Dialectical behavior therapy for suicidal adolescents with borderline personality disorder

Three-level containment model of hospitalized adolescents with borderline pathology: a holistic therapeutic perspective

Borderline personality disorders account for 50% of adolescent hospitalization cases in psychiatry. The severity and psychopathological complexity of these symptoms indicate the need for inclusive models of understanding. Adopting a holistic approach allows for the consideration of not only the patient's environment, but also their position within that environment and their life history. In this article, a model based on the concept of therapeutic containment at three levels is presented. Global containment refers to the mindset and organization of the institution that provides care, which is itself a part of society at a specific time. Local containment focuses on understanding and therapeutic interventions within the immediate social environment of the individual. Lastly, individual containment encompasses the development of independent processes during the course of care. These three levels are integrated in the hospital treatment of borderline personality disorders, forming a trans-theoretical approach.

Dialectical Behavioral Skills Group Therapy for Parents of Adolescents With Borderline Personality Disorder: A Pilot Study

Research has indicated the effectiveness of Dialectical behavior therapy in adolescents (DBT-A) with severe emotion dysregulation and other symptoms of Borderline Personality Disorder (BPD). The objective was to determine if DBT skills group with caregivers only could influence in potential mediators of DBT outcomes including rearing styles, emotion regulation and mindfulness skills, evaluated in both parents and adolescents. We implemented a 12-week group intervention based on DBT-A addressed to seven parents of adolescents with features of BPD. We tested differences after treatment using the non-parametric Wilcoxon test and calculated effect sizes. To understand individual changes, we reported clinical reliable change (CRC). The intervention was effective for improving rearing styles, emotion regulation and mindfulness skills in adolescents. Changes were stable after 6 months. The intervention showed good levels of satisfaction reported by parents. A short DBT group-only intervention with caregivers could modify relevant processes related with features of BPD in adolescents. Early interventions with adolescents with symptoms of BPD could prevent the development of BPD influencing in potential mediation mechanisms.

A systematic review of cognitive behavior therapy and dialectical behavior therapy for adolescent eating disorders

BACKGROUND

Eating disorders have serious psychological and physical consequences. Current evidence-based treatments for adolescents with eating disorders have modest effects, underscoring the need to improve current treatment approaches. Cognitive behavior therapy (CBT) and dialectical behavior therapy (DBT) have been proposed as alternative treatment options, with burgeoning research in this area. This review aims to summarize and critically analyze the current literature on the feasibility, acceptability, effectiveness, and efficacy of CBT and DBT for adolescent eating disorders, and then proposes areas of future research.

METHODS

PsycINFO and PubMed were searched using the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines to identify studies examining the feasibility, acceptability, effectiveness and/or efficacy of CBT or DBT for adolescent eating disorders.

RESULTS

Eligible studies (N = 50; CBT: n = 40, DBT: n = 10) indicated that both treatments are reasonably feasible, acceptable, and possibly effective for adolescent eating disorders across diagnoses and levels of care, though efficacy trials are lacking.

CONCLUSIONS

CBT and DBT demonstrate promise as alternatives to family-based approaches for adolescent eating disorders. Adequately powered trials to establish the effectiveness and efficacy of CBT and DBT are needed, particularly ones that compare these treatments against other leading approaches. Despite high rates of relapse and likelihood for severe and enduring illness, there is a dearth of evidence-based treatment options for adolescents with eating disorders. Potentially viable but less well-studied treatments for adolescents with eating disorders include cognitive behavior therapy (CBT) and dialectical behavior therapy (DBT). This systematic review of CBT and DBT for adolescent eating disorders focuses on feasibility (i.e., how easy it was to implement the treatment), acceptability (i.e., how well the intervention was received by patients and therapists), effectiveness (i.e., how well the intervention performed under routine, real-world circumstances), and efficacy (i.e., how well the intervention performed in highly-controlled research settings). This review concludes that research supports the feasibility and acceptability of these approaches, as well as preliminary evidence of their effectiveness. However, the field is lacking studies that systematically compare CBT and DBT to other evidence-based approaches. Recommendations to advance research on CBT and DBT for adolescent eating disorders are provided, including a call for efficacy studies that clarify their performance compared to other leading approaches.

A mixed methods exploratory evaluation of burnout in frontline staff implementing dialectical behavior therapy on a pediatric eating disorders unit

BACKGROUND

Eating disorders are life-threatening illnesses that commonly affect adolescents. The treatment of individuals with eating disorders can involve slow treatment progression and addressing comorbidities which can contribute to staff burnout. Dialectical behavior therapy (DBT) has emerged as a viable treatment option and has reduced staff burnout in several other settings. Our aim was to describe frontline staff burnout using mixed methodology on a DBT-trained combined inpatient/day hospital unit for pediatric eating disorders.

METHOD

Frontline staff were trained to provide DBT skills for adolescents with eating disorders. Twelve months following the training and implementation, they completed the Copenhagen Burnout Inventory (CBI) and a qualitative interview. Directed and summative content analyses were used.

RESULTS

Eleven frontline staff including nurses, child life specialists and child and youth workers participated. The CBI revealed that only one staff member experienced high personal burnout, while another experienced high client-related burnout. Qualitative data indicated that all frontline staff felt DBT had the potential to reduce burnout.

CONCLUSION

Qualitative data indicate that staff believe that DBT may hold promise in reducing burnout for pediatric frontline staff who treat children and adolescents with eating disorders. Further study is needed. Understanding burnout is particularly important for nursing staff in inpatient and day hospital settings for eating disorders, as nursing staff generally have the most frequent patient contact; thought to be a risk factor for burnout. The reduction of burnout can prevent detrimental effects on job performance, personal well-being, and patient outcomes. Our exploratory study shows that frontline staff believe that DBT may have the potential to reduce burnout in staff treating children and adolescents with eating disorders in a combined inpatient/day hospital setting. Further study is needed in this area.

Analysis of the mediating effect of mentalization on the relationship between attachment styles and emotion dysregulation

The current study aims to explore the relationship between attachment styles, mentalization and emotion dysregulation. Moreover, the mediation effect of mentalization in the relationship between attachment and emotion dysregulation is analyzed. A sample composed of 607 participants taken from the Spanish general population completed the measures in a cross-sectional designed study. The results show that secure attachment is negatively related to emotion dysregulation dimensions, whereas insecure attachment styles show a positive correlation. Furthermore, the mentalization variables are in general significantly related to emotion dysregulation. The mediation model shows a large mediational effect size (f²  = 2.64). The results suggest that mentalization significantly mediates the relationship between emotion dysregulation and preoccupation, self-sufficiency, and childhood trauma. These results have important implications, as they indicate that clinical interventions on mentalization should reduce emotion dysregulation even in those people with a predominant insecure attachment style.

Preliminary evaluation of an intensive integrated individual and family therapy model for self-harming adolescents

BACKGROUND

To investigate the outcome of an integrated individual and family therapy (Intensive Contextual Treatment: ICT) in terms of reducing suffering and increasing functional adjustment among self-harming and/or suicidal adolescents with high symptom loads and their families.

METHODS

Forty-nine self-harming and/or suicidal adolescents, Mage = 14.6, of predominantly Swedish origin and female gender (85.7%) participated with their parents. The study had a within group design with repeated measures at pre- and post-treatment, as well as six- and twelve-months follow-ups. Self-reports were used for the main outcomes; self-harm rates, suicide attempts, parent-reported days of inpatient/institutional care, internalized and externalized symptoms, perceived stress, emotion regulation, school hours and adjustment. Secondary outcomes were levels of reported expressed emotions within family dyads, as well as parental anxiety, depression and stress.

RESULTS

From pre- to post-assessment, the adolescents reported significant reductions of self-harm (p = .001, d = 0.54) and suicide attempts (p < .0001, d = 1.38). Parent-reported days of inpatient/institutional care were reduced, as well as parent- and adolescent-reported internalizing and externalizing symptoms. Furthermore, school attendance and adjustment were improved, and the adolescents reported experiencing less criticism while parents reported less emotional over-involvement. The results were maintained at follow-ups.

CONCLUSIONS

The adolescents and the parents reported improvements for the main outcomes. This treatment appears promising in keeping the families in treatment and out of hospital, suggesting that an integrative approach may be beneficial and feasible for this group.

TRIAL REGISTRATION

This study has been approved 19/12 2011, by the regional review board in Stockholm (Dnr 2011/1593-31/5).

Borderline personality disorder in adolescents: prevalence, diagnosis, and treatment strategies

Using the same Diagnostic and Statistical Manual of Mental Disorders, fifth version (DSM-V) criteria as in adults, borderline personality disorder (BPD) in adolescents is defined as a 1-year pattern of immature personality development with disturbances in at least five of the following domains: efforts to avoid abandonment, unstable interpersonal relationships, identity disturbance, impulsivity, suicidal and self-mutilating behaviors, affective instability, chronic feelings of emptiness, inappropriate intense anger, and stress-related paranoid ideation. BPD can be reliably diagnosed in adolescents as young as 11 years. The available epidemiological studies suggest that the prevalence of BPD in the general population of adolescents is around 3%. The clinical prevalence of BPD ranges from 11% in adolescents consulting at an outpatient clinic to 78% in suicidal adolescents attending an emergency department. The diagnostic procedure is based on a clinical assessment with respect to developmental milestones and the interpersonal context. The key diagnostic criterion is the 1-year duration of symptoms. Standardized, clinician-rated instruments are available for guiding this assessment (eg, the Diagnostic Interview for Borderlines-Revised and the Childhood Interview for DSM-IV-TR BPD). The assessment should include an evaluation of the suicidal risk. Differential diagnosis is a particular challenge, given the high frequency of mixed presentations and comorbidities. With respect to clinical and epidemiological studies, externalizing disorders in childhood constitute a risk factor for developing BPD in early adolescence, whereas adolescent depressive disorders are predictive of BPD in adulthood. The treatment of adolescents with BPD requires commitment from the parents, a cohesive medical team, and a coherent treatment schedule. With regard to evidence-based medicine, psychopharmacological treatment is not recommended and, if ultimately required, should be limited to second-generation antipsychotics. Supportive psychotherapy is the most commonly available first-line treatment. Randomized controlled trials have provided evidence in favor of the use of specific, manualized psychotherapies (dialectic-behavioral therapy, cognitive analytic therapy, and mentalization-based therapy).

Effects of dialectical behavior therapy skills training on outcomes for mental health staff in a child and adolescent residential setting

Training in Dialectical Behavior Therapy (DBT) skills coaching is desirable for staff in psychiatric settings, due to the efficacy of DBT in treating difficult patient populations. In such settings, training resources are typically limited, and staff turnover is high, necessitating brief training. This study evaluated the effects of a brief training in DBT skills coaching for nursing staff working in a child and adolescent psychiatric residential program. Nursing staff (n = 22) completed assessments of DBT skill knowledge, burnout, and stigma towards patients with borderline personality disorder (BPD) before and after a six-week DBT skills coaching training. Repeated measure ANOVAs were conducted to examine changes on all measures from pre- to post- treatment and hierarchical linear regressions to examine relationships between pre- training DBT knowledge, burnout, and BPD stigma and these same measures post-training. The brief DBT skill coaching training significantly increased DBT knowledge (p = .007) and decreased staff personal (p = .02) and work (p = .03) burnout and stigma towards BPD patients (p = .02). Burnout indices and BPD stigma were highly correlated at both time points (p < .001); however, while pre-training BPD stigma significantly predicted post-training client burnout (p = .04), pre-training burnout did not predict post-training BPD stigma. These findings suggest that brief training of psychiatric nursing staff in DBT skills and coaching techniques can result in significant benefits, including reduced staff burnout and stigma toward patients with BPD-related problems, and that reducing BPD stigma may particularly promote lower burnout.

Dialectical behavior therapy for adolescents with bipolar disorder: results from a pilot randomized trial

OBJECTIVE

The purpose of this study was to conduct a pilot randomized trial of dialectical behavior therapy (DBT) versus psychosocial treatment as usual (TAU) for adolescents diagnosed with bipolar disorder (BP).

METHODS

We recruited participants 12-18 years of age with a primary BP diagnosis (I, II, or operationalized not otherwise specified [NOS] criteria) from a pediatric specialty clinic. Eligible patients were assigned using a 2:1 randomization structure to either DBT (n=14) or psychosocial TAU (n=6). All patients received medication management from a study-affiliated psychiatrist. DBT included 36 sessions (18 individual, 18 family skills training) over 1 year. TAU was an eclectic psychotherapy approach consisting of psychoeducational, supportive, and cognitive behavioral techniques. An independent evaluator, blind to treatment condition, assessed outcomes including affective symptoms, suicidal ideation and behavior, nonsuicidal self-injurious behavior, and emotional dysregulation, quarterly over 1 year.

RESULTS

Adolescents receiving DBT attended significantly more therapy sessions over 1 year than did adolescents receiving TAU, possibly reflecting greater engagement and retention; both treatments were rated as highly acceptable by adolescents and parents. As compared with adolescents receiving TAU, adolescents receiving DBT demonstrated significantly less severe depressive symptoms over follow-up, and were nearly three times more likely to demonstrate improvement in suicidal ideation. Models indicate a large effect size, for more weeks being euthymic, over follow-up among adolescents receiving DBT. Although there were no between-group differences in manic symptoms or emotional dysregulation with treatment, adolescents receiving DBT, but not those receiving TAU, evidenced improvement from pre- to posttreatment in both manic symptoms and emotional dysregulation.

CONCLUSIONS

DBT may offer promise as an adjunct to pharmacotherapy in the treatment of depressive symptoms and suicidal ideation for adolescents with BP. The DBT focus on commitment to treatment may be important for the treatment of early-onset BP. Larger controlled trials are needed to establish the efficacy of this approach, examine impact on suicidal behavior, and demonstrate cost effectiveness.

Borderline personality disorder in adolescents: the He-who-must-not-be-named of psychiatry

This article reviews the possibility and pertinence of diagnosing borderline personality disorder in adolescents. The etiology and clinical manifestations of this disorder in adolescents are discussed, and its management is addressed in terms of psychotherapy, pharmacology, hospitalization issues, and family involvement considerations.

Psychotherapeutic approaches to non-suicidal self-injury in adolescents

Non-suicidal self-injury (NSSI) among adolescents is gaining increasing attention in both clinical and scientific arenas. The lifetime prevalence of NSSI is estimated to vary between 7.5% to 8% for preadolescents, increasing to between 12% and 23% for adolescents. Despite the prevalence and the increasing interest in NSSI, few psychotherapeutic treatments have been designed specifically for NSSI, and no treatments have been evaluated specifically for the treatment of NSSI among adolescents. Consequently, child and adolescent clinicians are left with little evidence-based guidance for treating this challenging population. To provide some guidance, evaluations of treatments for adults with NSSI and for adolescents with related conditions, such as deliberate self-harm and borderline personality disorder, are reviewed. Clinical guidelines and resources are also discussed to assist with the gaps in the knowledge base for treatment of NSSI among adolescents.

Development of borderline personality disorder in adolescence and young adulthood: introduction to the special section

Recognizable symptoms and features of borderline personality disorder (BPD) appear during adolescence. However, there has been resistance to diagnose or research this disorder prior to adulthood because of clinical lore that BPD is a long-standing illness and that personality traits are not stable until adulthood. This has resulted in little information regarding the development of and risk factors for BPD in youth. The goal of this special section is to examine the development of BPD in adolescence and young adulthood using a broad collection of approaches, including a theoretical review paper, two prospective studies, and a multi-method cross-sectional study. This body of work provides new insights into vulnerabilities that may transact with early attachment relationships and experiences to predict the emergence of BPD in adolescence and young adulthood. These papers also point to future research that is needed to better understand the etiology, development, and course of BPD.