
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Manfredi P, Taglietti C. A psychodynamic contribution to the understanding of anger - The importance of diagnosis before treatment. RESEARCH IN PSYCHOTHERAPY: PSYCHOPATHOLOGY, PROCESS AND OUTCOME 2022; 25. [PMID: 35796598 PMCID: PMC9422318 DOI: 10.4081/ripppo.2022.587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 05/16/2022] [Indexed: 11/23/2022]
Abstract
This paper starts from the claim that a shared understanding of anger, in both its normal and psychopathological dimensions, is missing and that there are various therapeutic paths that seem to be less effective than those related to other pathologies. A major limitation of anger research and of its treatments lies in the lack of precise clinical diagnoses to inform therapy. For this reason, the first aim of our work is to survey critical literature in order to find useful elements to differentiate anger, starting from the evidence of negative and positive outcomes of treatments. Such evidence will then be enhanced in our proposal of interpretation and intervention, within a dynamic framework and with particular reference to Orefice’s thought. The core focus is to explore the different functions that anger has for the patient and to investigate the elementary functioning of the self. Our reading of the phenomena related to anger will provide useful tools both for understanding the dynamics underlying anger and as a guide for clinical intervention.
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Chen SY, Cheng Y, Zhao WW, Zhang YH. Effects of dialectical behaviour therapy on reducing self-harming behaviours and negative emotions in patients with borderline personality disorder: A meta-analysis. J Psychiatr Ment Health Nurs 2021; 28:1128-1139. [PMID: 34519138 DOI: 10.1111/jpm.12797] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 08/26/2021] [Accepted: 09/07/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Dialectical behaviour therapy(DBT) has been widely used for borderline personality disorder(BPD). Existing studies are limited to behaviours such as self-harm, and the results for reducing self-harm were controversial. Few have systematically evaluated the effect of DBT on self-harming behaviours and negative emotions. AIM This study aims to evaluate the effects of DBT on self-harming behaviours and negative emotions in patients with BPD. METHODS RCTs on DBT for BPD were searched from PubMed, Embase, etc., and the results were performed by RevMan 5.3. RESULTS The meta-analysis demonstrated that DBT reduced self-harming behaviours, and alleviated depression, but had a negligible effect on suicidal ideation and anger. One subgroup revealed that standard DBT improved depression significantly, but DBT skills training improved poorly. Another subgroup revealed that there was a significant reduction in depression among patients receiving DBT for 4 months to 14 months, but not at 4 months. DISCUSSION AND IMPLICATIONS FOR PRACTICE Findings indicate that DBT can reduce self-harming behaviours and improve depression, but effects on suicidal ideation and anger are insignificant. Subgroup analysis suggests that standard DBT and DBT-ST lasting beyond 4 months benefits on BPD. Given the quality and quantity restrictions of RCTs, more high-quality RCTs need to verify these effects.
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Affiliation(s)
- Shu-Yan Chen
- School of Nursing, Nanjing Medical University, Nanjing, China
| | - Yin Cheng
- School of Nursing, Nanjing Medical University, Nanjing, China
| | - Wei-Wei Zhao
- School of Nursing, Nanjing Medical University, Nanjing, China.,Department of Nursing, Affiliated Nanjing Brain Hospital, Nanjing Medical University, Nanjing, China
| | - Yan-Hong Zhang
- School of Nursing, Nanjing Medical University, Nanjing, China.,Department of Nursing, Affiliated Nanjing Brain Hospital, Nanjing Medical University, Nanjing, China
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13
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Hesser H. Identifying causal mechanisms in psychotherapy: What can we learn from causal mediation analysis? Clin Psychol Psychother 2021; 29:1050-1058. [PMID: 34768315 DOI: 10.1002/cpp.2687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 11/04/2021] [Indexed: 11/09/2022]
Abstract
Despite widespread interest in the development of process-based psychotherapies, little is still known about the underlying processes that underpin our most effective therapies. Statistical mediation analysis is a commonly used analytical method to evaluate how, or by which processes, a therapy causes change in an outcome. Causal mediation analysis (CMA) represents a new advancement in mediation analysis that employs causally defined direct and indirect effects based on potential outcomes. These novel ideas and analytical techniques have been characterized as revolutionary in epidemiology and biostatistics, although they are not (yet) widely known among researchers in clinical psychology. In this paper, I outline the fundamental concepts underlying CMA, clarify the differences between the CMA approach and the traditional approach to mediation, and identify two important data analytical aspects that have been emphasized as a result of these recent advancements. To illustrate the key ideas, assumptions, and mathematical definitions intuitively, an applied clinical example from a previously published randomized controlled trial is used. CMA's main contributions are discussed, as well as some of the key challenges. Finally, it is argued that the most significant contribution of CMA is the formalization of mediation in a unified causal framework with clear assumptions.
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Affiliation(s)
- Hugo Hesser
- School of Law, Psychology and Social Work, Center for Health and Medical Psychology, Örebro University, Örebro, Sweden.,Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden
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Bohus M, Stoffers-Winterling J, Sharp C, Krause-Utz A, Schmahl C, Lieb K. Borderline personality disorder. Lancet 2021; 398:1528-1540. [PMID: 34688371 DOI: 10.1016/s0140-6736(21)00476-1] [Citation(s) in RCA: 81] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 01/18/2021] [Accepted: 02/18/2021] [Indexed: 12/15/2022]
Abstract
Borderline personality disorder (BPD) is a mental disorder with a high burden on patients, family members, and health-care systems. The condition was previously regarded as untreatable, but progress in understanding and management has resulted in earlier diagnosis and better treatment outcomes. A coherent syndrome of BPD typically onsets during adolescence (after age 12 years). BPD is often preceded by or co-develops with symptoms of internalising disorders (depression and anxiety), externalising disorders (conduct problems, hyperactivity, and substance use), or both. BPD is associated with various poor outcomes, including low occupational and educational attainment, lack of long-term relationships, increased partner conflict, sexual risk-taking, low levels of social support, low life satisfaction, and increased service use. Psychotherapy is the main treatment for BPD; drug treatment is only indicated for comorbid conditions that require medication, or during a crisis if psychosocial interventions are insufficient. Awareness of BPD by non-specialists, as well as specialists, is key to appropriate early intervention.
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Affiliation(s)
- Martin Bohus
- Institute for Psychiatric and Psychosomatic Psychotherapy, Central Institute of Mental Health Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany; Harvard Medical School, Boston, MA, USA
| | - Jutta Stoffers-Winterling
- Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany; Leibniz Institute for Resilience Research, Mainz, Germany
| | - Carla Sharp
- Department of Psychology, University of Houston, Houston, TX, USA
| | - Annegret Krause-Utz
- Department of Clinical Psychology, Leiden University, Leiden Institute of Brain and Cognition, Leiden, Netherlands
| | - Christian Schmahl
- Department of Psychosomatic Medicine and Psychotherapy, Central Institute of Mental Health Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Klaus Lieb
- Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany; Leibniz Institute for Resilience Research, Mainz, Germany.
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Beuchat H, Grandjean L, Despland J, Pascual‐Leone A, Gholam M, Swendsen J, Kramer U. Ecological momentary assessment of emotional processing: An exploratory analysis comparing daily life and a psychotherapy analogue session. COUNSELLING & PSYCHOTHERAPY RESEARCH 2021. [DOI: 10.1002/capr.12455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Hélène Beuchat
- Département de Psychiatrie Centre Hospitalier Universitaire Vaudois Prilly Switzerland
| | - Loris Grandjean
- Département de Psychiatrie Centre Hospitalier Universitaire Vaudois Prilly Switzerland
| | - Jean‐Nicolas Despland
- Département de Psychiatrie Centre Hospitalier Universitaire Vaudois Prilly Switzerland
| | | | | | | | - Ueli Kramer
- Département de Psychiatrie Centre Hospitalier Universitaire Vaudois Prilly Switzerland
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Mehlum L. Mechanisms of change in dialectical behaviour therapy for people with borderline personality disorder. Curr Opin Psychol 2021; 37:89-93. [DOI: 10.1016/j.copsyc.2020.08.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 08/12/2020] [Accepted: 08/16/2020] [Indexed: 01/03/2023]
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Caletti E, Pagliari C, Vai B, Delvecchio G, Brambilla P. Which are the best questionnaires to longitudinally evaluate mindfulness skills in personality disorders? J Affect Disord 2020; 277:169-174. [PMID: 32829192 DOI: 10.1016/j.jad.2020.08.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 08/03/2020] [Accepted: 08/06/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Personality disorders (PDs) are severe mental illnesses, characterized by inflexible and enduring response patterns in a broad range of personal and social situations. With the aim of identifying effective and evidence-based interventions, in the last decades we observed a flourishing of the so-called "thirdwave" cognitive-behavioural therapies, where mindfulness appears as relevant factor in promoting individual well-being and treatment response. In this regard, several authors tried to develop new instruments that enable to measure mindfulness skills, such as the Kentucky Inventory of Mindfulness Skills (KIMS), the Five Facet Mindfulness Questionnaire (FFMQ) and the Philadelphia Mindfulness Scale (PHLMS). The aim of this review is to provide new insights about the mindfulness questionnaires currently used in longitudinal studies in PDs by providing a benchmark for future studies evaluating mindfulness changes associated to therapeutic interventions. METHODS In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic search in PubMed was performed. Three reviewers conducted the data extraction. Longitudinal studies on PDs evaluating mindfulness skills through a validated questionnaire were selected. Ten studies met the selection criteria. RESULTS The majority of the studies reviewed (N=7) detected an increase in mindfulness skills (4 rated with FFMQ, 2 KIMS, and 1 Philadelphia Mindfulness Scale). Finally, from the selected studies mindfulness changes were also associated with clinical amelioration. LIMITATIONS Few studies evaluate male patients and PDs other than borderline personality disorder. CONCLUSION Although mindfulness is a complex construct to operationalize, the considered questionnaires emerged as useful instruments for clinicians to detect changes in mindfulness abilities. In particular, currently the FFMQ appears as the most suitable measure.
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Affiliation(s)
- Elisabetta Caletti
- Department of Neurosciences and Mental Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, via F. Sforza 35, 20122 Milan, Italy
| | | | - Benedetta Vai
- Division of Neuroscience, Psychiatry and Clinical Psychobiology, IRCCS Ospedale San Raffaele, Fondazione Centro San Raffaele, Milano, Italy
| | - Giuseppe Delvecchio
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Paolo Brambilla
- Department of Neurosciences and Mental Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, via F. Sforza 35, 20122 Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
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[New insights into diagnostics and therapy of personality disorders-Changes in ICD-11]. DER NERVENARZT 2020; 91:863-871. [PMID: 32542432 DOI: 10.1007/s00115-020-00936-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Personality disorders (PD) occur frequently and show high remission rates in the long term, while psychosocial recovery remains unsuccessful in a substantial proportion of cases. In ICD-11 the traditional view that PDs have a high stability is abandoned. Instead, the minimum duration is 2 years. The diagnostic process differentiates between three degrees of severity (mild, moderate, severe) and five prominent personality trait domains. Optionally, a borderline qualifying factor can be additionally codified. There is sufficient empirical evidence only for the treatment of borderline PD (BPD). Disorder-specific psychotherapy, in particular dialectic behavioral therapy (DBT) and mentalization-based therapy (MBT) have proven to be effective. Therapy modules targeting functional impairments and prominent personality trait domains could close the existing gaps in the disorder-specific treatment of PD.
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Stoffers-Winterling J, Storebø OJ, Simonsen E, Lieb K. Störungsspezifische Psychotherapie der Borderline-Persönlichkeitsstörung. PSYCHOTHERAPEUT 2020. [DOI: 10.1007/s00278-020-00443-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Kramer U, Beuchat H, Grandjean L, Pascual-Leone A. How Personality Disorders Change in Psychotherapy: a Concise Review of Process. Curr Psychiatry Rep 2020; 22:41. [PMID: 32519017 DOI: 10.1007/s11920-020-01162-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
PURPOSE OF REVIEW The present review summarizes the current state of the art in psychotherapy processes during treatments for clients with personality disorders. We outline some methodological challenges in the discipline of process research, give a brief historical account on process research, and then focus on specific processes studied from an empirical perspective. RECENT FINDINGS The current review acknowledges the centrality of the therapeutic relationship, in particular the therapeutic alliance, therapist empathy, and responsiveness in explaining outcome across treatment modalities for personality disorders. The review describes evidence from three overall and overlapping lines of inquiry that have garnered scientific interest in the past years. For emotional change (regulation, awareness, and transformation), socio-cognitive change (mentalizing, meta-cognition, and interpersonal patterns), and increase in insight and change in defense mechanisms, evidence is moderate to strong for these processes to contribute to healthy change in treatments for personality disorders, in particular borderline personality disorder. Avenues of future studies are outlined.
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Affiliation(s)
- Ueli Kramer
- Department of Psychiatry-CHUV, Institute of Psychotherapy, University of Lausanne, Place Chauderon 18, CH-1003, Lausanne, Switzerland. .,General Psychiatry Service, Department of Psychiatry-CHUV, University of Lausanne, Lausanne, Switzerland. .,Department of Psychology, University of Windsor, Windsor, Canada.
| | - Hélène Beuchat
- Department of Psychiatry-CHUV, Institute of Psychotherapy, University of Lausanne, Place Chauderon 18, CH-1003, Lausanne, Switzerland
| | - Loris Grandjean
- Department of Psychiatry-CHUV, Institute of Psychotherapy, University of Lausanne, Place Chauderon 18, CH-1003, Lausanne, Switzerland
| | - Antonio Pascual-Leone
- Department of Psychiatry-CHUV, Institute of Psychotherapy, University of Lausanne, Place Chauderon 18, CH-1003, Lausanne, Switzerland.,Department of Psychology, University of Windsor, Windsor, Canada
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21
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Storebø OJ, Stoffers-Winterling JM, Völlm BA, Kongerslev MT, Mattivi JT, Jørgensen MS, Faltinsen E, Todorovac A, Sales CP, Callesen HE, Lieb K, Simonsen E. Psychological therapies for people with borderline personality disorder. Cochrane Database Syst Rev 2020; 5:CD012955. [PMID: 32368793 PMCID: PMC7199382 DOI: 10.1002/14651858.cd012955.pub2] [Citation(s) in RCA: 112] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Ole Jakob Storebø
- Child and Adolescent Psychiatric Department, Region Zealand, Roskilde, Denmark
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
- Department of Psychology, Faculty of Health Science, University of Southern Denmark, Odense, Denmark
| | | | - Birgit A Völlm
- Department of Forensic Psychiatry, Center for Neurology, University Rostock, Rostock, Germany
| | - Mickey T Kongerslev
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
- Department of Psychology, Faculty of Health Science, University of Southern Denmark, Odense, Denmark
| | - Jessica T Mattivi
- Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany
| | - Mie S Jørgensen
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
| | - Erlend Faltinsen
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
| | - Adnan Todorovac
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
| | - Christian P Sales
- Duncan MacMillan House, Nottinghamshire Healthcare NHS Foundation Trust, Nottingham, UK
- Institute of Mental Health, Department of Psychiatry & Applied Psychology, Nottingham, UK
| | | | - Klaus Lieb
- Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany
| | - Erik Simonsen
- Psychiatric Research Unit, Region Zealand Psychiatry, Slagelse, Denmark
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Kramer U, Grandjean L, Beuchat H, Kolly S, Conus P, de Roten Y, Draganski B, Despland JN. Mechanisms of change in brief treatments for borderline personality disorder: a protocol of a randomized controlled trial. Trials 2020; 21:335. [PMID: 32299512 PMCID: PMC7160891 DOI: 10.1186/s13063-020-4229-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 03/03/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Borderline personality disorder (BPD) is one of the most frequent, most debilitating and lethal mental conditions and is associated with a serious burden of disease. Treatment for patients with BPD involves structured psychotherapy, and may involve brief psychiatric treatment as first-line intervention. No controlled study has assessed the effectiveness of such brief intervention. Whereas most psychotherapy studies in patients with BPD focus on the effectiveness of the intervention, we still lack an understanding of how and why these effects are produced from a patient process perspective. It is therefore of utmost importance to study the treatment-underlying mechanisms of change. The present study plans to apply novel measurement methods for assessing change in two central psychobiological processes in BPD: emotion and socio-cognitive processing. The study uses theory-driven and ecologically valid experimental tasks, which take the patient's individual experience as the anchor, by integrating methodology from psychotherapy process and neurofunctional imagery research. METHODS The aim of this two-arm, randomized controlled study is to test the effects (i.e., symptom reduction) and the underlying mechanisms of change associated with a brief psychiatric treatment (10 sessions over 4 months), compared with treatment as usual. Participants (N = 80 patients with BPD) undergo assessments at four points (intake, 2 months, discharge, and 12-month follow up). In addition to symptom measures, individuals undergo a 2-step assessment for the potential mechanisms of change (i.e., emotion and socio-cognitive processing): (1) behavioral and (2) (for a sub-sample) neurofunctional. We hypothesize that change in the mechanisms explains the treatment effects. DISCUSSION This study uses an easy-to-implement treatment of BPD, and a sophisticated assessment procedure to demonstrate the critical role of psychobiological change in emotion and socio-cognitive processing in brief treatments. It will help increase the effectiveness of brief treatment for BPD and help diminish the societal burden of disease related to BPD, in these early stages of treatment. TRIAL REGISTRATION {2}: ClinicalTrials.gov: NCT03717818. Registered on 24 October 2018). Protocol version {3} number 2 from 9 February 2018.
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Affiliation(s)
- Ueli Kramer
- Institute of Psychotherapy and General Psychiatry Service, Department of Psychiatry, Lausanne University Clinic and University of Lausanne and Lausanne University Hospital, Place Chauderon 18, CH-1003, Lausanne, Switzerland. .,General Psychiatry Service, Department of Psychiatry, Lausanne University Clinic and University of Lausanne, Lausanne, Switzerland. .,Department of Psychology, University of Windsor, Windsor, Canada.
| | - Loris Grandjean
- Institute of Psychotherapy and General Psychiatry Service, Department of Psychiatry, Lausanne University Clinic and University of Lausanne and Lausanne University Hospital, Place Chauderon 18, CH-1003, Lausanne, Switzerland
| | - Hélène Beuchat
- Institute of Psychotherapy and General Psychiatry Service, Department of Psychiatry, Lausanne University Clinic and University of Lausanne and Lausanne University Hospital, Place Chauderon 18, CH-1003, Lausanne, Switzerland
| | - Stéphane Kolly
- General Psychiatry Service, Department of Psychiatry, Lausanne University Clinic and University of Lausanne, Lausanne, Switzerland
| | - Philippe Conus
- General Psychiatry Service, Department of Psychiatry, Lausanne University Clinic and University of Lausanne, Lausanne, Switzerland
| | - Yves de Roten
- Institute of Psychotherapy and General Psychiatry Service, Department of Psychiatry, Lausanne University Clinic and University of Lausanne and Lausanne University Hospital, Place Chauderon 18, CH-1003, Lausanne, Switzerland
| | - Bogdan Draganski
- Department of Clinical Neurosciences, Lausanne University Clinic and University of Lausanne, Lausanne, Switzerland
| | - Jean-Nicolas Despland
- Institute of Psychotherapy and General Psychiatry Service, Department of Psychiatry, Lausanne University Clinic and University of Lausanne and Lausanne University Hospital, Place Chauderon 18, CH-1003, Lausanne, Switzerland
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Stratton N, Mendoza Alvarez M, Labrish C, Barnhart R, McMain S. Predictors of Dropout From a 20-Week Dialectical Behavior Therapy Skills Group for Suicidal Behaviors and Borderline Personality Disorder. J Pers Disord 2020; 34:216-230. [PMID: 30179573 DOI: 10.1521/pedi_2018_32_391] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Treatment dropout among individuals with borderline personality disorder (BPD) is associated with negative psychosocial outcomes. Identifying predictors of dropout among this population is critical to understanding how to improve treatment retention. The present study extends the current literature by examining both static and dynamic predictors of dropout. Chronically suicidal outpatients diagnosed with BPD (N = 42) were randomly assigned to a 20-week dialectical behavior therapy (DBT) skills training group. Static and dynamic predictors were assessed at baseline, 5, 10, 15, 20 weeks, and 3 months post-intervention. A post-hoc two-stage logistic regression analysis was conducted to predict dropout propensity. Receiving disability benefits at baseline and decreases in mindfulness were associated with significantly increased probability of dropout. Clinicians working with chronically self-harming outpatients diagnosed with BPD would benefit from prioritizing clinical interventions that enhance mindfulness in order to decrease dropout propensity.
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Affiliation(s)
- Natalie Stratton
- Department of Psychology, Ryerson University, Toronto, Ontario, Canada
| | | | | | | | - Shelley McMain
- Centre for Addiction and Mental Health, Toronto.,Department of Psychiatry, University of Toronto
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Keefe KM, Hetzel-Riggin MD, Sunami N. The Mediating Roles of Hostility and Dissociation in the Relationship Between Sexual Assault and Suicidal Thinking in College Students. JOURNAL OF INTERPERSONAL VIOLENCE 2020; 35:1635-1653. [PMID: 29294684 DOI: 10.1177/0886260517698282] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Sexual assault and suicide are two serious public health concerns. Research has documented the relationship between sexual assault and suicidal thinking and attempts; however, limited research explores the more multifaceted relationships between posttraumatic stress reactions and suicidal ideation in college students through unsuccessful modulation of emotion. The authors hypothesized a mediation model where the relationship between sexual assault and suicidal ideation is mediated by dissociation and hostility. In total, 1,677 undergraduate students were administered modified versions of the Traumatic Life Events Questionnaire (TLEQ), Symptom Checklist-90-Revised (SCL-90-R), and Peritraumatic Dissociative Experiences Questionnaire (PDEQ). The results revealed both significant partial but equal mediators of hostility and dissociation. However, a portion of the direct effect between sexual assault and suicidal ideation remained unaccounted for by indirect effects. The current model supports previous work on dialectical behavior therapy that says either side of the dialectic between extreme expression and suppression of hostility increases the likelihood of suicidal thinking after sexual assault. With sexual assault survivors, practitioners should use strategies that emphasize both anger expression and healthy avoidance as a way to modulate emotion to potentially reduce suicidal thoughts. Future research should focus on different gender models, additional possible mediators such as alcohol use and guilt, and different forms of sexual assault. Limitations of the correlational, cross-sectional methodology are discussed.
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Affiliation(s)
| | | | - Naoyuki Sunami
- Western Illinois University, Macomb, USA
- University of Delaware, Newark, USA
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Tan YM, Lee CW, Averbeck LE, Brand-de Wilde O, Farrell J, Fassbinder E, Jacob GA, Martius D, Wastiaux S, Zarbock G, Arntz A. Schema therapy for borderline personality disorder: A qualitative study of patients' perceptions. PLoS One 2018; 13:e0206039. [PMID: 30462650 PMCID: PMC6248917 DOI: 10.1371/journal.pone.0206039] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 10/05/2018] [Indexed: 12/04/2022] Open
Abstract
Schema therapy (ST) has been found to be effective in the treatment of borderline personality disorder (BPD). However very little is known about how the therapy is experienced by individuals with BPD including which specific elements of ST are helpful or unhelpful from their perspectives. The aim of this study is to explore BPD patients’ experiences of receiving ST, in intensive group or combined group-individual format. Qualitative data were collected through semi-structured interviews with 36 individuals with a primary diagnosis of BPD (78% females) who received ST for at least 12 months. Participants were recruited as part of an international, multicenter randomized controlled trial (RCT). Interview data (11 Australian, 12 Dutch, 13 German) were analyzed following the procedures of qualitative content analysis. Patients’ perceptions of the benefits gained in ST included improved self-understanding, and better awareness and management of their own emotional processes. While some aspects of ST, such as experiential techniques were perceived as emotionally confronting, patient narratives informed that this was necessary. Some recommendations for improved implementation of ST include the necessary adjunct of individual sessions to group ST and early discussion of therapy termination. Implications of the findings are also discussed, in particular the avenues for assessing the suitability of patients for group ST; management of group conflict and the optimal format for delivering treatment in the intensive group versus combined group-individual formats.
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Affiliation(s)
- Yeow May Tan
- Department of Psychology and Exercise Science, Murdoch University, Perth, Australia
| | - Christopher W Lee
- Department of Psychology and Exercise Science, Murdoch University, Perth, Australia.,Department of Health and Medical Sciences, University of Western Australia, Perth, Australia
| | - Lynn E Averbeck
- Institute of Psychology, University of Hamburg, Hamburg, Germany
| | - Odette Brand-de Wilde
- De Viersprong, Netherlands Institute of Personality Disorders, Halsteren, The Netherlands
| | - Joan Farrell
- Department of Psychology, Indiana University-Purdue University Indianapolis, Indianapolis, United States of America
| | - Eva Fassbinder
- Department of Psychiatry and Psychotherapy, University of Lübeck, Lübeck, Germany
| | - Gitta A Jacob
- Department of Clinical Psychology and Psychotherapy, University of Freiburg, Freiburg, Germany
| | - Desiree Martius
- Department of Clinical Psychology, University of Amsterdam, Amsterdam, The Netherlands
| | - Sophie Wastiaux
- Department of Clinical Psychology, University of Amsterdam, Amsterdam, The Netherlands
| | - Gerhard Zarbock
- IVAH - Institut für Verhaltenstherapie-Ausbildung, Hamburg, Germany
| | - Arnoud Arntz
- Department of Clinical Psychology, University of Amsterdam, Amsterdam, The Netherlands
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Little H, Tickle A, das Nair R. Process and impact of dialectical behaviour therapy: A systematic review of perceptions of clients with a diagnosis of borderline personality disorder. Psychol Psychother 2018; 91:278-301. [PMID: 29034599 DOI: 10.1111/papt.12156] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 09/04/2017] [Indexed: 12/22/2022]
Abstract
PURPOSE To identify, appraise, and synthesize findings from qualitative studies of individuals diagnosed with borderline personality disorder who have experienced dialectical behaviour therapy, to gain further understanding of their perceptions of the process and impact of therapy. METHODS We conducted a comprehensive systematic search of the literature from several online databases, and appraised them using an adapted version of the Critical Appraisal Skills Programme tool. A meta-ethnographic approach was used to synthesize the data. RESULTS Seven studies met the criteria to be included and their quality subsequently appraised. Four main themes were identified through the synthesis process: life before DBT; the relationships that support change; developing self-efficacy; and a shift in perspectives. CONCLUSIONS The findings of the synthesis highlight the importance of a number of key factors in the process of DBT, and the impact that the therapy has both on day-to-day life and on individuals' identity. PRACTITIONER POINTS Existing outcome measures may not capture the complexity and magnitude of impact of DBT on individuals with BPD. Exploring first-hand accounts of individuals undertaking DBT can offer unique insight into the processes of therapy.
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Affiliation(s)
- Hannah Little
- University of Nottingham and Nottinghamshire Healthcare NHS Trust, UK
| | - Anna Tickle
- University of Nottingham and Nottinghamshire Healthcare NHS Trust, UK
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27
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Emotional processing in an expressive writing task on trauma. Complement Ther Clin Pract 2018; 32:116-122. [DOI: 10.1016/j.ctcp.2018.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 05/25/2018] [Accepted: 06/05/2018] [Indexed: 01/04/2023]
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Euler S, Stalujanis E, Allenbach G, Kolly S, de Roten Y, Despland JN, Kramer U. Dialectical behavior therapy skills training affects defense mechanisms in borderline personality disorder: An integrative approach of mechanisms in psychotherapy. Psychother Res 2018; 29:1074-1085. [DOI: 10.1080/10503307.2018.1497214] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Affiliation(s)
- Sebastian Euler
- Psychiatric University Hospital (UPK), University of Basel, Basel, Switzerland
| | - Esther Stalujanis
- Psychiatric University Hospital (UPK), University of Basel, Basel, Switzerland
- Division of Clinical Psychology and Psychiatry, University of Basel, Basel, Switzerland
- Division of Clinical Psychology and Cognitive Behavioral Therapy, International Psychoanalytic University, Berlin, Germany
| | - Gilles Allenbach
- Psychiatric University Hospital (CHUV), University of Lausanne, Lausanne, Switzerland
| | - Stéphane Kolly
- Psychiatric University Hospital (CHUV), University of Lausanne, Lausanne, Switzerland
| | - Yves de Roten
- Psychiatric University Hospital (CHUV), University of Lausanne, Lausanne, Switzerland
| | - Jean-Nicolas Despland
- Psychiatric University Hospital (CHUV), University of Lausanne, Lausanne, Switzerland
| | - Ueli Kramer
- Psychiatric University Hospital (CHUV), University of Lausanne, Lausanne, Switzerland
- Department of Psychology, University of Windsor, Windsor, Canada
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Zalewski M, Lewis JK, Martin CG. Identifying novel applications of dialectical behavior therapy: considering emotion regulation and parenting. Curr Opin Psychol 2018; 21:122-126. [PMID: 29529427 DOI: 10.1016/j.copsyc.2018.02.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 02/19/2018] [Indexed: 11/25/2022]
Abstract
Dialectical behavior therapy (DBT) is an effective treatment for an increasing number of mental disorders. Its increased application to a range of disorders has been prompted by the recognition that DBT targets emotion dysregulation, which is a transdiagnostic feature underlying several forms of psychopathology. More recently, DBT has been used to target additional clinically relevant domains that are outside diagnostically bound categories, such as improving parenting quality as a means of preventing psychopathology in children of parents with psychopathology. As the ability to regulate emotions is critical to parenting, this paper uses the connection between DBT, emotion regulation, and parenting as an illustration of how focusing on mechanistic features by which DBT is effective aids in strategically identifying areas by which DBT may be a highly useful treatment option.
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Abstract
Emotional knowledge about one's own and others' emotional experience are central features of mental health and may be characteristic of therapeutic processes leading to good outcome. Clients with personality disorders (PDs) often lack in their ability to access and accept emotional experiences, or to reflect on emotion and use it in adaptive ways. The present theoretical and clinical review discusses self-knowledge, and lack thereof, in personality disorders, from an emotion-focused perspective. A first section differentiates between two fundamental types of meaning construction processing. The second section describes, from an integrative therapy perspective, how self-knowledge may be facilitated in psychotherapy by the client-therapist interaction. A subsequent section discusses lack of awareness of one's own emotions in the construction of meaning associated with PDs. The final section describes initial studies that demonstrate change occurring in constructing emotional self-knowledge as a correlate of treatment. The concepts of the review are illustrated throughout with three clinical cases of PD.
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Affiliation(s)
- Ueli Kramer
- Institute of Psychotherapy, Department of Psychiatry-CHUV, University of Lausanne, Switzerland, and General Psychiatry Service, Department of Psychiatry-CHUV, University of Lausanne
| | - Antonio Pascual-Leone
- Institute of Psychotherapy, Department of Psychiatry-CHUV, University of Lausanne, Switzerland, and General Psychiatry Service, Department of Psychiatry-CHUV, University of Lausanne.,Department of Psychology, University of Windsor, Ontario, Canada
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Euler S, Wrege J, Busmann M, Lindenmeyer HJ, Sollberger D, Lang UE, Gaab J, Walter M. Exclusion-Proneness in Borderline Personality Disorder Inpatients Impairs Alliance in Mentalization-Based Group Therapy. Front Psychol 2018; 9:824. [PMID: 29910754 PMCID: PMC5992402 DOI: 10.3389/fpsyg.2018.00824] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 05/07/2018] [Indexed: 11/13/2022] Open
Abstract
Interpersonal sensitivity, particularly threat of potential exclusion, is a critical condition in borderline personality disorder (BPD) which impairs patients’ social adjustment. Current evidence-based treatments include group components, such as mentalization-based group therapy (MBT-G), in order to improve interpersonal functioning. These treatments additionally focus on the therapeutic alliance since it was discovered to be a robust predictor of treatment outcome. However, alliance is a multidimensional factor of group therapy, which includes the fellow patients, and may thus be negatively affected by the exclusion-proneness of BPD patients. The aim of this pilot study was to examine the predictive value of threat of social exclusion for the therapeutic alliance in MBT-G. In the first part of the study, social exclusion was experimentally induced in 23 BPD inpatients and 28 healthy subjects using the Cyberball paradigm, a virtual ball tossing game. The evoked level of threat was measured with the Need-Threat Scale (NTS) which captures four dimensions of fundamental human needs, i.e., the need for belongingness, for self-esteem, for control, and for a meaningful existence. In the second part of the study, therapeutic alliance was measured on three dimensions, the therapists, the fellow patients and the group as a whole, using the Group-Questionnaire (GQ-D). BPD patients scored higher in their level of threat according to the NTS in both, the inclusion and the exclusion condition. The level of threat after exclusion predicted impairments of the therapeutic alliance in MBT-G. It was associated with more negative relationships, lower positive bonding and a lower positive working alliance with the fellow patients and lower positive bonding to the group as a whole whilst no negative prediction of the alliance to the therapists was found. Consequently, our translational study design has shown that Cyberball is an appropriate tool to use as an approach for clinical questions. We further conclude that exclusion-proneness in BPD is a critical feature with respect to alliance in group treatments. In order to neutralize BPD patients’ exclusion bias, therapists may be advised to provide an “inclusive stance,” especially in initial sessions. It is also recommendable to strengthen patient to patient relations.
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Affiliation(s)
- Sebastian Euler
- Department of Psychiatry (UPK), University of Basel, Basel, Switzerland.,Research Department of Clinical, Educational and Health Psychology, University College London, London, United Kingdom
| | - Johannes Wrege
- Department of Psychiatry (UPK), University of Basel, Basel, Switzerland
| | - Mareike Busmann
- Department of Psychiatry (UPK), University of Basel, Basel, Switzerland
| | - Hannah J Lindenmeyer
- Department of Psychiatry (UPK), University of Basel, Basel, Switzerland.,Department of Counseling and Clinical Psychology, Teachers College, Columbia University, New York, NY, United States
| | | | - Undine E Lang
- Department of Psychiatry (UPK), University of Basel, Basel, Switzerland
| | - Jens Gaab
- Division of Clinical Psychology and Psychotherapy, Faculty of Psychology, University of Basel, Basel, Switzerland
| | - Marc Walter
- Department of Psychiatry (UPK), University of Basel, Basel, Switzerland
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Haberman A, Shahar B, Bar-Kalifa E, Zilcha-Mano S, Diamond GM. Exploring the process of change in emotion-focused therapy for social anxiety. Psychother Res 2018; 29:908-918. [PMID: 29366385 DOI: 10.1080/10503307.2018.1426896] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Objective: This study examined purported change mechanisms in emotion-focused therapy for social anxiety disorder. Methods: The sample included nine clients who had participated in a multiple-baseline case study trial examining the efficacy of emotion-focused therapy for social anxiety disorder (SAD). Multilevel analyses were conducted to examine the trajectories of emotions over the course of treatment, and whether primary adaptive emotions in a given session predicted levels of SAD symptoms, self-criticism, and self-reassurance over the course of the following week. Results: Findings showed a significant decrease in shame, and a marginally significant increase in assertive anger, over the course of treatment. Adaptive sadness/grief in a given session predicted less fear of negative evaluation over the course of the following week. Shame in a given session predicted higher levels of inadequate-self over the course of the following week. Finally, shame, and to a lesser degree assertive anger, in a given session predicted reassurance of self over the course of the following week. Neither assertive anger nor adaptive sadness/grief in a given session predicted levels of self-criticism over the course of the following week. Conclusions: These findings lend partial preliminary support for the therapeutic role of evoking and processing adaptive sadness/grief and assertive anger in the treatment of SAD.
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Affiliation(s)
- Ann Haberman
- Department of Psychology, Ben-Gurion University, Beer-Sheva, Israel
| | - Ben Shahar
- The Paul Baerwald School of Social Work and Social Welfare, The Hebrew Universityof Jerusalem, Jerusalem, Israel
| | - Eran Bar-Kalifa
- Department of Psychology, Ben-Gurion University, Beer-Sheva, Israel
| | | | - Gary M Diamond
- Department of Psychology, Ben-Gurion University, Beer-Sheva, Israel
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Kramer U. Mechanisms of Change in Treatments of Personality Disorders: Introduction to the Special Section. J Pers Disord 2018; 32:1-11. [PMID: 29388900 DOI: 10.1521/pedi.2018.32.supp.1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The present introduction to the Special Section on Mechanisms of Change in Treatments of Personality Disorders explains the value of research focusing on processes of change in psychotherapy by referring to a variety of methodologies. Whereas outcome for these treatments has been repeatedly demonstrated, it remains an open question what the core psychobiological features of change are. Taking a radically empirical perspective, this introduction focuses on patient and therapeutic relationship variables, such as emotional and socio-cognitive processing. The six empirical articles of the Special Section are introduced, as are the three discussions of the Special Section.
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Affiliation(s)
- Ueli Kramer
- Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Abstract
OBJECTIVE The present paper elaborates a process perspective of change in psychotherapy for personality disorders (PDs). Firstly, the paper reviews the literature of mechanisms of change in treatments of PD, with the main focus on emotional processing and socio-cognitive processing. Secondly, it proposes an illustrative case-series analysis of eight cases, drawn from a mediation analysis conducted within the context of a randomized controlled trial for borderline personality disorder (BPD). METHOD As such, cases with good and poor outcomes are compared, as are cases with poor and good intake features and cases with poor and good process markers across treatment. RESULTS The results illustrate possible pathways to healthy change over the course of four months of treatment, and possible pathways of the absence of change. CONCLUSIONS These results are discussed with regard to three main research perspectives: the combination of qualitative and quantitative methodology in psychotherapy research may be applied to case study research, a neurobehavioral perspective on change may incorporate the individualized experience in the laboratory and therapist responsiveness to patient characteristics may be a core feature of fostering change. Clinical or methodological significance of this article: The present paper illustrates individual pathways to change in personality disorders. It illustrates how coping capacities influence the process of psychotherapy and outcome in personality disorders. It demonstrates the relevance of individualizing treatments for personality disorders. It demonstrates several integrative features of psychotherapy research, in particular the use of neurobehavioral paradigms and the integration of single-case research within randomized controlled trials.
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Affiliation(s)
- Ueli Kramer
- a Department of Psychiatry , Institute of Psychotherapy and General Psychiatry, University of Lausanne , Lausanne , Switzerland.,b Department of Psychology , University of Windsor , Windsor , Canada
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35
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Pascual-Leone A. How clients “change emotion with emotion”: A programme of research on emotional processing. Psychother Res 2017; 28:165-182. [DOI: 10.1080/10503307.2017.1349350] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Rudge S, Feigenbaum JD, Fonagy P. Mechanisms of change in dialectical behaviour therapy and cognitive behaviour therapy for borderline personality disorder: a critical review of the literature. J Ment Health 2017; 29:92-102. [PMID: 28480806 DOI: 10.1080/09638237.2017.1322185] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Background: Little is known about the "active ingredients" of psychological therapy for Borderline Personality Disorder (BPD) despite a growing evidence base documenting its clinical effectiveness. This information can be used by clinicians to inform service planning and care pathways.Aims: The aim of this study was to review published empirical research investigating the potential mechanisms underlying therapeutic change in Dialectical Behaviour Therapy (DBT) and Cognitive Behaviour Therapy (CBT) for BPD.Method: A thorough search of the PsychInfo, CINAHL Plus, PubMed, MEDLINE and EMBASE databases revealed research into potential mechanisms of change.Results: A total of 52 abstracts were reviewed. After a full text screen of the most relevant studies, 14 met inclusion criteria. Twelve examined DBT and two CBT. Mechanisms of change identified broadly fell into three categories: emotion regulation/self-control, skills use and therapeutic alliance/investment in treatment. Outcomes measured included general mental health diagnoses (e.g. anxiety, depression) and BPD-specific symptoms (e.g. self-harm/suicidality, impulsivity, substance misuse, anger).Conclusion: Further empirically robust research is required to test hypotheses about the influence of the proposed mechanisms on therapeutic change in psychological therapies for BPD.
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Affiliation(s)
- Susie Rudge
- Research Department of Clinical, Educational and Health Psychology, University College London, London, UK and
| | - Janet Denise Feigenbaum
- Research Department of Clinical, Educational and Health Psychology, University College London, London, UK and.,North East London NHS Foundation Trust, London, UK
| | - Peter Fonagy
- Research Department of Clinical, Educational and Health Psychology, University College London, London, UK and
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Pascual-Leone A, Yeryomenko N, Sawashima T, Warwar S. Building emotional resilience over 14 sessions of emotion focused therapy: Micro-longitudinal analyses of productive emotional patterns. Psychother Res 2017; 29:171-185. [PMID: 28468535 DOI: 10.1080/10503307.2017.1315779] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVE Pascual-Leone and Greenberg's sequential model of emotional processing has been used to explore process in over 24 studies. This line of research shows emotional processing in good psychotherapy often follows a sequential order, supporting a saw-toothed pattern of change within individual sessions (progressing "2-steps-forward, 1-step-back"). However, one cannot assume that local in-session patterns are scalable across an entire course of therapy. Thus, the primary objective of this exploratory study was to consider how the sequential patterns identified by Pascual-Leone, may apply across entire courses of treatment. METHOD Intensive emotion coding in two separate single-case designs were submitted for quantitative analyses of longitudinal patterns. Comprehensive coding in these cases involved recording observations for every emotional event in an entire course of treatment (using the Classification of Affective-Meaning States), which were then treated as a 9-point ordinal scale. RESULTS Applying multilevel modeling to each of the two cases showed significant patterns of change over a large number of sessions, and those patterns were either nested at the within-session level or observed at the broader session-by-session level of change. DISCUSSION Examining successful treatment cases showed several theoretically coherent kinds of temporal patterns, although not always in the same case. Clinical or methodological significance of this article: This is the first paper to demonstrate systematic temporal patterns of emotion over the course of an entire treatment. (1) The study offers a proof of concept that longitudinal patterns in the micro-processes of emotion can be objectively derived and quantified. (2) It also shows that patterns in emotion may be identified on the within-session level, as well as the session-by-session level of analysis. (3) Finally, observed processes over time support the ordered pattern of emotional states hypothesized in Pascual-Leone and Greenberg's (2007) model of emotional processing.
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Affiliation(s)
- A Pascual-Leone
- a Department of Psychology , University of Windsor , Windsor , Canada
| | - N Yeryomenko
- a Department of Psychology , University of Windsor , Windsor , Canada
| | - T Sawashima
- a Department of Psychology , University of Windsor , Windsor , Canada
| | - S Warwar
- b Private Practice , Toronto , Canada
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Dillon A, Timulak L, Greenberg LS. Transforming core emotional pain in a course of emotion-focused therapy for depression: A case study. Psychother Res 2016; 28:406-422. [DOI: 10.1080/10503307.2016.1233364] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
- Andrew Dillon
- School of Psychology, Trinity College Dublin, Dublin, Republic of Ireland
| | - Ladislav Timulak
- School of Psychology, Trinity College Dublin, Dublin, Republic of Ireland
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Kramer U. The Role of Coping Change in Borderline Personality Disorder: A Process-Outcome Analysis on Dialectical-Behaviour Skills Training. Clin Psychol Psychother 2016; 24:302-311. [PMID: 27098296 DOI: 10.1002/cpp.2017] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 03/11/2016] [Accepted: 03/22/2016] [Indexed: 11/06/2022]
Abstract
Difficulty in emotion regulation is a hallmark feature of patients with borderline personality disorder (BPD). Skills training concepts based on dialectical-behaviour therapy (DBT) are common and effective treatment options for specifically addressing lacking skills in emotion regulation. However, so far it is unclear which aspects of coping change over the course of DBT skills training and if these coping strategies predict symptom change. The present process-outcome analysis, based on a randomized controlled study, aims at investigating these questions, by referring to a general conception of coping and by using an observer-rated approach to assess coping strategies directly in the therapy sessions. In total, n = 31 patients with BPD underwent two individual clinical interview assessments (pre- and post-study intervention; half of the patients underwent DBT skills training, half were in a wait-list control). All individual assessment sessions were transcribed and analysed using the Coping Action Pattern Rating Scale. Outcome was assessed pre- and post-intervention using the Outcome Questionnaire-45.2 and the Borderline Symptom List 23. The results showed increase in overall coping functioning in patients who underwent the DBT skills training, compared with the controls, and specific increases in relatedness coping where the stress is appraised as challenge, along with specific decreases in autonomy coping where the stress is appraised as threat. These changes predicted changes in general distress and borderline symptomatology. The results are interpreted within a general framework aiming at understanding the psychological effects of treatments for BPD, in particular effects related to coping. Effective emotion regulation strategies may therefore be important candidates as potential change mechanisms in treatments for BPD. Copyright © 2016 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGE It seems important for clinicians to assess the quality of coping strategies as they occur within the session facing a patient with borderline personality disorder. Clinicians may foster the emergence of support-seeking and self-reliance coping strategies in order to increase the effectiveness of therapy. Clinicians may monitor closely the patient's use of ineffective emotion regulation strategies, in particular opposition and submission, with the aim of reducing them early in therapy.
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Affiliation(s)
- Ueli Kramer
- Institute of Psychotherapy, Department of Psychiatry-CHUV, University of Lausanne, Lausanne, Switzerland.,General Psychiatry Service, Department of Psychiatry-CHUV, University of Lausanne, Lausanne, Switzerland.,Department of Psychology, University of Windsor, Windsor, Canada
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40
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Pascual-Leone A, Kramer U. Developing Emotion-Based Case Formulations: A Research-Informed Method. Clin Psychol Psychother 2016; 24:212-225. [PMID: 26750303 DOI: 10.1002/cpp.1998] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 11/13/2015] [Accepted: 11/20/2015] [Indexed: 12/20/2022]
Abstract
OBJECTIVES New research-informed methods for case conceptualization that cut across traditional therapy approaches are increasingly popular. This paper presents a trans-theoretical approach to case formulation based on the research observations of emotion. METHODS The sequential model of emotional processing (Pascual-Leone & Greenberg, 2007) is a process research model that provides concrete markers for therapists to observe the emerging emotional development of their clients. We illustrate how this model can be used by clinicians to track change and provides a 'clinical map,' by which therapist may orient themselves in-session and plan treatment interventions. RESULTS Emotional processing offers as a trans-theoretical framework for therapists who wish to conduct emotion-based case formulations. First, we present criteria for why this research model translates well into practice. Second, two contrasting case studies are presented to demonstrate the method. CONCLUSIONS The model bridges research with practice by using client emotion as an axis of integration. Key Practitioner Message Process research on emotion can offer a template for therapists to make case formulations while using a range of treatment approaches. The sequential model of emotional processing provides a 'process map' of concrete markers for therapists to (1) observe the emerging emotional development of their clients, and (2) help therapists develop a treatment plan. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
| | - Ueli Kramer
- Institute for Psychotherapy, Department of Psychiatry-CHUV, University of Windsor, Psychology, Prilly-Lausanne, Switzerland
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