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Assmann N, Schaich A, Arntz A, Wagner T, Herzog P, Alvarez-Fischer D, Sipos V, Jauch-Chara K, Klein JP, Hüppe M, Schweiger U, Fassbinder E. The Effectiveness of Dialectical Behavior Therapy Compared to Schema Therapy for Borderline Personality Disorder: A Randomized Clinical Trial. PSYCHOTHERAPY AND PSYCHOSOMATICS 2024; 93:249-263. [PMID: 38986457 PMCID: PMC11332312 DOI: 10.1159/000538404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 03/09/2024] [Indexed: 07/12/2024]
Abstract
INTRODUCTION In the treatment of borderline personality disorder (BPD), there is empirical support for both dialectical behavior therapy (DBT) and schema therapy (ST); these treatments have never been compared directly. This study examines whether either of them is more effective than the other in treating patients with BPD. METHODS In this randomized, parallel-group, rater-blind clinical trial, outpatients aged between 18 and 65 years with a primary diagnosis of BPD were recruited in a tertiary outpatient treatment center (Lübeck, Germany). Participants were randomized to DBT or ST with one individual and one group session per week over 1.5 years. The primary outcome was the BPD symptom severity assessed with the mean score of the Borderline Personality Disorder Severity Index at 1-year naturalistic follow-up. RESULTS Between November 26, 2014, and December 14, 2018, we enrolled 164 patients (mean age = 33.7 [SD = 10.61] years). Of these, 81 (49.4%) were treated with ST and 83 (50.6%) with DBT, overall, 130 (79.3%) were female. Intention-to-treat analysis with generalized linear mixed models did not show a significant difference at 1-year naturalistic follow-up between DBT and ST for the BPDSI total score (mean difference 3.32 [95% CI: -0.58-7.22], p = 0.094, d = -24 [-0.69; 0.20]) with lower scores for DBT. Pre-to-follow-up effect sizes were large in both groups (DBT: d = 2.45 [1.88-3.02], ST: d = 1.78 [1.26-2.29]). CONCLUSION Patients in both treatment groups showed substantial improvements indicating that even severely affected patients with BPD and various comorbid disorders can be treated successfully with DBT and ST. An additional non-inferiority trial is needed to show if both treatments are equally effective. The trial was retrospectively registered on the German Clinical Trials Register, DRKS00011534 without protocol changes.
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Affiliation(s)
- Nele Assmann
- Department of Psychiatry, Psychosomatics and Psychotherapy, University of Lübeck, Lübeck, Germany
- Department of Psychiatry and Psychotherapy, Christian-Albrechts-Universität zu Kiel, Kiel, Germany
| | - Anja Schaich
- Department of Psychiatry, Psychosomatics and Psychotherapy, University of Lübeck, Lübeck, Germany
- Department of Psychiatry and Psychotherapy, Christian-Albrechts-Universität zu Kiel, Kiel, Germany
| | - Arnoud Arntz
- Department of Clinical Psychology, University of Amsterdam, Amsterdam, The Netherlands
| | - Till Wagner
- Department of Psychiatry, Psychosomatics and Psychotherapy, University of Lübeck, Lübeck, Germany
| | - Philipp Herzog
- Department of Psychiatry, Psychosomatics and Psychotherapy, University of Lübeck, Lübeck, Germany
- Department of Psychology, Harvard University, Cambridge, MA, USA
- Department of Psychology, University of Kaiserslautern–Landau, Landau, Germany
| | - Daniel Alvarez-Fischer
- Department of Psychiatry, Psychosomatics and Psychotherapy, University of Lübeck, Lübeck, Germany
- Institute of Neurogenetics, University of Lübeck, Lübeck, Germany
| | - Valerija Sipos
- Department of Psychiatry, Psychosomatics and Psychotherapy, University of Lübeck, Lübeck, Germany
| | - Kamila Jauch-Chara
- Department of Psychiatry, Psychosomatics and Psychotherapy, University of Lübeck, Lübeck, Germany
- Department of Psychiatry and Psychotherapy, Christian-Albrechts-Universität zu Kiel, Kiel, Germany
| | - Jan Philipp Klein
- Department of Psychiatry, Psychosomatics and Psychotherapy, University of Lübeck, Lübeck, Germany
| | - Michael Hüppe
- Department of Anaesthesiology, University of Lübeck, Lübeck, Germany
| | - Ulrich Schweiger
- Department of Psychiatry, Psychosomatics and Psychotherapy, University of Lübeck, Lübeck, Germany
| | - Eva Fassbinder
- Department of Psychiatry, Psychosomatics and Psychotherapy, University of Lübeck, Lübeck, Germany
- Department of Psychiatry and Psychotherapy, Christian-Albrechts-Universität zu Kiel, Kiel, Germany
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Tracy M, Penney E, Norton AR. Group schema therapy for personality disorders: Systematic review, research agenda and treatment implications. Psychother Res 2024:1-20. [PMID: 38862126 DOI: 10.1080/10503307.2024.2361451] [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: 11/08/2023] [Accepted: 05/22/2024] [Indexed: 06/13/2024] Open
Abstract
OBJECTIVE There are significant temporal and financial barriers for individuals with personality disorders (PD) receiving evidence-based psychological treatments. Emerging research indicates Group Schema Therapy (GST) may be an accessible, efficient, and cost-effective PD intervention, however, there has been no synthesis of the available evidence to date. This review therefore aimed to investigate the efficacy of GST for PDs by systematically synthesizing available literature. METHOD Five electronic databases were screened with resulting studies subjected to a specific eligibility criteria, which yielded fourteen relevant studies. Characteristics were extracted and methodological quality rigorously assessed. RESULTS Strong support was evidenced for GST's ability to reduce Cluster B and C symptomology, particularly for Borderline and Avoidant PD. GST appeared to improve global symptom severity, quality of life and functional capacity, as well as treatment targets such as schemas and modes. CONCLUSION Although not without limitations and a moderate risk of bias, the current body of evidence supports GST as a potential solution to current service deficits in economical and evidence-based care for individuals with PD. Implications for treatment and future research are discussed.
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Affiliation(s)
- Mikaela Tracy
- Discipline of Clinical Psychology, Graduate School of Health, University of Technology Sydney, Sydney, Australia
- Faculty of Science, School of Psychology, The University of Sydney, Sydney, Australia
| | - Erika Penney
- Discipline of Clinical Psychology, Graduate School of Health, University of Technology Sydney, Sydney, Australia
| | - Alice R Norton
- Discipline of Clinical Psychology, Graduate School of Health, University of Technology Sydney, Sydney, Australia
- Faculty of Science, School of Psychology, The University of Sydney, Sydney, Australia
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van Houten J, Bouwmeester S, Bachrach N. Effectiveness of Day Treatment Group Schema Therapy for Personality Disorders: A Multiple Baseline Single-Case Study. Clin Psychol Psychother 2024; 31:e2964. [PMID: 38528762 DOI: 10.1002/cpp.2964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 02/01/2024] [Accepted: 02/05/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND Schema therapy is effective for most outpatients with personality disorders (PDs). However, a subgroup does not sufficiently benefit from outpatient programmes. Despite its common clinical use, a thorough evaluation of day treatment group schema therapy (GST) is lacking. AIMS This study aimed to investigate the effectiveness of day treatment GST for patients with PDs. METHODS AND PROCEDURES Negative core beliefs were the primary outcome in a multiple baseline single-case design, measured weekly before and during 30 weeks of day treatment GST. Secondary outcomes included severity of primary PD, early maladaptive schemas (EMS), schema modes and general psychopathology measured before and after day treatment GST. Intervention effects were evaluated through visual inspection and randomization test analysis, with a reliable change index calculated for the secondary outcome measures. OUTCOMES AND RESULTS A total of 79% of treatment completers showed a significant positive effect of day treatment GST with large effect sizes (Cohen's d: 0.96-10.04). Secondary outcomes supported these findings: 56% had a significant decrease in the severity of primary PD and 53% in general psychopathology. In addition, 63% of EMS and 72% of schema modes (87.5% for functional schema modes) showed significant positive reliable changes. CONCLUSIONS AND IMPLICATIONS This is the first empirical study that demonstrated the effectiveness of day treatment GST in patients with severe PDs. Day treatment GST can serve as a stepped care treatment option for nonresponsive patients in outpatient programmes. Further randomized controlled (cost-)effectiveness research is necessary to substantiate these findings and investigate the specific patient populations for which day treatment is essential.
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Affiliation(s)
- Joska van Houten
- Department of Trauma Related and Personality Disorders, GGZ Oost Brabant, Helmond, The Netherlands
| | - Samantha Bouwmeester
- Department of Developmental Psychology, Tilburg University, Tilburg, The Netherlands
| | - Nathan Bachrach
- Department of Trauma Related and Personality Disorders, GGZ Oost Brabant, Helmond, The Netherlands
- Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands
- Department of Mental Health Care Psychology, RINO Zuid, Eindhoven, The Netherlands
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Söderholm JJ, Socada JL, Ekelund J, Isometsä E. How changes in depression severity and borderline personality disorder intensity are linked - a cohort study of depressed patients with and without borderline personality disorder. Borderline Personal Disord Emot Dysregul 2024; 11:3. [PMID: 38369499 PMCID: PMC10875744 DOI: 10.1186/s40479-024-00247-2] [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: 12/19/2023] [Accepted: 02/03/2024] [Indexed: 02/20/2024] Open
Abstract
BACKGROUND Borderline personality disorder (BPD) is often complicated by comorbid major depressive episodes (MDEs), which can occur as part of major depressive disorder (MDD) or bipolar disorder (BD). Such comorbidity is related to worse outcomes in both disorders. Subsyndromal features of BPD are also common in depression. However, studies of simultaneous changes in BPD and depression severities are scarce, and their interactions are poorly understood. AIMS Studying the associations between changes in BPD and depression symptoms over the course of an MDE. METHODS In a 6-month naturalistic cohort study of MDE/BPD, MDE/MDD, and MDE/BD patients (N = 95), we measured change in BPD features between baseline and six months with the Borderline Personality Disorder Severity Index (BPDSI), an interviewer-rated instrument quantifying recent temporal frequency of BPD symptoms. We examined changes in BPD severity and their correlation with depression severity and other clinical measures and compared these across patient groups. RESULTS There were significant reductions in BPD severity, both in number of positive BPD criteria (-0.35, sd 1.38, p = 0.01672) and in BPDSI scores (-4.23, SD 6.74, p < 0.001), reflecting mainly a reduction in temporal frequency of symptoms. These were similar in all diagnostic groups. In multivariate regression models, changes in depression severity independently associated with changes in symptoms in the BDSI. This relationship was strongest in MDE/BPD patients but was not found in MDD patients without BPD. CONCLUSIONS In the six-month follow-up, BPD features in MDE patients alleviated mainly by decreasing temporal symptom frequency and intensity. In BPD patients with comorbid MDE, changes in both conditions are strongly correlated.
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Affiliation(s)
- John J Söderholm
- Department of Psychiatry, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - J Lumikukka Socada
- Department of Psychiatry, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jesper Ekelund
- Department of Psychiatry, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Erkki Isometsä
- Department of Psychiatry, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
- Department of Psychiatry, University of Helsinki, P.O. Box 22, Helsinki, FI-00014, Finland.
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Pol SM, de Jong A, Trompetter H, Bohlmeijer ET, Chakhssi F. Effectiveness of compassion-focused therapy for self-criticism in patients with personality disorders: a multiple baseline case series study. Personal Ment Health 2024; 18:69-79. [PMID: 37942561 DOI: 10.1002/pmh.1597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 09/22/2023] [Accepted: 10/18/2023] [Indexed: 11/10/2023]
Abstract
OBJECTIVE Targeting self-criticism, the tendency to negatively evaluate and judge aspects of oneself, may improve treatment efficacy for personality disorders (PDs). This study aimed to test whether adding 12-week group compassion-focused therapy (CFT) that explicitly targets self-criticism to treatment as usual (TAU) would reduce self-criticism in patients with PDs. METHOD Twelve patients with PDs participated in a multiple baseline study, randomly allocated to different baseline lengths. The primary outcome was twice-weekly assessed self-critical beliefs during baseline, treatment, and follow-up phases. Secondary outcomes were self-criticism, self-compassion, and PD severity at the end of CFT and follow-up (trial registered: NL8131). Nine participants completed the intervention. No significant changes were observed during CFT, but at follow-up significant decrease in self-critical beliefs (Cohen's d = -0.43; 95% CI = -0.73 to -0.12) was reported compared to baseline. On secondary outcomes, most participants showed reliable improvement on self-reported criticism (66.7%) and self-compassion (55.6%), and a minority of patients showed reliable improvement in PD severity (33.3%). CONCLUSIONS This study seems to provide preliminary evidence for the effectiveness of 12-week CFT for self-critical beliefs in patients with PDs compared to TAU. CFT for self-criticism in PDs may complement treatment offerings and warrant further research.
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Affiliation(s)
- Silvia M Pol
- GGNet Group for Mental Health Care in East-Gelderland and Zutphen, Scelta, Zutphen, The Netherlands
| | - Audrey de Jong
- GGNet Group for Mental Health Care in East-Gelderland and Zutphen, Scelta, Zutphen, The Netherlands
| | - Hester Trompetter
- Department of Medical and Clinical Psychology, Tilburg University Tilburg School of Social and Behavioral Sciences, Tilburg, The Netherlands
| | - Ernst T Bohlmeijer
- Psychology, Health & Technology, University of Twente Faculty of Behaviourial, Management and Social sciences, Enschede, The Netherlands
| | - Farid Chakhssi
- GGNet Group for Mental Health Care in East-Gelderland and Zutphen, Scelta, Zutphen, The Netherlands
- Dimence Groep, Deventer, The Netherlands
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Socada JL, Söderholm JJ, Rosenström T, Lahti J, Ekelund J, Isometsä ET. Affect dimensions and variability during major depressive episodes: Ecological momentary assessment of unipolar, bipolar, and borderline patients and healthy controls. J Psychiatr Res 2024; 170:408-416. [PMID: 38218014 DOI: 10.1016/j.jpsychires.2024.01.010] [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: 08/10/2023] [Revised: 12/21/2023] [Accepted: 01/05/2024] [Indexed: 01/15/2024]
Abstract
Differentiating major depressive episodes (MDEs) of major depressive disorder (MDD), bipolar disorder (MDE/BD) and the MDEs comorbid with borderline personality disorder (MDE/BPD) is crucial for appropriate treatment, and knowledge of phenomenological differences may aid this. However, studies comparing affect experiences of these three patient groups and healthy subjects are scarce. In our study, participants (N = 114), including patients with MDD (n = 34), MDE/BD (n = 27), and MDE/BPD (n = 24), and healthy controls (HC, n = 29) responded to ecological momentary assessment (EMA) with ten circumplex model affect items ten times daily for seven days (7709 recordings). Explorative factor analysis resulted in two affect dimensions. The positive dimension included active, excited, cheerful (high arousal), and content (low arousal) affects, and the negative dimension irritated, angry, and nervous (high arousal) affects. Relative to HC, patients reported 3.5-fold negative affects (mean MDD 1.36 (SD 0.92), MDE/BD 1.43 (0.76), MDE/BPD 1.81 (0.95) vs. HC 0.44 (0.49) (p < 0.01)) but 0.5-fold positive affects (2.01 (0.90), 1.95 (0.89), 2.24 (1.03), vs. 3.2 (0.95), respectively (p < 0.01)). We used multilevel modelling. Negative-affect within-individual stability was lowest in MDE/BPD and highest in MDD. Negative affect predicted concurrent positive affect more in MDE/BPD than in MDD. Moderate size of subcohorts and no inpatients were limitations. Despite apparently similar MDEs, affective experiences may differ between BPD, BD, and MDD patients. Clinical subgroups of patients with depression may vary in affective instability and concurrent presence of negative and positive affects during depression.
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Affiliation(s)
- J Lumikukka Socada
- Department of Psychiatry, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - John J Söderholm
- Department of Psychiatry, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Tom Rosenström
- Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Jari Lahti
- Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, Helsinki, Finland; Folkhälsan Research Centre, Helsinki, Finland
| | - Jesper Ekelund
- Department of Psychiatry, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Erkki T Isometsä
- Department of Psychiatry, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
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Dippold B, Beller J, Kröger C, Dreyße K. [Factorial and Convergent Validity of the Short Form of the "Questionnaire of Thoughts and Feelings" (QTF-14) for Borderline Personality Disorder]. Psychother Psychosom Med Psychol 2024; 74:43-48. [PMID: 37931650 DOI: 10.1055/a-2177-1676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
The "Questionnaire of Thoughts and Feelings" (QTF) is being used as screening instrument as well as tool for treatment planning and treatment evaluation for patients with borderline personality disorder (BPD). The primary goal of this study was the validation of the dimensional structure of the short version with 14 items, QTF-14. Additionally, item characteristics, reliability and evidence of convergent validity were examined. A diagnostically homogenous sample of patients with BPD (N=3035) of a psychosomatic clinic was presented with several self-assessment inventories, including the QTF-14. The expected single-factor model of the structure of the FGG showed unacceptable model fit indices (CFI=0.751; TLI=0.706; RMSEA=0.115; SRMR=0.073). Exploratory factor analysis showed evidence of two or three specific factors. In a subsequent confirmatory factor analysis, a bifactor model with two specific factors proved to be preferable (CFI=0.956; TLI=0.936; RMSEA=0.054; SRMR=0.034). The internal consistency of the total scale as well as the suggested subscales "Relationship Difficulties and Emotional Dysregulation" and "Autoaggression" was acceptable to good (ω=.81-.84; α=.79-.85). Associations with similar scales were as expected. Good psychometric properties of the QTF-14 can be confirmed in this study. Using the suggested subscales could support treatment planning.
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Affiliation(s)
- Brigitte Dippold
- Klinische Psychologie und Psychotherapie, Institut für Psychologie, Universität Hildesheim
| | | | - Christoph Kröger
- Klinische Psychologie und Psychotherapie, Institut für Psychologie, Universität Hildesheim
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Koppeschaar A, Bachrach N, Arntz A. Timing of imagery rescripting during schema therapy for borderline personality disorder: the LUCY trial. Front Psychiatry 2023; 14:1204439. [PMID: 38152355 PMCID: PMC10751307 DOI: 10.3389/fpsyt.2023.1204439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 11/06/2023] [Indexed: 12/29/2023] Open
Abstract
Background Early childhood adversity plays an important role in the etiology of borderline personality disorder (BPD). Current evidence suggests that trauma treatment for patients with BPD can be performed safely and that early trauma treatment has a positive effect on the course of PD. However, there is a scarcity of RCTs comparing the effects of the timing of trauma treatment during schema therapy (ST) for BPD on BPD severity. Therefore, the LUCY trial investigates the effects of the timing of trauma treatment by comparing early trauma treatment using imagery rescripting (ImRs) on the course of BPD during ST to trauma treatment in the middle of the treatment course. Methods In this multicenter RCT, two conditions are compared among 73 individuals with BPD. The participants receive combined individual and group ST in both conditions. However, in condition (A), participants directly start ImRs in the individual sessions in months 2-4, and in condition (B), participants receive ST-as-Usual (STAU), in which ImRs is not allowed during months 2-4. The treatment follows ST treatment protocols, consists of a fixed combination of individual sessions and group sessions with a maximum of nine patients, and has a maximum duration of 25 months. The primary outcome is change in BPD severity, which is assessed using the Borderline Personality Disorder Severity Index-5 by independent raters blinded to the treatment. Secondary outcome measures include treatment retention, disconnection/rejection schemas, general functioning, posttraumatic stress disorder symptoms, general psychopathological complaints, quality of life, happiness, schemas, and schema modes. Multilevel analysis will be performed to analyze and compare changes in BPD severity between conditions and generalized linear mixed model analyses to test predictors and moderators. Discussion This study will increase the knowledge on whether trauma treatment early in therapy positively affects the course of BPD manifestations during ST. When the early application of ImRs leads to a faster decrease in BPD manifestations, the treatment of BPD patients might be shortened, leading to improved treatment outcomes and decreased healthcare expenses. Moreover, the planned sub-studies will expand our knowledge of how ST works and the factors that influence the outcome of treatment.
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Affiliation(s)
- Annemieke Koppeschaar
- Parnassia Groep Academy, The Hague, Netherlands
- Academic Centre for Trauma and Personality, Amsterdam, Netherlands
| | - Nathan Bachrach
- Department of Medical and Clinical Psychology, Tilburg University, Tilburg, Netherlands
- Department of Personality Disorders, GGZ-Oost Brabant, Helmond, Netherlands
| | - Arnoud Arntz
- Department of Clinical Psychology, University of Amsterdam, Amsterdam, Netherlands
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Zou M, Broadbear JH, Rao S. Exploring the Utility of Neurostimulation Therapies in the Treatment of Borderline Personality Disorder: A Systematic Literature Review. J ECT 2023; 39:151-157. [PMID: 36988515 DOI: 10.1097/yct.0000000000000916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
Abstract
ABSTRACT The use of electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS) in the treatment of people diagnosed with borderline personality disorder (BPD) highlights the need for systematic review of the evidence supporting this practice. A comprehensive literature search identified seven original clinical research studies investigating the use of brain stimulation therapies in people diagnosed with BPD. The lack of consistent study design, diagnostic methodology, treatment parameters, and outcome measures precluded analysis of aggregated study results. There were no ECT studies evaluating BPD symptom outcomes; however, studies of ECT in patients with comorbid BPD and depression suggested that depressive symptoms were less responsive to ECT compared with depression-only patients. The few studies available suggest that TMS may lead to clinically and statistically significant improvements in BPD symptoms and depressive symptoms. Similar overall improvements were reported despite the use of heterogeneous TMS treatment protocols, highlighting the importance of including a sham condition to investigate the contribution of the placebo effect to overall improvement. There is still no clear evidence supporting the use of ECT for treating people with BPD (with or without depression); therefore, the use of ECT in this population should be approached with caution. Although TMS shows early promise, the low numbers of participants in the few available studies suggest the urgent need for larger randomized controlled trials to provide an evidence base for this increasingly popular treatment.
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Affiliation(s)
- Michael Zou
- From the Spectrum Personality Disorder and Complex Trauma Service
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Jiménez S, Arango de Montis I, Garza-Villarreal EA. Modeling vulnerability and intervention targets in the Borderline Personality Disorder system: A network analysis of in silico and in vivo interventions. PLoS One 2023; 18:e0289101. [PMID: 37523373 PMCID: PMC10389718 DOI: 10.1371/journal.pone.0289101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 07/11/2023] [Indexed: 08/02/2023] Open
Abstract
Modeling psychopathology as a complex dynamic system represents Borderline Personality Disorder (BPD) as a constellation of symptoms (e.g., nodes) that feedback and self-sustain each other shaping a network structure. Through in silico interventions, we simulated the evolution of the BPD system by manipulating: 1) the connectivity strength between nodes (i.e., vulnerability), 2) the external disturbances (i.e., stress) and 3) the predisposition of symptoms to manifest. Similarly, using network analysis we evaluated the effect of an in vivo group psychotherapy to detect the symptoms modified by the intervention. We found that a network with greater connectivity strength between nodes (more vulnerable) showed a higher number of activated symptoms than networks with less strength connectivity. We also found that increases in stress affected more vulnerable networks compared to less vulnerable ones, while decreases in stress revealed a hysteresis effect in the most strongly connected networks. The in silico intervention to symptom alleviation revealed the relevance of nodes related to difficulty in anger regulation, nodes which were also detected as impacted by the in vivo intervention. The complex systems methodology is an alternative to the common cause model with which research has approached the BPD phenomenon.
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Affiliation(s)
- Said Jiménez
- Departamento de Psicología, Tecnológico de Monterrey, Ciudad de México, México
- Unidad de Investigación en Medicina Basada en Evidencias, Hospital Infantil de México Federico Gómez, Ciudad de México, México
| | - Iván Arango de Montis
- Clínica de Trastorno Límite de Personalidad, Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz, Ciudad de México, México
| | - Eduardo A Garza-Villarreal
- Instituto de Neurobiología, Universidad Nacional Autónoma de México Campus Juriquilla, Querétaro, México
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11
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Salmon AP, Nicol K, Kaess M, Jovev M, Betts JK, Chanen AM. Associations of state or trait dissociation with severity of psychopathology in young people with borderline personality disorder. Borderline Personal Disord Emot Dysregul 2023; 10:20. [PMID: 37303050 DOI: 10.1186/s40479-023-00226-z] [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: 11/01/2022] [Accepted: 05/22/2023] [Indexed: 06/13/2023] Open
Abstract
BACKGROUND State and trait dissociation are associated with borderline personality disorder (BPD) severity and severity of commonly co-occurring mental health symptoms. Although these distinct constructs do not consistently co-occur in experimental settings, they are frequently reported as the same construct, namely dissociation. This study aimed to investigate the co-occurrence of state and trait dissociation among young people with BPD and to examine whether state or trait dissociation were associated with symptom severity in this population. METHODS State dissociation was induced using a stressful behavioural task in a clinical sample of 51 young people (aged 15-25 years) with three or more BPD features. Diagnoses, state and trait dissociation, BPD severity and severity of posttraumatic stress disorder (PTSD), depressive, and stress symptoms were assessed by self-report or research interview. RESULTS A chi-square test of independence showed a strong association between state and trait dissociation. Bonferroni corrected t-tests showed that state dissociation was significantly associated with PTSD symptom severity and likely associated with BPD severity and severity of depressive and stress symptoms. Trait dissociation was not associated with symptom severity or severity of BPD features. CONCLUSIONS These findings highlight the need to distinguish between state and trait dissociation in personality disorder research. They suggest that state dissociation might be an indicator of higher severity of psychopathology in young people with BPD.
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Affiliation(s)
- Ashleigh P Salmon
- Orygen, Melbourne, Australia
- Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia
| | - Katie Nicol
- Orygen, Melbourne, Australia
- Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia
| | - Michael Kaess
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
- Department of Child and Adolescent Psychiatry, Center for Psychosocial Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Jennifer K Betts
- Orygen, Melbourne, Australia
- Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia
| | - Andrew M Chanen
- Orygen, Melbourne, Australia.
- Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia.
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Daniëls M, Van HL, van den Heuvel B, Dekker JJM, Peen J, Bosmans J, Arntz A, Huibers MJH. Individual psychotherapy for cluster-C personality disorders: protocol of a pragmatic RCT comparing short-term psychodynamic supportive psychotherapy, affect phobia therapy and schema therapy (I-FORCE). Trials 2023; 24:260. [PMID: 37020251 PMCID: PMC10077625 DOI: 10.1186/s13063-023-07136-z] [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: 03/21/2022] [Accepted: 02/04/2023] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND Cluster-C personality disorders (PDs) are highly prevalent in clinical practice and are associated with unfavourable outcome and chronicity of all common mental health disorders (e.g. depression and anxiety disorders). Although several forms of individual psychotherapy are commonly offered in clinical practice for this population, evidence for differential effectiveness of different forms of psychotherapy is lacking. Also, very little is known about the underlying working mechanisms of these psychotherapies. Finding evidence on the differential (cost)-effectiveness for this group of patients and the working mechanisms of change is important to improve the quality of care for this vulnerable group of patients. OBJECTIVE In this study, we will compare the differential (cost)-effectiveness of three individual psychotherapies: short-term psychodynamic supportive psychotherapy (SPSP), affect phobia therapy (APT) and schema therapy (ST). Although these psychotherapies are commonly used in clinical practice, evidence for the Cluster-C PDs is limited. Additionally, we will investigate predictive factors, non-specific and therapy-specific mediators. METHODS This is a mono-centre randomized clinical trial with three parallel groups: (1) SPSP, (2) APT, (3) ST. Randomization on patient level will be pre-stratified according to type of PD. The total study population to be included consists of 264 patients with Cluster-C PDs or other specified PD with mainly Cluster-C traits, aged 18-65 years, seeking treatment at NPI, a Dutch mental health care institute specialized in PDs. SPSP, APT and ST (50 sessions per treatment) are offered twice a week in sessions of 50 min for the first 4 to 5 months. After that, session frequency decreases to once a week. All treatments have a maximum duration of 1 year. Change in the severity of the PD (ADP-IV) will be the primary outcome measure. Secondary outcome measures are personality functioning, psychiatric symptoms and quality of life. Several potential mediators, predictors and moderators of outcome are also assessed. The effectiveness study is complemented with a cost-effectiveness/utility study, using both clinical effects and quality-adjusted life-years, and primarily based on a societal approach. Assessments will take place at baseline, start of treatment and at 1, 3, 6, 9, 12, 18, 24 and 36 months. DISCUSSION This is the first study comparing psychodynamic treatment to schema therapy for Cluster-C PDs. The naturalistic design enhances the clinical validity of the outcome. A limitation is the lack of a control group for ethical reasons. TRIAL REGISTRATION NL72823.029.20 [Registry ID: CCMO]. Registered on 31 August 2020. First participant included on 23 October 2020.
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Affiliation(s)
| | | | | | - Jack J M Dekker
- Department of Clinical Psychology, VU University Amsterdam, Amsterdam, The Netherlands
| | - Jaap Peen
- Arkin Mental Health Care, Amsterdam, The Netherlands
| | - Judith Bosmans
- Department of Health Sciences, Faculty of Science, VU University Amsterdam, Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Arnoud Arntz
- Department of Clinical Psychology, University of Amsterdam, Amsterdam, The Netherlands
| | - Marcus J H Huibers
- Arkin Mental Health Care, Amsterdam, The Netherlands
- Department of Clinical Psychology, Utrecht University, Utrecht, The Netherlands
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13
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A Feasibility Study Investigating Mechanisms of Change in Public Mental Health Dialectical Behaviour Therapy Programmes. BEHAVIOUR CHANGE 2023. [DOI: 10.1017/bec.2023.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
Abstract
Few studies have investigated the feasibility of researching brief forms of dialectical behaviour therapy (DBT) for borderline personality disorder (BPD) in public mental health settings. This study aimed to provide preliminary evidence for the feasibility of implementing DBT over a 6-month period for BPD symptoms within Australian public mental health services. Of the 79 participants with BPD recruited, 62 commenced and 24 participants completed the therapy. The participants attended one of three outpatient DBT programmes and completed measures of BPD symptoms, DBT skills-use, and difficulties with emotion regulation at baseline and after 6 months of treatment. A major challenge with feasibility identified was the high attrition rate (61%). However, for completers there were significant improvements in BPD symptoms, DBT skills-use, and difficulties with emotion regulation. These effect sizes were used to estimate the sample sizes needed by future larger trials of brief DBT for BPD in public health settings. The implementation of brief DBT for BPD patients within a public mental health outpatient setting, appears to result in significant reductions in BPD symptoms. However, further exploration of strategies to reduce drop-out rates are required.
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14
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Boog M, Goudriaan AE, Wetering BJMVD, Franken IHA, Arntz A. Schema therapy for patients with borderline personality disorder and comorbid alcohol dependence: A multiple-baseline case series design study. Clin Psychol Psychother 2022; 30:373-386. [PMID: 36399433 DOI: 10.1002/cpp.2803] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 11/10/2022] [Accepted: 11/14/2022] [Indexed: 11/19/2022]
Abstract
This study tested the effectiveness of schema therapy (ST) for borderline personality disorder (BPD) and comorbid alcohol dependence (AD). Twenty patients participated in a case series study with multiple baselines. The baseline phase consisted of treatment as usual. It was followed by a case conceptualization phase, an experiential techniques phase and a behavioural change phase. Patients showed a significant decrease in BPD and AD symptoms; change was mainly accomplished in the experiential techniques phase, with medium to large effect sizes. Three months after termination of therapy, 68% of the patients had remitted from BPD, and the number of drinking days decreased clearly. This study shows that, although treatment is challenging in this group of patients, meaningful change can be obtained in patients with BPD and AD using ST.
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Affiliation(s)
- Michiel Boog
- Antes Mental Health Care, Rotterdam, the Netherlands.,Institute of Psychology, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Anna E Goudriaan
- Department of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.,Arkin Mental Health Care, Amsterdam, the Netherlands
| | | | - Ingmar H A Franken
- Institute of Psychology, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Arnoud Arntz
- Department of Clinical Psychology, University of Amsterdam, Amsterdam, the Netherlands
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15
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van Schie CC, Chiu CD, Rombouts SARB, Heiser WJ, Elzinga BM. Finding a positive me: Affective and neural insights into the challenges of positive autobiographical memory reliving in borderline personality disorder. Behav Res Ther 2022; 158:104182. [PMID: 36137418 DOI: 10.1016/j.brat.2022.104182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 07/27/2022] [Accepted: 08/08/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND This study aimed to investigate whether people with borderline personality disorder (BPD) can benefit from reliving positive autobiographical memories in terms of mood and state self-esteem and elucidate the neural processes supporting optimal memory reliving. Particularly the role of vividness and brain areas involved in autonoetic consciousness were studied, as key factors involved in improving mood and state self-esteem by positive memory reliving. METHODS Women with BPD (N = 25), Healthy Controls (HC, N = 33) and controls with Low Self-Esteem (LSE, N = 22) relived four neutral and four positive autobiographical memories in an MRI scanner. After reliving each memory mood and vividness was rated. State self-esteem was assessed before and after the Reliving Autobiographical Memories (RAM) task. RESULTS Overall, mood and state self-esteem were lower in participants with BPD compared to HC and LSE, but both the BPD and LSE group improved significantly after positive memory reliving. Moreover, participants with BPD indicated that they relived their memories with less vividness than HC but not LSE, regardless of valence. When reliving (vs reading) memories, participants with BPD showed increased precuneus and lingual gyrus activation compared to HC but not LSE, which was inversely related to vividness. DISCUSSION Women with BPD seem to experience more challenges in reliving neutral and positive autobiographical memories with lower vividness and less deactivated precuneus potentially indicating altered autonoetic consciousness. Nevertheless, participants with BPD do benefit in mood and self-esteem from reliving positive memories. These findings underline the potential of positive autobiographical memory reliving and suggest that interventions may be further shaped to improve mood and strengthen self-views in people with BPD.
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Affiliation(s)
- Charlotte C van Schie
- Institute of Psychology, Leiden University, Leiden, the Netherlands; Leiden Institute for Brain and Cognition, Leiden, the Netherlands; School of Psychology and Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, Australia.
| | - Chui-De Chiu
- Department of Psychology, The Chinese University of Hong Kong, Hong Kong, China
| | - Serge A R B Rombouts
- Institute of Psychology, Leiden University, Leiden, the Netherlands; Leiden Institute for Brain and Cognition, Leiden, the Netherlands; Department of Radiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Willem J Heiser
- Institute of Psychology, Leiden University, Leiden, the Netherlands
| | - Bernet M Elzinga
- Institute of Psychology, Leiden University, Leiden, the Netherlands; Leiden Institute for Brain and Cognition, Leiden, the Netherlands
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16
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van Trigt S, van der Zweerde T, van Someren E, van Straten A, van Marle H. Guided internet-based cognitive behavioral therapy for insomnia in patients with borderline personality disorder: Study protocol for a randomized controlled trial. Internet Interv 2022; 29:100563. [PMID: 35899204 PMCID: PMC9310106 DOI: 10.1016/j.invent.2022.100563] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 07/12/2022] [Accepted: 07/16/2022] [Indexed: 11/14/2022] Open
Abstract
Borderline personality disorder (BPD) is a highly disabling psychiatric disorder with emotion dysregulation at its core, resulting in affective instability, impulsivity and sometimes self-harming or suicidal behavior. Sleep is increasingly recognized to play a crucial role in emotion regulation. BPD patients often suffer from (severe) insomnia, potentially aggravating symptoms and preventing recovery from BPD. Yet, the effects of insomnia treatments have not been investigated in context of BPD. Guided internet-based cognitive behavioral therapy for insomnia (iCBT-I; i-Sleep) has been proven effective in improving both insomnia and affective symptoms. In this randomized controlled trial among 96 patients with a DSM-5 diagnosis of BPD (or other personality disorder with ≥4 BPD traits) and insomnia symptoms, we will test the effectiveness of iCBT-I before regular BPD treatment starts, during the waitlist period, on BPD symptoms. Patients in the control group monitor their sleep through a sleep diary during the waitlist period and also receive standard BPD treatment after that. Using linear mixed models we will test the hypothesis that the iCBT-I group improves more than the control group on BPD symptoms (primary outcome), insomnia severity, additional subjective and objective sleep variables, emotion regulation, comorbid anxiety and depression complaints, and quality of life. These effects are thought to arise from a direct effect of improved sleep on emotion regulation and a synergistic effect on the consolidation and internalization of the BPD treatment effect. To our knowledge, this is the first trial assessing effectiveness of CBT-I in patients with BPD (traits). The accessibility of the studied intervention greatly facilitates clinical implication in case of positive results.
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Affiliation(s)
- S. van Trigt
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Psychiatry, De Boelelaan 1117, Amsterdam, the Netherlands,Amsterdam Public Health, Mental Health Program, Amsterdam, the Netherlands,Corresponding author at: Amsterdam UMC, location Vrije Universiteit Amsterdam, Psychiatry, De Boelelaan 1117, Amsterdam, the Netherlands.
| | - T. van der Zweerde
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Psychiatry, De Boelelaan 1117, Amsterdam, the Netherlands,GGZ inGeest Mental Health Care, Amsterdam, the Netherlands
| | - E.J.W. van Someren
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Psychiatry, De Boelelaan 1117, Amsterdam, the Netherlands,Amsterdam Neuroscience, Mood, Anxiety, Psychosis, Sleep & Stress Program, Amsterdam, the Netherlands,Department of Sleep and Cognition, Netherlands Institute for Neuroscience, an Institute of the Royal Netherlands Academy of Arts and Sciences, Amsterdam, the Netherlands,Department of Integrative Neurophysiology, Center for Neurogenomics and Cognitive Research, Amsterdam Neuroscience, Vrije Universiteit, Amsterdam, the Netherlands
| | - A. van Straten
- Amsterdam Public Health, Mental Health Program, Amsterdam, the Netherlands,Vrije Universiteit Amsterdam, Clinical, Neuro and Developmental Psychology, Amsterdam, the Netherlands
| | - H.J.F. van Marle
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Psychiatry, De Boelelaan 1117, Amsterdam, the Netherlands,GGZ inGeest Mental Health Care, Amsterdam, the Netherlands,Amsterdam Neuroscience, Mood, Anxiety, Psychosis, Sleep & Stress Program, Amsterdam, the Netherlands
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17
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de Wilde Brand O, Clarke S, Arntz A. The use of borderline personality disorder severity index-iv feedback in adjusting borderline personality disorder treatment: therapists and patients perspectives. BMC Psychiatry 2022; 22:469. [PMID: 35836201 PMCID: PMC9284892 DOI: 10.1186/s12888-022-04104-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 06/29/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Previous research has emphasized the importance of therapists giving Routine Outcome Monitoring (ROM) feedback to their patients. It has been shown that several factors influence therapists' tendency to provide ROM feedback to their patients. METHODS In this qualitative study, using a semi-structured interview followed by thematic analysis using Atlas.ti, we focused on experiences of therapists and patients with a disorder specific ROM instrument: the Borderline Personality Disorder Severity Index-IV (BPDSI-IV). Ten patients with a borderline personality disorder who had been in Mentalization Based Treatment (MBT) and ten MBT-therapists treating patients with a borderline personality disorder were interviewed. RESULTS Qualitative analysis revealed that patients experienced benefits of ROM using the BPDSI-IV. Patients gained more insight in and recognition of their borderline personality disorder symptoms. They also felt more understood by the therapist because they got an opportunity to explain their symptoms in a different way than in a regular therapy session. Therapists shared they didn't always use all the ROM outcomes as serious feedback for adjusting treatment. They preferred to use the BPDSI-IV over the other ROM instruments, because the BPDSI-IV is disorder specific, which gives insight into the treatment course of the patient. CONCLUSIONS Experiences of both patients and therapists with the BPDSI-IV were positive. It seems to be valuable and promising for healthcare institutions to evaluate treatment with a disorder specific ROM instrument.
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Affiliation(s)
- Odette de Wilde Brand
- grid.487405.a0000 0004 0407 9940De Viersprong, Netherlands Institute of Personality Disorders, PO Box 7, 4660 AA Halsteren, The Netherlands
| | - Sharon Clarke
- grid.487405.a0000 0004 0407 9940De Viersprong, Netherlands Institute of Personality Disorders, PO Box 7, 4660 AA Halsteren, The Netherlands
| | - Arnoud Arntz
- Department of Clinical Psychology, University of Amsterdam, PO Box 15933, 1001NK, Amsterdam, The Netherlands.
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18
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Wibbelink CJM, Arntz A, Grasman RPPP, Sinnaeve R, Boog M, Bremer OMC, Dek ECP, Alkan SG, James C, Koppeschaar AM, Kramer L, Ploegmakers M, Schaling A, Smits FI, Kamphuis JH. Towards optimal treatment selection for borderline personality disorder patients (BOOTS): a study protocol for a multicenter randomized clinical trial comparing schema therapy and dialectical behavior therapy. BMC Psychiatry 2022; 22:89. [PMID: 35123450 PMCID: PMC8817780 DOI: 10.1186/s12888-021-03670-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 12/21/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Specialized evidence-based treatments have been developed and evaluated for borderline personality disorder (BPD), including Dialectical Behavior Therapy (DBT) and Schema Therapy (ST). Individual differences in treatment response to both ST and DBT have been observed across studies, but the factors driving these differences are largely unknown. Understanding which treatment works best for whom and why remain central issues in psychotherapy research. The aim of the present study is to improve treatment response of DBT and ST for BPD patients by a) identifying patient characteristics that predict (differential) treatment response (i.e., treatment selection) and b) understanding how both treatments lead to change (i.e., mechanisms of change). Moreover, the clinical effectiveness and cost-effectiveness of DBT and ST will be evaluated. METHODS The BOOTS trial is a multicenter randomized clinical trial conducted in a routine clinical setting in several outpatient clinics in the Netherlands. We aim to recruit 200 participants, to be randomized to DBT or ST. Patients receive a combined program of individual and group sessions for a maximum duration of 25 months. Data are collected at baseline until three-year follow-up. Candidate predictors of (differential) treatment response have been selected based on the literature, a patient representative of the Borderline Foundation of the Netherlands, and semi-structured interviews among 18 expert clinicians. In addition, BPD-treatment-specific (ST: beliefs and schema modes; DBT: emotion regulation and skills use), BPD-treatment-generic (therapeutic environment characterized by genuineness, safety, and equality), and non-specific (attachment and therapeutic alliance) mechanisms of change are assessed. The primary outcome measure is change in BPD manifestations. Secondary outcome measures include functioning, additional self-reported symptoms, and well-being. DISCUSSION The current study contributes to the optimization of treatments for BPD patients by extending our knowledge on "Which treatment - DBT or ST - works the best for which BPD patient, and why?", which is likely to yield important benefits for both BPD patients (e.g., prevention of overtreatment and potential harm of treatments) and society (e.g., increased economic productivity of patients and efficient use of treatments). TRIAL REGISTRATION Netherlands Trial Register, NL7699 , registered 25/04/2019 - retrospectively registered.
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Affiliation(s)
- Carlijn J. M. Wibbelink
- Department of Clinical Psychology, University of Amsterdam, Nieuwe Achtergracht 129-B, Amsterdam, 1018 WS the Netherlands
| | - Arnoud Arntz
- Department of Clinical Psychology, University of Amsterdam, Nieuwe Achtergracht 129-B, Amsterdam, 1018 WS the Netherlands
| | - Raoul P. P. P. Grasman
- Department of Clinical Psychology, University of Amsterdam, Nieuwe Achtergracht 129-B, Amsterdam, 1018 WS the Netherlands
| | - Roland Sinnaeve
- Department of Neurosciences, Mind Body Research, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Michiel Boog
- Department of Addiction and Personality, Antes Mental Health Care, Max Euwelaan 1, Rotterdam, 3062 MA the Netherlands
- Institute of Psychology, Erasmus University Rotterdam, P.O. Box 1738, Rotterdam, 3000 DR the Netherlands
| | - Odile M. C. Bremer
- Arkin Mental Health, NPI Institute for Personality Disorders, Domselaerstraat 128, Amsterdam, 1093 MB the Netherlands
| | - Eliane C. P. Dek
- PsyQ Personality Disorders Rotterdam-Kralingen, Max Euwelaan 70, Rotterdam, 3062 MA the Netherlands
| | | | - Chrissy James
- Department of Personality Disorders, Outpatient Clinic De Nieuwe Valerius, GGZ inGeest, Amstelveenseweg 589, Amsterdam, 1082 JC the Netherlands
| | | | - Linda Kramer
- GGZ Noord-Holland-Noord, Stationsplein 138, 1703 WC Heerhugowaard, the Netherlands
| | | | - Arita Schaling
- Pro Persona, Willy Brandtlaan 20, Ede, 6716 RR the Netherlands
| | - Faye I. Smits
- GGZ Rivierduinen, Sandifortdreef 19, Leiden, 2333 ZZ the Netherlands
| | - Jan H. Kamphuis
- Department of Clinical Psychology, University of Amsterdam, Nieuwe Achtergracht 129-B, Amsterdam, 1018 WS the Netherlands
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19
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Boog M, Dugonjic H, Arntz A, Goudriaan AE, Wetering BJMVD, Franken IHA. Borderline Personality Disorder With Versus Without Alcohol Use Disorder: Comparing Impulsivity and Schema Modes. J Pers Disord 2022; 36:1-18. [PMID: 33999655 DOI: 10.1521/pedi_2021_35_521] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Substance use disorders (SUDs) and borderline personality disorder (BPD) are highly comorbid. In the present study, an attempt was made to understand the differences between BPD and BPD with comorbid SUD (BPD + alcohol use disorder [AUD]), by studying impulsivity and schema modes (i.e., maladaptive moment-to-moment emotional states and coping responses). BPD patients, BPD+AUD patients, and nonpatients (NP) were compared regarding behavioral impulsivity (motor impulsivity, risk taking, delay discounting), and schema modes. The two patient groups displayed greater delay discounting than the NP group. Further, BPD and BPD+AUD groups were different from the NP group regarding all schema modes investigated. However, no differences were found on any of the dependent variables between the two patient groups. It is suggested that although BPD patients are in general more impulsive and have more maladaptive moment-to-moment emotional states and coping responses, BPD patients with and without AUD seem not to be different in this respect.
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Affiliation(s)
- Michiel Boog
- Antes Mental Health Care, Rotterdam, the Netherlands.,Institute of Psychology, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | | | - Arnoud Arntz
- Department of Clinical Psychology, University of Amsterdam, the Netherlands
| | - Anna E Goudriaan
- Department of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.,Arkin Mental Health Care, Amsterdam, the Netherlands
| | | | - Ingmar H A Franken
- Institute of Psychology, Erasmus University Rotterdam, Rotterdam, the Netherlands
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20
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Koivisto M, Melartin T, Lindeman S. Self-invalidation in borderline personality disorder: A content analysis of patients' verbalizations. Psychother Res 2022; 32:922-935. [PMID: 35021964 DOI: 10.1080/10503307.2022.2025627] [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] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVE The ability to trust one's own perceptions is crucial for psychological well-being and growth. The relevance of its opposite, self-invalidation (SI), to the psychopathology of borderline personality disorder (BPD) is emphasized in many contemporary theories of evidence-based treatments for BPD. Empirical research on this topic remains scarce, however. This study aimed to describe manifestations of SI in individuals with BPD during a 40-session psychoeducational intervention based mainly on schema therapy. METHOD Transcripts of videotaped group sessions were analyzed inductively using qualitative content analysis. RESULTS SI emerged as a recurrent, ubiquitous phenomenon. The content analysis yielded three core categories of SI: (1) a self-critical and harsh attitude towards the self (subcategories reflected punitive internalizations that could engender fear-based inertia, self-erasing, submissive coping behavior, and temporal fluctuation in SI), (2) a deficient sense of normalcy, and self-doubt, and (3) self-stigma. We also found an association of SI with various dimensions of BPD, including difficulty in the identification of emotions, secondary emotional reactions such as guilt, shame, anger, and resentment, self-related and interpersonal problems, and suicidal urges. CONCLUSIONS SI is a detrimental cognitive-emotional process relevant to BPD that merits treatment. Efforts to reduce self-stigma, a pernicious aspect of SI, are imperative.
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Affiliation(s)
- Maaria Koivisto
- University of Eastern Finland, Kuopio, Finland.,Central Finland Health Care District, Jyväskylä, Finland
| | | | - Sari Lindeman
- Central Finland Health Care District, Jyväskylä, Finland
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21
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Chanen AM, Betts JK, Jackson H, Cotton SM, Gleeson J, Davey CG, Thompson K, Perera S, Rayner V, Chong SY, McCutcheon L. A Comparison of Adolescent versus Young Adult Outpatients with First-Presentation Borderline Personality Disorder: Findings from the MOBY Randomized Controlled Trial. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2022; 67:26-38. [PMID: 33576244 PMCID: PMC8811246 DOI: 10.1177/0706743721992677] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE The increasing focus on adolescent personality disorder has tended to ignore evidence of the developmental continuity of the period from puberty to young adulthood. This study aims to: (1) describe the characteristics of a sample of young people with borderline personality disorder (BPD) who had no previous history of evidence-based treatment for the disorder and (2) compare their characteristics by participant age group. METHODS One hundred and thirty-nine young people (15 to 25 years) with BPD, newly enrolled in the Monitoring Outcomes of BPD in Youth randomized controlled trial, completed semi-structured interview and self-report measures assessing demographic, clinical, and functional characteristics. Younger (aged 15 to 17 years; n = 64) and older (aged 18 to 25 years; n = 75) participants were compared on these same variables using t-tests, chi-square tests, and logistic regression. RESULTS Young outpatients with BPD had extensive and severe psychopathology and were functioning poorly. Adolescents and young adults with BPD showed substantial similarities on 20 key aspects of their presentation. Significant between-groups differences were observed in household makeup, treatment history, antisocial personality disorder, emotion dysregulation, substance use, age of commencement and extent of self-harm, and achievement of age-appropriate educational milestones. Adolescent BPD group membership was predicted by family composition and self-harm, whereas young adult BPD group membership was predicted by not achieving age-appropriate milestones, vocational disengagement, and emotion dysregulation. The final model explained 54% of the variance and correctly classified 80.2% of the sample by age. CONCLUSIONS Both adolescents and young adults with early stage BPD present with severe and often similar problems to one another, supporting developmental continuity across this age range. However, there are also meaningful differences in presentation, suggesting that pathways to care might differ by age and/or developmental stage. Detection and intervention for personality disorder should not be delayed until individuals reach 18 years of age.
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Affiliation(s)
- Andrew M Chanen
- Orygen, Melbourne, Australia.,Centre for Youth Mental Health, The University of Melbourne, Australia
| | - Jennifer K Betts
- Orygen, Melbourne, Australia.,Centre for Youth Mental Health, The University of Melbourne, Australia
| | - Henry Jackson
- Melbourne School of Psychological Sciences, The University of Melbourne, Australia
| | - Sue M Cotton
- Orygen, Melbourne, Australia.,Centre for Youth Mental Health, The University of Melbourne, Australia
| | - John Gleeson
- Healthy Brain and Mind Research Centre and School of Behavioural and Health Sciences, Australian Catholic University, Melbourne Campus, Australia
| | - Christopher G Davey
- Orygen, Melbourne, Australia.,Centre for Youth Mental Health, The University of Melbourne, Australia.,Department of Psychiatry, The University of Melbourne, Australia
| | - Katherine Thompson
- Orygen, Melbourne, Australia.,Centre for Youth Mental Health, The University of Melbourne, Australia
| | - Sharnel Perera
- Orygen, Melbourne, Australia.,Centre for Youth Mental Health, The University of Melbourne, Australia
| | - Victoria Rayner
- Orygen, Melbourne, Australia.,Centre for Youth Mental Health, The University of Melbourne, Australia
| | - Sinn Yuin Chong
- Orygen, Melbourne, Australia.,Centre for Youth Mental Health, The University of Melbourne, Australia
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22
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Klein JP, Hauer-von Mauschwitz A, Berger T, Fassbinder E, Mayer J, Borgwardt S, Wellhöfer B, Schweiger U, Jacob G. Effectiveness and safety of the adjunctive use of an internet-based self-management intervention for borderline personality disorder in addition to care as usual: results from a randomised controlled trial. BMJ Open 2021; 11:e047771. [PMID: 34497078 PMCID: PMC8438831 DOI: 10.1136/bmjopen-2020-047771] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
IMPORTANCE Borderline personality disorder (BPD) is a severe mental disorder that is often inadequately treated. OBJECTIVE To determine if adding a self-management intervention to care as usual (CAU) is effective and safe. DESIGN Randomised, controlled, rater-blind trial. Duration of treatment and assessments: 12 months. SETTING Secondary care, recruited mainly via the internet. PARTICIPANTS Patients with BPD and BPD Severity Index (BPDSI) of at least 15. INTERVENTIONS CAU by treating psychiatrist and/or psychotherapist alone or adjunctive use of an internet-based self-management intervention that is based on schema therapy (priovi). MAIN OUTCOME MEASURE Outcomes were assessed by trained raters. The primary outcome was change in BPDSI. The safety outcome was the number of serious adverse events (SAEs). The primary outcome time point was 12 months after randomisation. RESULTS Of 383 participants assessed for eligibility, 204 were included (91.7% female, mean age: 32.4 years; 74% were in psychotherapy and 26% were in psychiatric treatment). The slope of BPDSI change did not differ significantly between groups from baseline to 12 months (F3,248= 1.857, p=0.14). At 12 months, the within-group effect sizes were d=1.38 (95% CI 1.07 to 1.68) for the intervention group and d=1.02 (95% CI 0.73 to 1.31) for the control group. The between-group effect size was d=0.27 (95% CI 0.00 to 0.55) in the intention-to-treat sample and d=0.39 (95% CI 0.09 to 0.68) for those who used the intervention for at least 3 hours (per-protocol sample). We found no significant differences in SAEs. CONCLUSIONS We have not found a significant effect in favour of the intervention. This might be due to the unexpectedly large effect in the group receiving CAU by a psychiatrist and/or psychotherapist alone. TRIAL REGISTRATION NCT03418142.
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Affiliation(s)
- Jan Philipp Klein
- Department of Psychiatry, Psychosomatics and Psychotherapy, University of Lübeck, Lubeck, Germany
| | | | - Thomas Berger
- Department of Clinical Psychology and Psychotherapy, University of Bern, Bern, Switzerland
| | - Eva Fassbinder
- Department of Psychiatry, Psychosomatics and Psychotherapy, University of Lübeck, Lubeck, Germany
- Department of Psychiatry and Psychotherapy, Christian-Albrechts-Universität zu Kiel, Kiel, Germany
| | | | - Stefan Borgwardt
- Department of Psychiatry, Psychosomatics and Psychotherapy, University of Lübeck, Lubeck, Germany
| | | | - Ulrich Schweiger
- Department of Psychiatry, Psychosomatics and Psychotherapy, University of Lübeck, Lubeck, Germany
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23
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von Klipstein L, Borsboom D, Arntz A. The exploratory value of cross-sectional partial correlation networks: Predicting relationships between change trajectories in borderline personality disorder. PLoS One 2021; 16:e0254496. [PMID: 34329316 PMCID: PMC8323921 DOI: 10.1371/journal.pone.0254496] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 06/28/2021] [Indexed: 02/04/2023] Open
Abstract
Objective Within the network approach to psychopathology, cross-sectional partial correlation networks have frequently been used to estimate relationships between symptoms. The resulting relationships have been used to generate hypotheses about causal links between symptoms. In order to justify such exploratory use of partial correlation networks, one needs to assume that the between-subjects relationships in the network approximate systematic within-subjects relationships, which are in turn the results of some within-subjects causal mechanism. If this assumption holds, relationships in the network should be mirrored by relationships between symptom changes; if links in networks approximate systematic within-subject relationships, change in a symptom should relate to change in connected symptoms. Method To investigate this implication, we combined longitudinal data on the Borderline Personality Disorder Severity Index from four samples of borderline personality disorder patients (N = 683). We related parameters from baseline partial correlation networks of symptoms to relationships between change trajectories of these symptoms. Results Across multiple levels of analysis, our results showed that parameters from baseline partial correlation networks are strongly predictive of relationships between change trajectories. Conclusions By confirming its implication, our results support the idea that cross-sectional partial correlation networks hold a relevant amount of information about systematic within-subjects relationships and thereby have exploratory value to generate hypotheses about the causal dynamics between symptoms.
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Affiliation(s)
- Lino von Klipstein
- Department of Psychiatry, Interdisciplinary Center Psychopathology and Emotion Regulation (ICPE), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- * E-mail:
| | - Denny Borsboom
- Department of Psychological Methods, University of Amsterdam, Amsterdam, The Netherlands
| | - Arnoud Arntz
- Department of Clinical Psychology, University of Amsterdam, Amsterdam, The Netherlands
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24
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Blankers M, Koppers D, Laurenssen EMP, Peen J, Smits ML, Luyten P, Busschbach J, Kamphuis JH, Kikkert M, Dekker JJM. Mentalization-Based Treatment Versus Specialist Treatment as Usual for Borderline Personality Disorder: Economic Evaluation Alongside a Randomized Controlled Trial With 36-Month Follow-Up. J Pers Disord 2021; 35:373-392. [PMID: 31682194 DOI: 10.1521/pedi_2019_33_454] [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] [Indexed: 11/20/2022]
Abstract
The authors present an economic evaluation performed alongside a randomized controlled trial of mentalization-based treatment in a day hospital setting (MBT-DH) versus specialist treatment as usual (S-TAU) for borderline personality disorder (BPD) with a 36-month follow-up period. Ninety-five patients from two Dutch treatment institutes were randomly assigned. Societal costs were compared with the proportion of BPD remissions and quality-adjusted life years (QALYs) measured using the five-dimensional EuroQol instrument. The incremental societal costs for one additional QALY could not be calculated. The costs for one additional BPD remission with MBT-DH are approximately €29,000. There was a 58% likelihood that MBT-DH leads to more remitted patients at additional costs compared with S-TAU, and a 35% likelihood that MBT-DH leads to more remissions at lower costs. MBT-DH is not cost-effective compared with S-TAU with QALYs as the outcome, and slightly more cost-effective than S-TAU at 36 months with BPD symptoms as the outcome.
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Affiliation(s)
- Matthijs Blankers
- Arkin Mental Health Care, Amsterdam, The Netherlands.,Trimbos-Institute, Netherlands Institute of Mental Health and Addiction, Utrecht, The Netherlands.,Department of Psychiatry, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - David Koppers
- Arkin Mental Health Care, Amsterdam, The Netherlands
| | | | - Jaap Peen
- Arkin Mental Health Care, Amsterdam, The Netherlands
| | - Maaike L Smits
- Viersprong Institute for Studies on Personality Disorders, Bergen op Zoom, The Netherlands
| | - Patrick Luyten
- Faculty of Psychology and Educational Sciences, University of Leuven, Belgium.,Research Department of Clinical, Educational and Health Psychology, University College London, UK
| | - Jan Busschbach
- Viersprong Institute for Studies on Personality Disorders, Bergen op Zoom, The Netherlands.,Department of Psychiatry, Section Medical Psychology and Psychotherapy, Erasmus MC, Rotterdam, The Netherlands
| | - Jan H Kamphuis
- Department of Psychology, University of Amsterdam, The Netherlands
| | | | - Jack J M Dekker
- Arkin Mental Health Care, Amsterdam, The Netherlands.,Department of Clinical Psychology, Vrije Universiteit Amsterdam, The Netherlands
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25
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Vatheuer CC, Dzionsko I, Maier S, Näher T, van Zutphen L, Sprenger A, Jacob GA, Arntz A, Domes G. Looking at the bigger picture: Cortical volume, thickness and surface area characteristics in borderline personality disorder with and without posttraumatic stress disorder. Psychiatry Res Neuroimaging 2021; 311:111283. [PMID: 33812313 DOI: 10.1016/j.pscychresns.2021.111283] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 03/05/2021] [Accepted: 03/19/2021] [Indexed: 11/21/2022]
Abstract
Borderline personality disorder (BPD) is a severe psychiatric disorder accompanied by multiple comorbidities. Neuroimaging studies have identified structural abnormalities in BPD with most findings pointing to gray matter volume reductions in the fronto-limbic network, although results remain inconsistent. Similar alterations were found in posttraumatic stress disorder (PTSD), a common comorbidity of BPD. Only a small number of studies have investigated structural differences in BPD patients regarding comorbid PTSD specifically and studies conducting additional surface analyses are scarce. We investigated structural differences in women with BPD with and without PTSD and non-patient controls. Automated voxel-based and region-based volumetric analyses were applied. Additionally, four surface-based measures were analyzed: cortical thickness, gyrification index, fractal dimension, and sulcus depth. Analyses did not identify cortical volume alterations in the fronto-limbic network. Instead, hypergyrification was detected in the right superior parietal cortex in BPD patients compared to non-patient controls. No distinction was revealed between BPD patients with and without PTSD. These findings underline the importance of a holistic investigation examining volumetric and surface measures as these might enhance the understanding of structural alterations in BPD.
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Affiliation(s)
- C Carolyn Vatheuer
- Department of Biological and Clinical Psychology, University of Trier, Johanniterufer 15, 54290 Trier, Germany
| | - Inga Dzionsko
- Department of Biological and Clinical Psychology, University of Trier, Johanniterufer 15, 54290 Trier, Germany
| | - Simon Maier
- Department of Psychiatry and Psychotherapy, Section for Experimental Neuropsychiatry, Medical Center, University of Freiburg, Freiburg, Germany
| | - Tim Näher
- Department of Biological and Clinical Psychology, University of Trier, Johanniterufer 15, 54290 Trier, Germany
| | - Linda van Zutphen
- Department of Clinical Psychological Science, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, The Netherlands
| | | | - Gitta A Jacob
- Department of Clinical Psychology and Psychotherapy, University of Freiburg, Freiburg, Germany
| | - Arnoud Arntz
- Department of Clinical Psychology, University of Amsterdam, Amsterdam, The Netherlands
| | - Gregor Domes
- Department of Biological and Clinical Psychology, University of Trier, Johanniterufer 15, 54290 Trier, Germany; Institute of Psychobiology, University of Trier, Trier, Germany.
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26
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van Zutphen L, Siep N, Jacob GA, Domes G, Sprenger A, Willenborg B, Goebel R, Tüscher O, Arntz A. Impulse control under emotion processing: an fMRI investigation in borderline personality disorder compared to non-patients and cluster-C personality disorder patients. Brain Imaging Behav 2021; 14:2107-2121. [PMID: 31321661 PMCID: PMC7647993 DOI: 10.1007/s11682-019-00161-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Impulsivity is a characteristic syndromal and neurobehavioral feature of borderline personality disorder (BPD). Research suggests an important interaction between high negative emotions and low behavioral inhibition in BPD. However, knowledge about the generalizability across stimulus categories and diagnosis specificity is limited. We investigated neural correlates of hypothesized impaired response inhibition of BPD patients to negative, positive and erotic stimuli, by comparing them to non-patients and cluster-C personality disorder patients. During fMRI scanning, 53 BPD patients, 34 non-patients and 20 cluster-C personality disorder patients completed an affective go/no-go task, including social pictures. BPD patients showed more omission errors than non-patients, independent of the stimulus category. Furthermore, BPD patients showed higher activity in the inferior parietal lobule and frontal eye fields when inhibiting negative versus neutral stimuli. Activity of the inferior parietal lobule correlated positively with the BPD checklist subscale impulsivity. When inhibiting emotional stimuli, BPD patients showed an altered brain activity in the inferior parietal lobe and frontal eye fields, whereas previously shown dysfunctional prefrontal activity was not replicated. BPD patients showed a general responsivity across stimulus categories in the frontal eye fields, whereas effects in the inferior parietal lobe were specific for negative stimuli. Results of diagnosis specificity support a dimensional rather than a categorical differentiation between BPD and cluster-C patients during inhibition of social emotional stimuli. Supported by behavioral results, BPD patients showed no deficiencies in emotionally modulated response inhibition per se but the present findings rather hint at attentional difficulties for emotional information.
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Affiliation(s)
- Linda van Zutphen
- Department of Clinical Psychological Science, Faculty of Psychology and Neuroscience, Maastricht University, PO Box 616, 6200, MD, Maastricht, the Netherlands.
| | - Nicolette Siep
- Department of Clinical Psychological Science, Faculty of Psychology and Neuroscience, Maastricht University, PO Box 616, 6200, MD, Maastricht, the Netherlands
| | - Gitta A Jacob
- Department of Clinical Psychology and Psychotherapy, University of Freiburg, Freiburg, Germany
| | - Gregor Domes
- Department of Psychology, Laboratory for Biological and Personality Psychology, University of Freiburg, Freiburg, Germany.,Freiburg Brain Imaging Center, University Medical Center Freiburg, Freiburg, Germany.,Department of Biological and Clinical Psychology, University of Trier, Trier, Germany
| | - Andreas Sprenger
- Departments of Neurology and Psychology, University of Lübeck, Lübeck, Germany
| | - Bastian Willenborg
- Department of Psychiatry and Psychotherapy, University of Lübeck, Lübeck, Germany
| | - Rainer Goebel
- Department of Cognitive Neuroscience, Maastricht University, Maastricht, the Netherlands.,Department of Neuroimaging and Neuromodeling, Netherlands Institute for Neuroscience, Royal Netherlands Academy of Arts and Sciences (KNAW), Amsterdam, the Netherlands
| | - Oliver Tüscher
- Department of Clinical Psychology and Psychotherapy, University of Freiburg, Freiburg, Germany.,Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany
| | - Arnoud Arntz
- Department of Clinical Psychological Science, Faculty of Psychology and Neuroscience, Maastricht University, PO Box 616, 6200, MD, Maastricht, the Netherlands.,Department of Clinical Psychology, University of Amsterdam, Amsterdam, the Netherlands
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27
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Konvalin F, Grosse-Wentrup F, Nenov-Matt T, Fischer K, Barton BB, Goerigk S, Brakemeier EL, Musil R, Jobst A, Padberg F, Reinhard MA. Borderline Personality Features in Patients With Persistent Depressive Disorder and Their Effect on CBASP Outcome. Front Psychiatry 2021; 12:608271. [PMID: 33790813 PMCID: PMC8006327 DOI: 10.3389/fpsyt.2021.608271] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 02/15/2021] [Indexed: 12/23/2022] Open
Abstract
Introduction: The Cognitive Behavioral Analysis System of Psychotherapy (CBASP) was developed for the treatment of persistent depressive disorder (PDD), where comorbid personality disorders (PD) are common. In contrast to other PD, comorbid borderline personality disorder (BPD) is often regarded as an exclusion criterion for CBASP. In clinical settings, however, subthreshold BPD symptoms are prevalent in PDD and may not be obvious at an initial assessment prior to therapy. As data on their impact on CBASP outcome are very limited, this naturalistic study investigates BPD features in PDD and their relevance for the therapeutic outcome of a multimodal CBASP inpatient program. Method: Sixty patients (37 female, mean age 38.3, SD 11.9 years) meeting DSM-5 criteria for PDD underwent a 10 weeks CBASP inpatient program. BPD features (i.e., number of fulfilled DSM-5 criteria) together with childhood maltreatment and rejection sensitivity were assessed on admission. Before and after treatment, severity of depressive symptoms was measured using the Montgomery-Asberg Depression Rating Scale (MADRS) and the Beck Depression Inventory (BDI-II). BPD symptoms were assessed using the Borderline Personality Disorder Severity Index (BPDSI-IV) and the Borderline Symptom List (BSL-23). Intercorrelations of baseline characteristics and symptom change during treatment were analyzed. Results: Patients with PDD met a mean of 1.5 (SD 1.6) BPD criteria with 4 patients fulfilling ≥5 criteria. BPD symptoms and depressive symptoms showed a strong correlation, and BPD symptoms were additionally correlated with emotional abuse and rejection sensitivity. There was no association between BPD features at baseline and improvement on the MADRS, however, BPD features tended to be associated with a lower response according to the BDI-II score after 10 weeks of treatment. Furthermore, BPD symptoms (i.e., abandonment, impulsivity and affective instability) were reduced after 10 weeks of CBASP treatment. Discussion: BPD symptoms are prevalent in patients with PDD and highly intertwined with the experience of depressive symptoms. In this naturalistic study in PDD, BPD features at baseline did not limit the clinical response to CBASP. Future studies may extend the spectrum of PDD to comorbid subsyndromal or even syndromal BPD in order to develop tailored psychotherapeutic treatment for these complex affective disorders.
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Affiliation(s)
- Franziska Konvalin
- Department of Psychiatry and Psychotherapy, LMU University Hospital Munich, Munich, Germany
| | | | - Tabea Nenov-Matt
- Department of Psychiatry and Psychotherapy, LMU University Hospital Munich, Munich, Germany
| | - Kai Fischer
- Department of Psychiatry and Psychotherapy, LMU University Hospital Munich, Munich, Germany
| | - Barbara B. Barton
- Department of Psychiatry and Psychotherapy, LMU University Hospital Munich, Munich, Germany
| | - Stephan Goerigk
- Department of Psychiatry and Psychotherapy, LMU University Hospital Munich, Munich, Germany
| | - Eva-Lotta Brakemeier
- Department of Clinical Psychology and Psychotherapy, University of Greifswald, Greifswald, Germany
| | - Richard Musil
- Department of Psychiatry and Psychotherapy, LMU University Hospital Munich, Munich, Germany
| | - Andrea Jobst
- Department of Psychiatry and Psychotherapy, LMU University Hospital Munich, Munich, Germany
| | - Frank Padberg
- Department of Psychiatry and Psychotherapy, LMU University Hospital Munich, Munich, Germany
| | - Matthias A. Reinhard
- Department of Psychiatry and Psychotherapy, LMU University Hospital Munich, Munich, Germany
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28
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Koivisto M, Melartin T, Lindeman S. "If you don't have a word for something, you may doubt whether it's even real" - how individuals with borderline personality disorder experience change. Psychother Res 2021; 31:1036-1050. [PMID: 33568008 DOI: 10.1080/10503307.2021.1883763] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Objective: This study explored how psychological change was experienced and what treatment-related factors or events were perceived as supporting or hindering their process by individuals with borderline personality disorder. Methods: Eight BPD sufferers attended a 40-session psychoeducational group intervention at a community mental health care center. At intervention end, personal experience of meaningful change was explored in an in-depth interview and data were content-analyzed. Change in BPD symptoms was assessed by the Borderline Personality Disorder Severity Index IV interview. Results: The qualitative content analysis on subjectively perceived meaningful change yielded three core categories: (1) improved ability to observe and understand mental events, (2) decreased disconnection from emotions, emergence of new or adaptive emotional reactions and decrease in maladaptive ones, and (3) a new, more adaptive experience of self and agency. Accordingly, (1) learning and (2) normalizing emerged as the main categories of helpful treatment factors. In turn, treatment-related factors perceived as obstacles were: (1) aggression in the group, and (2) inflexibility. With respect to symptom change, four participants were considered clinically as remitted, and two showed a reliable change. Conclusions: Long-term psychoeducational group therapy seems to enhance mentalization / metacognitive functioning and promote self (or personality) integration in BPD patients.
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Affiliation(s)
| | | | - Sari Lindeman
- University of Eastern Finland, Central Finland Health Care District
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29
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Socada JL, Söderholm JJ, Rosenström T, Ekelund J, Isometsä E. Presence and Overlap of Bipolar Symptoms and Borderline Features during Major Depressive Episodes. J Affect Disord 2021; 280:467-477. [PMID: 33246197 DOI: 10.1016/j.jad.2020.11.043] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 09/28/2020] [Accepted: 11/07/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Bipolar symptoms and borderline personality features occur in both unipolar and bipolar major depressive episodes (MDEs). We investigated their prevalence, severity, co-occurrence and overlap. METHODS We interviewed 124 psychiatric outpatients with MDE using the Structured Clinical Interview for DSM-IV-TR Axis I and II Disorders, the Borderline Personality Disorder Severity Index (BPDSI-IV), and about past (hypo)manic episodes, and stratified them according to the principal diagnosis into subcohorts of major depressive disorder (MDD, n = 50), bipolar disorder (BD, n = 43), and borderline personality disorder (BPD, n = 31). We quantified (hypo)manic symptoms using a novel semi-structured interview (MIXed symptoms during MDE, MIX-MDE) with good psychometric qualities. RESULTS The subcohorts did not differ in MDE severity. They differed significantly in some (hypo)manic symptoms being present on most days in 24% of MDD, 30% of BD, and 42% of BPD subcohort, but only 5% of the BD subcohort fulfilled the DSM-5 mixed features. The mean MIX-MDE scores were 5.7 (SD 4.0), 12.0 (8.2) and 10.5 (7.5), and BPDSI-IV scores 15.6 (7.0), 17.2 (6.2) and 26.9 (8.7), respectively (both p < 0.001). (Hypo)manic days and unspecific symptoms of distractibility and irritability inflated the correlation of observed (hypo)manic symptoms and borderline features. LIMITATIONS Moderate sample size, limited age variation (18-50 years); no previous validation of MIX-MDE. CONCLUSIONS Presence of some mixed and borderline features is common in MDEs, with overlap and diagnosis-specific differences. Unspecific symptoms of irritability and distractibility and the aggravating impact of hypomania on perceived BPD features blur the differential diagnosis.
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Affiliation(s)
- J Lumikukka Socada
- Department of Psychiatry, University of Helsinki and Helsinki University Hospital, Finland
| | - John J Söderholm
- University of Helsinki, Health Services of the City of Helsinki, Finland
| | - Tom Rosenström
- Department of Psychiatry, University of Helsinki and Helsinki University Hospital, Finland
| | - Jesper Ekelund
- University of Turku and Turku University Central Hospital, Finland
| | - Erkki Isometsä
- Department of Psychiatry, University of Helsinki and Helsinki University Hospital, Finland.
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30
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Dreyße K, Zöllner E, Behrens C, Armbrust M, Kröger C. [Convergent and Factorial Validity of the Impulsivity and Emotion Dysregulation Scale (IED-27) for Borderline Personality Disorder]. Psychother Psychosom Med Psychol 2021; 71:177-184. [PMID: 33440448 DOI: 10.1055/a-1322-3334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
There is a growing consensus that emotion dysregulation is the defining feature of borderline personality disorder, but there are also persisting competing views on the pathology and dimensional structure of the disorder. The "Impulsivity and Emotion Dysregulation Scale" (IED-27) is already being used for assessing patients with borderline personality disorder. The particular aim of this study was to gain evidence of the dimensional structure of the disorder by confirmatory factorial analysis. A heterogeneous sample of patients with borderline personality disorder (n=484), attention deficit (hyperactivity) disorder (n=191) and eating disorders (n=197) of a psychosomatic clinic were given general and specific self-assessment inventories via computer-assisted testing system, including the IED-27. Results showed a bifactor model with a general factor and three specific factors: "emotional dysregulation", "relationship difficulties" and "self-injuries and suicidal behaviours", to be the model with the best fit (ΔCFI=0,032). The internal consistency of the sample seems to be good (ω=0,83-0,93) and expected correlations to similar subscales could be proved. Good psychometric criteria of the IED-27 were replicated in this study. Prospectively, the subscales allow a more detailed representation and specific treatment planning.
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Affiliation(s)
- Kathrin Dreyße
- Psychosomatische Klinik und Psychotherapie, Schön Klinik Bad Bramstedt, Deutschland
| | - Elena Zöllner
- Institut fur Psychologie, Klinische Psychologie und Psychotherapie, Universität Hildesheim, Deutschland
| | - Carolin Behrens
- Institut fur Psychologie, Klinische Psychologie und Psychotherapie, Universität Hildesheim, Deutschland
| | - Michael Armbrust
- Psychosomatische Klinik und Psychotherapie, Schön Klinik Bad Bramstedt, Deutschland
| | - Christoph Kröger
- Institut fur Psychologie, Klinische Psychologie und Psychotherapie, Universität Hildesheim, Deutschland
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31
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Riemann G, Chrispijn M, Weisscher N, Regeer E, Kupka RW. A Feasibility Study of the Addition of STEPPS in Outpatients With Bipolar Disorder and Comorbid Borderline Personality Features: Promises and Pitfalls. Front Psychiatry 2021; 12:725381. [PMID: 34858221 PMCID: PMC8631960 DOI: 10.3389/fpsyt.2021.725381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 10/21/2021] [Indexed: 11/15/2022] Open
Abstract
Background: Pharmacotherapy is a cornerstone in bipolar disorder (BD) treatment whereas borderline personality disorder (BPD) is treated primarily with psychotherapy. Given the overlap in symptomatology, patients with BD may benefit from psychotherapy designed for BPD. Aims: This paper reports the findings of a non-controlled open feasibility study of STEPPS training in patients with BD and borderline personality features (BPF). Methods: Outpatients with BD were screened for BPD, and if positive interviewed with SCID-II. Patients with at least three BPF, always including impulsivity and anger burst, were included in the intervention study. Severity of BD and BPD and quality of life were assessed. Descriptive statistics were performed. Results: Of 111 patients with BD 49.5% also screened positive on BPD according to PDQ-4+, and 52.3% of these had BPD according to SCID-II. Very few participants entered the intervention study, and only nine patients completed STEPPS. Descriptive statistics showed improvement on all outcome variables post treatment, but no longer at 6-month follow up. We reflect on the potential reasons for the failed inclusion. Conclusion: Features of BPD were highly prevalent in patients with BD. Still, recruiting patients for a psychological treatment originally designed for BPD proved to be difficult. Feedback of participants suggests that the association of STEPPS with "borderline" had an aversive effect, which may have caused limited inclusion for screening and subsequent drop-out for the treatment. Therefore, STEPPS should be adapted for BD to be an acceptable treatment option. Clinical Trial Registration: www.ClinicalTrials.gov/3856, identifier: NTR4016.
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Affiliation(s)
- Georg Riemann
- Department of Applied Psychology, Saxion University of Applied Sciences, Deventer, Netherlands.,Dimence Mental Health, Center for Bipolar Disorders, Deventer, Netherlands
| | - Melissa Chrispijn
- Dimence Mental Health, Center for Bipolar Disorders, Deventer, Netherlands
| | - Nadine Weisscher
- Geestelijke Gezondheids Zorg (GGZ) Heuvelrug, Center for Mental Health, Driebergen, Netherlands
| | - Eline Regeer
- Center for Bipolar Disorders, Altrecht Institute for Mental Health Care, Utrecht, Netherlands
| | - Ralph W Kupka
- Center for Bipolar Disorders, Altrecht Institute for Mental Health Care, Utrecht, Netherlands.,Amsterdam University Medical Center (UMC), Department of Psychiatry, VU University, Amsterdam, Netherlands.,Geestelijke Gezondheids Zorg (GGZ) InGeest, Center for Mental Health Care, Amsterdam, Netherlands
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32
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Dreyße K, Beller J, Armbrust M, Kröger C. A hierarchical analysis of the latent trait of borderline personality disorder and its possible clinical implications. Psychiatry Res 2020; 288:113023. [PMID: 32360894 DOI: 10.1016/j.psychres.2020.113023] [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: 02/02/2020] [Revised: 03/16/2020] [Accepted: 04/14/2020] [Indexed: 11/19/2022]
Abstract
Borderline personality disorder (BPD) is a severe mental disorder which is accompanied by impaired functioning, complex psychosocial problems and incurs large costs. However, it rarely has been examined whether BPD symptoms form a hierarchical (Mokken) scale, which would imply that symptoms are ordered along a latent dimension of borderline severity. In this study the data from 1,198 inpatients of a psychosomatic clinic were examined. A non-parametric Mokken analysis was employed to investigate if the BPD symptoms measured by the impulsivity and emotion dysregulation scale (IES-27) formed a hierarchical scale. 16 of the 27 items, mainly regarding emotion dysregulation, formed a monotonous Mokken scale with a very strong hierarchy of BPD symptoms. These results imply that single BPD symptoms provide information about BPD severity, suggesting several important consequences regarding escalation of BPD, diagnosis and treatment, e.g. how to optimize treatment planning.
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Affiliation(s)
- Kathrin Dreyße
- Schön Clinic Bad Bramstedt, Birkenweg 10, Bad Bramstedt 24576, Germany.
| | - Johannes Beller
- Institute of Medical Sociology, Hannover Medical School, Carl-Neuberg-Straße 1, Hannover 30625
| | - Michael Armbrust
- Schön Clinic Bad Bramstedt, Birkenweg 10, Bad Bramstedt 24576, Germany
| | - Christoph Kröger
- Institute of Psychology, University of Hildesheim Foundation, Universitätsplatz 1, Hildesheim 31141, Germany
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33
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Kaiser D, Jacob GA, van Zutphen L, Siep N, Sprenger A, Tuschen-Caffier B, Senft A, Arntz A, Domes G. Patients with borderline personality disorder and comorbid PTSD show biased attention for threat in the facial dot-probe task. J Behav Ther Exp Psychiatry 2020; 67:101437. [PMID: 30563688 DOI: 10.1016/j.jbtep.2018.11.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 11/14/2018] [Accepted: 11/22/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND OBJECTIVES Biased attention to threat is likely to play a crucial role in the dysfunctional emotion-related information processing in borderline personality disorder (BPD). However, the role of comorbid posttraumatic stress disorder (PTSD) has not yet been fully disentangled. METHODS BPD patients with (n = 24) and without (n = 46) PTSD, 35 patients with Cluster-C personality disorder and 52 non-patients participated in the facial dot-probe task with angry, happy and neutral faces during automatic (100 ms), controlled (600 ms), and later (1200 ms) stages of information processing. RESULTS BPD patients showed a greater congruency effect to angry faces during the controlled stage of processing than controls. Specifically, in BPD with PTSD compared to controls, this effect was due to difficulties disengaging from threat, indicated by slower reaction times to incongruent angry targets compared to neutral trials. Regarding automatic and later stages of information processing, there was no attentional bias (AB) in BPD. None of the groups revealed biased attention for happy faces at any stages of information processing. LIMITATIONS We did not include a control group of PTSD patients without BPD. Therefore, we cannot rule out that the present AB in BPD is mainly due to PTSD-specific psychopathology. CONCLUSIONS These findings provide first evidence for an AB towards angry faces and difficulties disengaging from these threat-related social cues in adult BPD patients. Although BPD patients in general demonstrated an AB when compared with controls, this effect was especially pronounced for BPD with PTSD, suggesting a significant effect of trauma-related psychopathology on social attention in BPD.
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Affiliation(s)
- Deborah Kaiser
- Department of Biological and Clinical Psychology, University of Trier, Germany; Department of Clinical Psychology and Psychotherapy, University of Freiburg, Germany
| | | | - Linda van Zutphen
- Department of Clinical Psychological Science, University of Maastricht, the Netherlands
| | - Nicolette Siep
- Department of Clinical Psychological Science, University of Maastricht, the Netherlands
| | - Andreas Sprenger
- Department of Neurology and Institute of Psychology II, University of Luebeck, Germany
| | | | - Alena Senft
- Department of Psychiatry and Psychotherapy, University of Luebeck, Germany
| | - Arnoud Arntz
- Department of Clinical Psychology, University of Amsterdam, the Netherlands
| | - Gregor Domes
- Department of Biological and Clinical Psychology, University of Trier, Germany.
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van Schie CC, Chiu CD, Rombouts SARB, Heiser WJ, Elzinga BM. Stuck in a negative me: fMRI study on the role of disturbed self-views in social feedback processing in borderline personality disorder. Psychol Med 2020; 50:625-635. [PMID: 30867073 PMCID: PMC7093320 DOI: 10.1017/s0033291719000448] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 12/18/2018] [Accepted: 02/18/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND Interpersonal difficulties in borderline personality disorder (BPD) could be related to the disturbed self-views of BPD patients. This study investigates affective and neural responses to positive and negative social feedback (SF) of BPD patients compared with healthy (HC) and low self-esteem (LSE) controls and how this relates to individual self-views. METHODS BPD (N = 26), HC (N = 32), and LSE (N = 22) performed a SF task in a magnetic resonance imaging scanner. Participants received 15 negative, intermediate and positive evaluative feedback words putatively given by another participant and rated their mood and applicability of the words to the self. RESULTS BPD had more negative self-views than HC and felt worse after negative feedback. Applicability of feedback was a less strong determinant of mood in BPD than HC. Increased precuneus activation was observed in HC to negative compared with positive feedback, whereas in BPD, this was similarly low for both valences. HC showed increased temporoparietal junction (TPJ) activation to positive v. negative feedback, while BPD showed more TPJ activation to negative feedback. The LSE group showed a different pattern of results suggesting that LSE cannot explain these findings in BPD. CONCLUSIONS The negative self-views that BPD have, may obstruct critically examining negative feedback, resulting in lower mood. Moreover, where HC focus on the positive feedback (based on TPJ activation), BPD seem to focus more on negative feedback, potentially maintaining negative self-views. Better balanced self-views may make BPD better equipped to deal with potential negative feedback and more open to positive interactions.
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Affiliation(s)
- Charlotte C. van Schie
- Institute of Psychology, Leiden University, Leiden, The Netherlands
- Leiden Institute for Brain and Cognition, Leiden, The Netherlands
| | - Chui-De Chiu
- Department of Psychology, The Chinese University of Hong Kong, Hong Kong S. A. R., People's Republic of China
| | - Serge A. R. B. Rombouts
- Institute of Psychology, Leiden University, Leiden, The Netherlands
- Leiden Institute for Brain and Cognition, Leiden, The Netherlands
- Leiden University Medical Centre, Leiden, The Netherlands
| | - Willem J. Heiser
- Institute of Psychology, Leiden University, Leiden, The Netherlands
- Mathematical Institute, Leiden University, Leiden, The Netherlands
| | - Bernet M. Elzinga
- Institute of Psychology, Leiden University, Leiden, The Netherlands
- Leiden Institute for Brain and Cognition, Leiden, The Netherlands
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35
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Kleindienst N, Jungkunz M, Bohus M. A proposed severity classification of borderline symptoms using the borderline symptom list (BSL-23). Borderline Personal Disord Emot Dysregul 2020; 7:11. [PMID: 32514359 PMCID: PMC7262769 DOI: 10.1186/s40479-020-00126-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 04/21/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The Borderline Symptom List (BSL-23) is a well-established self-rating instrument to assess the severity of borderline typical psychopathology. However, a classification of severity levels for the BSL-23 is missing. METHODS Data from 1.090 adults were used to develop a severity classification for the Borderline Symptom List (BSL-23). The severity grading was based on the distribution of the BSL-23 in 241 individuals with a diagnosis of BPD. Data from three independent samples were used to validate the previously defined severity grades.These validation samples included a group of treatment seeking patients with a diagnosis of BPD (n = 317), a sample of individuals with mental illnesses other than BPD (n = 176), and a healthy control sample (n = 356). The severity grades were validated from comparisons with established assessment instruments such as the International Personality Disorders Examination, the Structured Clinical Interview for DSM-IV, the global severity index of the Symptom Checklist (GSI, SCL-90), the Global Assessment of Functioning (GAF), and the Beck Depression Inventory (BDI-II). RESULTS Six grades of symptom severity were defined for the BSL-23 mean score: none or low: 0-0.3; mild: 0.3-0.7; moderate: 0.7-1.7; high: 1.7-2.7; very high: 2.7-3.5; and extremely high: 3.5-4. These grades received consistent empirical support from the independent instruments and samples. For instance, individuals with a severity grade of none or low were virtually free from diagnostic BPD-criteria, had a GSI below the normative population, and a high level of global functioning corresponding to few or no symptoms. Severity grades indicating high to extremely high levels of BPD symptoms were observed at a much higher rate in treatment-seeking patients (70.0%) than in clinical controls (17.6%) and healthy controls (0.0%). The BSL-23 score that best separated treatment-seeking BPD patients and clinical controls was 1.50, whereas the clearest discrimination of BPD patients and healthy controls was found at a score of 0.64. CONCLUSIONS The grades of BPD-specific symptom severity derived from the distribution of the BSL-23 scores received consistent empirical validation from established assessments for psychopathology. Future studies should expand this validation by including additional instruments e.g., to assess self-esteem, loneliness, connectedness, and quality of life.
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Affiliation(s)
- Nikolaus Kleindienst
- Institute of Psychiatric and Psychosomatic Psychotherapy, Central Institute of Mental Health Mannheim, J5, D-68159 Mannheim, Germany / Medical Faculty Mannheim, Heidelberg University, J5, 68159 Mannheim, Germany
| | - Martin Jungkunz
- Institute of Psychiatric and Psychosomatic Psychotherapy, Central Institute of Mental Health Mannheim, J5, D-68159 Mannheim, Germany / Medical Faculty Mannheim, Heidelberg University, J5, 68159 Mannheim, Germany.,National Center for Tumor Diseases, Section for Translational Medical Ethics, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Bohus
- Institute of Psychiatric and Psychosomatic Psychotherapy, Central Institute of Mental Health Mannheim, J5, D-68159 Mannheim, Germany / Medical Faculty Mannheim, Heidelberg University, J5, 68159 Mannheim, Germany.,McLean Hospital, Harvard Medical School, Boston, MA USA
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36
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Kaltenegger HC, Philips B, Wennberg P. Autistic traits in mentalization-based treatment for concurrent borderline personality disorder and substance use disorder: Secondary analyses of a randomized controlled feasibility study. Scand J Psychol 2019; 61:416-422. [PMID: 31840273 DOI: 10.1111/sjop.12595] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 10/04/2019] [Indexed: 11/27/2022]
Abstract
Autism is suggested to be a dimensional construct and often represents a comorbid state. However, research on the clinical implications of the presence of autistic traits is scarce. This study aimed to investigate the impact of subclinical autistic traits in mentalization-based treatment (MBT) for concurrent borderline personality disorder (BPD) and substance use disorder (SUD). Based on the data of a randomized controlled feasibility study by Philips, Wennberg, Konradsson, and Franck (2018), secondary analyses were conducted. It was tested, if patients' (N = 46) levels of autistic traits were associated with treatment outcome measured in the course of and after treatment using interviews and self-report measures. Participants' autistic traits were not associated with the change in the severity of BPD throughout and at the end of the treatment. However, results showed associations between autistic traits and the change in patients' consumption of alcohol in the course of MBT. Furthermore, there was an association between autistic traits and the change in mentalizing capacity at the end of MBT, indicating that elevated autistic traits were associated with an improvement in mentalizing capacity. Autistic traits on a subclinical level do not appear to be a complicating factor in MBT for concurrent BPD and SUD. On the contrary, in terms of mentalizing capacity autistic traits might be associated with a larger potential for improvement or facilitate treatment outcome. Further research is needed to explore the role of higher autistic traits in treatment of this special patient group.
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Affiliation(s)
- Helena C Kaltenegger
- Department of Public Health Sciences, Stockholm University, Stockholm, Sweden.,Institute and Clinic for Occupational, Social and Environmental Medicine, University Hospital, LMU Munich, Germany
| | - Björn Philips
- Department of Psychology, Stockholm University, Stockholm, Sweden
| | - Peter Wennberg
- Department of Public Health Sciences, Stockholm University, Stockholm, Sweden.,Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
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37
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Kaiser D, Jacob GA, van Zutphen L, Siep N, Sprenger A, Tuschen-Caffier B, Senft A, Arntz A, Domes G. Biased Attention to Facial Expressions of Ambiguous Emotions in Borderline Personality Disorder: An Eye-Tracking Study. J Pers Disord 2019; 33:671-S8. [PMID: 30689505 DOI: 10.1521/pedi_2019_33_363] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Preliminary evidence suggests that biased attention could be crucial in fostering the emotion recognition abnormalities in borderline personality disorder (BPD). We compared BPD patients to Cluster-C personality disorder (CC) patients and non-patients (NP) regarding emotion recognition in ambiguous faces and their visual attention allocation to the eyes. The role of comorbid posttraumatic stress disorder (PTSD) in BPD regarding emotion recognition and visual attention was explored. BPD patients fixated the eyes of angry/happy, sad/happy, and fearful/sad blends longer than non-patients. This visual attention pattern was mainly driven by BPD patients with PTSD. This subgroup also demonstrated longer fixations than CC patients and a trend towards longer fixations than BPD patients without PTSD for the angry/happy and fearful/sad blends. Emotion recognition was not altered in BPD. Biased visual attention towards the eyes of ambiguous facial expressions in BPD might be due to trauma-related attentional bias rather than to impairments in facial emotion recognition.
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Affiliation(s)
- Deborah Kaiser
- Department of Psychology, University of Freiburg, Germany
| | | | - Linda van Zutphen
- Department of Clinical Psychological Science, University of Maastricht, The Netherlands
| | - Nicolette Siep
- Department of Clinical Psychological Science, University of Maastricht, The Netherlands
| | - Andreas Sprenger
- Department of Neurology and Institute of Psychology II, University of Luebeck, Germany
| | | | - Alena Senft
- Department of Psychiatry and Psychotherapy, University of Luebeck
| | - Arnoud Arntz
- Department of Clinical Psychology, University of Amsterdam, The Netherlands
| | - Gregor Domes
- Department of Biological and Clinical Psychology, University of Trier, Germany
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38
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Peter M, Arntz A, Klimstra TA, Faulborn M, Vingerhoets AJJM. Subjective emotional responses to IAPS pictures in patients with borderline personality disorder, cluster-C personality disorders, and non-patients. Psychiatry Res 2019; 273:712-718. [PMID: 31207857 DOI: 10.1016/j.psychres.2019.01.105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 12/19/2018] [Accepted: 01/18/2019] [Indexed: 11/19/2022]
Abstract
According to Linehan (1993), emotion dysregulation is a central feature of borderline personality disorder (BPD). We hypothesized that patients with BPD are emotionally hyperresponsive. For BPD treatment, it is important to evaluate this hypothesis, because, if it is supported, therapeutic interventions could be designed to help patients to better manage hyperemotional reactions. We investigated the subjective reactions (in terms of valence and arousal) of patients with BPD to visual emotional stimuli of the International Affective Picture System (IAPS). We hypothesized that, compared to patients with Cluster-C personality disorders and non-patients, BPD patients would show higher scores on the arousal dimension and higher negative scores on the valence dimension when rating IAPS pictures with varying degrees of arousal and valence. Ratings of valence and arousal for 40 IAPS pictures were collected from 39 borderline personality disorder (BPD), 36 patients diagnosed with Cluster-C personality disorders (PD), and a group of 226 non-patients. Contrary to expectations, BPD patients did not differ from the non-patients. This indicates that their self-report scores do not reflect hypersensitivity. We found that patients with BPD showed lower scores on arousal than Cluster-C PD patients. The scores on valence suggested that Cluster-C PD patients also experienced more positive emotions than BPD patients.
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Affiliation(s)
- M Peter
- Department of Personality Disorders, GGz Breburg, Lage Witsiebaan 4, Tilburg, the Netherlands.
| | - A Arntz
- Department of Clinical Psychology, Faculty of Social and Behavioral Sciences, University of Amsterdam, Nieuwe Achtergracht 129, Amsterdam, the Netherlands
| | - T A Klimstra
- Developmental Psychology, Tilburg University, Warandalaan 2, Tilburg, the Netherlands
| | - M Faulborn
- Department of Forensic Psychiatry, GGz Breburg, Lage Witsiebaan 4, Tilburg, the Netherlands
| | - A J J M Vingerhoets
- Department of Medical and Clinical Psychology, Tilburg University, Warandalaan 2, Tilburg, the Netherlands
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39
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Colle L, Gabbatore I, Riberi E, Borroz E, Bosco FM, Keller R. Mindreading abilities and borderline personality disorder: A comprehensive assessment using the Theory of Mind Assessment Scale. Psychiatry Res 2019; 272:609-617. [PMID: 30616131 DOI: 10.1016/j.psychres.2018.12.102] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 12/18/2018] [Accepted: 12/18/2018] [Indexed: 01/25/2023]
Abstract
Numerous studies have examined mindreading in borderline personality disorder (BPD). However, the empirical data obtained to date have not facilitated the development of a clear clinical profile of mindreading impairment in BPD due to a lack of consistency or incongruence across studies. One possible explanation for these inconsistencies and divergences in the current literature may lie in the multidimensional character of the mindreading construct; moreover, the heterogeneity of the experimental measures used to assess individuals with BPD mindreading skills may also need to be taken into account. The aim of the present study is to investigate mindreading skills and impairments in patients with BPD through direct comparison of a wide range of mindreading dimensions using a comprehensive semistructured interview, the Theory of Mind Assessment Scale (Th.o.m.a.s.) (Bosco et al., 2009). Our results show that the performance of patients with BPD differs from that of healthy controls only in certain specific dimensions of mindreading. The difficulties encountered by the patients with BPD typically emerge when mindreading tasks require them to disentangle their own subjective mindreading from that of another person, in other words, when they were required to assume an allocentric perspective.
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Affiliation(s)
- L Colle
- Department of Psychology, University of Turin, Italy; Neuroscience Institute of Turin, Italy
| | - I Gabbatore
- Department of Psychology, University of Turin, Italy; Child Language Research Center, University of Oulu, Finland.
| | - E Riberi
- Local Health Unit ASL City of Turin, Department of Mental Health, Turin, Italy
| | - E Borroz
- Local Health Unit ASL City of Turin, Department of Mental Health, Turin, Italy
| | - F M Bosco
- Department of Psychology, University of Turin, Italy; Neuroscience Institute of Turin, Italy
| | - R Keller
- Local Health Unit ASL City of Turin, Department of Mental Health, Turin, Italy
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40
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Jacob GA, Hauer A, Köhne S, Assmann N, Schaich A, Schweiger U, Fassbinder E. A Schema Therapy-Based eHealth Program for Patients with Borderline Personality Disorder (priovi): Naturalistic Single-Arm Observational Study. JMIR Ment Health 2018; 5:e10983. [PMID: 30559092 PMCID: PMC6315264 DOI: 10.2196/10983] [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: 05/06/2018] [Revised: 08/14/2018] [Accepted: 09/24/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Electronic health (eHealth) programs have been found to be effective in treating many psychological conditions. However, regarding borderline personality disorder (BPD), only a few eHealth programs have been tested, involving small interventions based on the dialectical behavior therapy treatment approach. We investigated priovi, a program based on the schema therapy (ST) approach. priovi is considerably more comprehensive than prior programs, offering broad psychoeducation content and many therapeutic exercises. OBJECTIVE We tested the acceptability and feasibility of priovi in 14 patients with BPD as an add-on to individual face-to-face ST. METHODS Patients received weekly individual ST and used priovi over a period of 12 months. We assessed BPD symptom severity using self-reported and interview-based measures. Qualitative interviews were conducted with both patients and therapists to assess their experiences with priovi. RESULTS BPD symptoms improved significantly (Cohen d=1.0). Overall, qualitative data showed that priovi was positively received by both patients and therapists. Some exercises provoked mild anxiety; however, no serious threat to safety was detected. CONCLUSIONS priovi is a potentially helpful and safe tool that could support individual ST. It needs to be further tested in a randomized controlled study. TRIAL REGISTRATION German Clinical Trials Register DRKS00011538; https://www.drks.de/drks_web/navigate.do? navigationId=trial.HTML&TRIAL_ID=DRKS00011538 (Archived by WebCite at http://www.webcitation.org/74jb0AgV8).
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Affiliation(s)
- Gitta Anne Jacob
- GAIA AG, Hamburg, Germany.,Department of Psychiatry and Psychotherapy, University of Lübeck, Lübeck, Germany
| | | | - Sandra Köhne
- Department of Psychiatry and Psychotherapy, University of Lübeck, Lübeck, Germany
| | - Nele Assmann
- Department of Psychiatry and Psychotherapy, University of Lübeck, Lübeck, Germany
| | - Anja Schaich
- Department of Psychiatry and Psychotherapy, University of Lübeck, Lübeck, Germany
| | - Ulrich Schweiger
- Department of Psychiatry and Psychotherapy, University of Lübeck, Lübeck, Germany
| | - Eva Fassbinder
- Department of Psychiatry and Psychotherapy, University of Lübeck, Lübeck, Germany
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41
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Fassbinder E, Assmann N, Schaich A, Heinecke K, Wagner T, Sipos V, Jauch-Chara K, Hüppe M, Arntz A, Schweiger U. PRO*BPD: effectiveness of outpatient treatment programs for borderline personality disorder: a comparison of Schema therapy and dialectical behavior therapy: study protocol for a randomized trial. BMC Psychiatry 2018; 18:341. [PMID: 30340474 PMCID: PMC6194626 DOI: 10.1186/s12888-018-1905-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 09/24/2018] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Borderline Personality Disorder (BPD) is a severe mental illness that is associated with low quality of life, low psychosocial functioning, and high societal costs. Treatments for BPD have improved in the last decades. Dialectical behavior therapy (DBT) and Schema therapy (ST) have demonstrated efficacy in reducing BPD symptoms and costs. However, research has not compared these two treatment approaches. In addition, there is a lack of 'real world studies' that replicate positive findings in regular mental healthcare settings. Thus, the PROgrams for Borderline Personality Disorder (PRO*BPD) study will compare the (cost-) effectiveness of DBT and ST in structured outpatient treatment programs in the routine clinical setting of an outpatient clinic. METHODS/DESIGN We aim to recruit 160 BPD patients, who will be randomly assigned to either DBT or ST. In both conditions, patients receive one group therapy and one individual therapy session/week for a maximum of 18 months. Both treatment programs have similar frameworks, which guarantee clinical equipoise. The primary outcome is a reduction of BPD-symptoms. Also, the costs related to BPD are assessed and an economic evaluation is performed from a societal perspective. Secondary outcomes examine other measures of BPD-typical and general psychopathology, comorbidity, quality of life, psychosocial functioning and participation. Data are collected prior to the beginning therapy and every six months until the end of therapy, as well as at six months, one year and two years of follow-up after the end of therapy. Finally, we conduct a qualitative study to understand patients' experiences with the two methods. DISCUSSION The PRO*BPD study is the first randomized trial to compare the (cost-) effectiveness of DBT and ST. By examining the clinical effectiveness of a broad spectrum of outcome parameters, conducting an economic evaluation and assessing patients' experiences, this study will significantly advance our knowledge on psychotherapy for BPD and will provide insight into the treatment approaches that should be offered to different BPD patients from clinical, economic and stakeholder's perspectives. TRIAL REGISTRATION German Clinical Trial Register, DRKS00011534 , Date of registration: 11/01/2017, retrospectively registered.
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Affiliation(s)
- Eva Fassbinder
- Department of Psychiatry and Psychotherapy, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.
| | - Nele Assmann
- 0000 0001 0057 2672grid.4562.5Department of Psychiatry and Psychotherapy, University of Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Anja Schaich
- 0000 0001 0057 2672grid.4562.5Department of Psychiatry and Psychotherapy, University of Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Kristin Heinecke
- 0000 0001 0057 2672grid.4562.5Department of Psychiatry and Psychotherapy, University of Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Till Wagner
- 0000 0001 0057 2672grid.4562.5Department of Psychiatry and Psychotherapy, University of Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Valerija Sipos
- 0000 0001 0057 2672grid.4562.5Department of Psychiatry and Psychotherapy, University of Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Kamila Jauch-Chara
- 0000 0001 0057 2672grid.4562.5Department of Psychiatry and Psychotherapy, University of Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
| | - Michael Hüppe
- 0000 0001 0057 2672grid.4562.5Department of Anaesthesiology, University of Lübeck, Lübeck, Germany
| | - Arnoud Arntz
- 0000000084992262grid.7177.6Department of Clinical Psychology, University of Amsterdam, Amsterdam, The Netherlands
| | - Ulrich Schweiger
- 0000 0001 0057 2672grid.4562.5Department of Psychiatry and Psychotherapy, University of Lübeck, Ratzeburger Allee 160, 23538 Lübeck, Germany
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42
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Zimmerman M, Morgan TA, Stanton K. The severity of psychiatric disorders. World Psychiatry 2018; 17:258-275. [PMID: 30192110 PMCID: PMC6127765 DOI: 10.1002/wps.20569] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 06/13/2018] [Accepted: 06/13/2018] [Indexed: 12/19/2022] Open
Abstract
The issue of the severity of psychiatric disorders has great clinical importance. For example, severity influences decisions about level of care, and affects decisions to seek government assistance due to psychiatric disability. Controversy exists as to the efficacy of antidepressants across the spectrum of depression severity, and whether patients with severe depression should be preferentially treated with medication rather than psychotherapy. Measures of severity are used to evaluate outcome in treatment studies and may be used as meaningful endpoints in clinical practice. But, what does it mean to say that someone has a severe illness? Does severity refer to the number of symptoms a patient is experiencing? To the intensity of the symptoms? To symptom frequency or persistence? To the impact of symptoms on functioning or on quality of life? To the likelihood of the illness resulting in permanent disability or death? Putting aside the issue of how severity should be operationalized, another consideration is whether severity should be conceptualized similarly for all illnesses or be disorder specific. In this paper, we examine how severity is characterized in research and contemporary psychiatric diagnostic systems, with a special focus on depression and personality disorders. Our review shows that the DSM-5 has defined the severity of various disorders in different ways, and that researchers have adopted a myriad of ways of defining severity for both depression and personality disorders, although the severity of the former was predominantly defined according to scores on symptom rating scales, whereas the severity of the latter was often linked with impairments in functioning. Because the functional impact of symptom-defined disorders depends on factors extrinsic to those disorders, such as self-efficacy, resilience, coping ability, social support, cultural and social expectations, as well as the responsibilities related to one's primary role function and the availability of others to assume those responsibilities, we argue that the severity of such disorders should be defined independently from functional impairment.
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Affiliation(s)
- Mark Zimmerman
- Department of Psychiatry and Human BehaviorBrown University School of Medicine, Rhode Island HospitalProvidenceRIUSA
| | - Theresa A. Morgan
- Department of Psychiatry and Human BehaviorBrown University School of Medicine, Rhode Island HospitalProvidenceRIUSA
| | - Kasey Stanton
- Department of Psychiatry and Human BehaviorBrown University School of Medicine, Rhode Island HospitalProvidenceRIUSA
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Klein JP, Hauer A, Berger T, Fassbinder E, Schweiger U, Jacob G. Protocol for the REVISIT-BPD Trial, a Randomized Controlled Trial Testing the Effectiveness of an Internet-Based Self-Management Intervention in the Treatment of Borderline Personality Disorder (BPD). Front Psychiatry 2018; 9:439. [PMID: 30298024 PMCID: PMC6160537 DOI: 10.3389/fpsyt.2018.00439] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 08/24/2018] [Indexed: 11/13/2022] Open
Abstract
Introduction: Borderline Personality Disorder (BPD) is a prevalent condition that is often under-treated. This is partly because very few psychotherapists offer treatment for this disabling disorder. Internet-based self-management interventions could contribute to reducing the treatment gap but-mainly due to safety concerns-these have never been tested for BPD in controlled trials. Methods: Patients with BPD will be recruited primarily via the internet and randomized to two groups: care as usual (CAU) alone) or the self-management intervention priovi® in addition to CAU. At the end of the diagnostic interview, all participants will discuss an emergency plan. The main outcome measure is the clinician-rated symptom severity using the BPD Severity Index (BPDSI). Secondary outcome measures include a range of self-reported scales, an SCID-diagnosis of BPD and several safety parameters including serious adverse events (e.g., a life-threatening event, hospitalization or suicide attempt). Discussion: This trial will evaluate the effectiveness of the self-management intervention, priovi, in reducing symptoms of BPD. It will also assess the safety of its use in this target population. If successful, this intervention would be the first comprehensive internet intervention for the treatment of BPD and complement the wide range of internet interventions effective in treating other mental disorders, particularly depression and anxiety disorders. Trial Registration: NCT03418142 (clinicaltrials.gov) on January 23rd 2018. Trial status: recruiting, currently N = 108 (July 2018).
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Affiliation(s)
- Jan Philipp Klein
- Department of Psychiatry and Psychotherapy, Lübeck University, Lübeck, Germany
| | | | - Thomas Berger
- Department of Clinical Psychology and Psychotherapy, Bern University, Bern, Switzerland
| | - Eva Fassbinder
- Department of Psychiatry and Psychotherapy, Lübeck University, Lübeck, Germany
| | - Ulrich Schweiger
- Department of Psychiatry and Psychotherapy, Lübeck University, Lübeck, Germany
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di Giacomo E, Arntz A, Fotiadou M, Aguglia E, Barone L, Bellino S, Carpiniello B, Colmegna F, Lazzari M, Lorettu L, Pinna F, Sicaro A, Signorelli MS, Clerici M. The Italian Version of the Borderline Personality Disorder Severity Index IV: Psychometric Properties, Clinical Usefulness, and Possible Diagnostic Implications. J Pers Disord 2018; 32:207-219. [PMID: 28604275 DOI: 10.1521/pedi_2017_31_294] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Borderline personality disorder (BPD) has a core embodied in affective and behavioral dysregulations, impulsivity, and relational disturbance. Clinical presentation might be heterogeneous due to a combination of different symptoms listed in the DSM-5. Clinical diagnosis and assessment of the severity of manifestations might be improved through the administration of structured interviews such as the Borderline Personality Disorder Severity Index, 4th edition (BPDSI-IV). The psychometric properties of the Italian version of the BPDSI-IV were examined for the first time in 248 patients affected by BPD and 113 patients affected by bipolar disorder, proving to be a valid and accurate instrument with good internal consistency and high accuracy. The Italian version also demonstrates significant validity in the discrimination between these clinical groups (p < 5001).
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Affiliation(s)
- Ester di Giacomo
- School of Medicine and Surgery, University of Milan, Bicocca, Italy.,Psychiatric, Department, S. Gerardo Health Care Trust, Monza, Italy.,PhD Program, in Neuroscience, Doctorate School, University of Milan, Bicocca
| | - Arnoud Arntz
- Department of Clinical, Psychology, University of Amsterdam, the Netherlands
| | - Maria Fotiadou
- Female Medium Secure Forensic Service, South London, and the Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Beckenham, UK
| | - Eugenio Aguglia
- Department of Clinical and Molecular Biomedicine, University of Catania, Italy
| | - Lavinia Barone
- Psychology, Section, Department of Brain and Behavioral Science, University of Pavia, Pavia, Italy
| | - Silvio Bellino
- Center for, Personality Disorders, Psychiatric Clinic, Department of Neuroscience, University of Turin, Italy
| | - Bernardo Carpiniello
- Department of Public Health, Clinical and Molecular Medicine, Psychiatric Unit, University of Cagliari, Italy
| | | | - Marina Lazzari
- Psychiatric, Department, S. Gerardo Health Care Trust, Monza, Italy
| | - Liliana Lorettu
- Psychiatric Clinic, Department of Biomedical Science, University of Sassari, Italy
| | - Federica Pinna
- Department of Public Health, Clinical and Molecular Medicine, Psychiatric Unit, University of Cagliari, Italy
| | - Aldo Sicaro
- Psychiatric, Department, S. Gerardo Health Care Trust, Monza, Italy
| | | | | | - Massimo Clerici
- School of Medicine and Surgery, University of Milan, Bicocca, Italy.,Psychiatric, Department, S. Gerardo Health Care Trust, Monza, Italy
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46
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Olajide K, Munjiza J, Moran P, O'Connell L, Newton-Howes G, Bassett P, Akintomide G, Ng N, Tyrer P, Mulder R, Crawford MJ. Development and Psychometric Properties of the Standardized Assessment of Severity of Personality Disorder (SASPD). J Pers Disord 2018; 32:44-56. [PMID: 28513349 DOI: 10.1521/pedi_2017_31_285] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Personality disorder (PD) is increasingly categorized according to its severity, but there is no simple way to screen for severity according to ICD-11 criteria. We set out to develop the Standardized Assessment of Severity of Personality Disorder (SASPD). A total of 110 patients completed the SASPD together with a clinical assessment of the severity of personality disorder. We examined the predictive ability of the SASPD using the area under the ROC curve (AUC). Two to four weeks later, 43 patients repeated the SASPD to examine reliability. The SASPD had good predictive ability for determining mild (AUC = 0.86) and moderate (AUC = 0.84) PD at cut points of 8 and 10, respectively. Test-retest reliability of the SASPD was high (intraclass correlation coefficient = 0.93, 95% CI [0.88, 0.96]). The SASPD thus provides a simple, brief, and reliable indicator of the presence of mild or moderate PD according to ICD-11 criteria.
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Affiliation(s)
- Kike Olajide
- Centre for Mental Health, Imperial College London
| | | | - Paul Moran
- School of Social and Community Medicine, University of Bristol, UK
| | | | - Giles Newton-Howes
- Department of Psychological Medicine, University of Otago, Wellington, New Zealand
| | | | | | - Nicola Ng
- Central and North West London NHS Foundation Trust
| | - Peter Tyrer
- Centre for Mental Health, Imperial College London
| | - Roger Mulder
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
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47
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Sinnaeve R, van den Bosch LMC, Hakkaart-van Roijen L, Vansteelandt K. Effectiveness of step-down versus outpatient dialectical behaviour therapy for patients with severe levels of borderline personality disorder: a pragmatic randomized controlled trial. Borderline Personal Disord Emot Dysregul 2018; 5:12. [PMID: 30002832 PMCID: PMC6040072 DOI: 10.1186/s40479-018-0089-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 06/26/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Step-down dialectical behaviour therapy (DBT) is a treatment consisting of 3 months of residential DBT plus 6 months of outpatient DBT. The program was specifically developed for people suffering from severe borderline personality disorder (BPD). The present study examines the effectiveness and cost-effectiveness of step-down DBT compared to 12 months of regular, outpatient DBT. METHODS Eighty-four participants reporting high levels of BPD-symptoms (mean age 26 years, 95% female) were randomly assigned to step-down versus standard DBT. Measurements were conducted at baseline and after 3, 6, 9 and 12 months. The Lifetime Parasuicide Count and BPD Severity Index (BPDSI) were used to assess suicidal behaviour, non-suicidal self-injury (NSSI) and borderline severity. Costs per Quality Adjusted Life Year (QALY) were calculated using data from the EQ-5D-3L and the Treatment Inventory Cost in Psychiatric Patients (TIC-P). RESULTS In step-down DBT, 95% of patients started the program, compared to 45% of patients in outpatient DBT. The probability of suicidal behaviour did not change significantly over 12 months. The probability of NSSI decreased significantly in step-down DBT, but not in outpatient DBT. BPDSI decreased significantly in both groups, with the improvement leveling off at the end of treatment. While step-down DBT was more effective in increasing quality of life, it also cost significantly more. The extra costs per gained QALY exceeded the €80,000 threshold that is considered acceptable for severely ill patients in the Netherlands. CONCLUSIONS A pragmatic randomized controlled trial in the Netherlands showed that 9 months of step-down DBT is an effective treatment for people suffering from severe levels of BPD. However, step-down DBT is not more effective than 12 months of outpatient DBT, nor is it more cost-effective. These findings should be considered tentative because of high noncompliance with the treatment assignment in outpatient DBT. Furthermore, the long-term effectiveness of step-down DBT, and moderators of treatment response, remain to be evaluated. TRIAL REGISTRATION www.clinicaltrials.govNCT01904227. Registered 22 July 2013 (retrospectively registered).
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Affiliation(s)
- Roland Sinnaeve
- 1GGZ Rivierduinen - Centre for Personality Disorders Jelgersma, Rhijngeesterstraatweg 13-C, 2342 AN Oegstgeest, The Netherlands.,3Z.org KU Leuven, University of Leuven, Leuvensesteenweg 517, 3070 Kortenberg, Belgium
| | - Louisa M C van den Bosch
- 1GGZ Rivierduinen - Centre for Personality Disorders Jelgersma, Rhijngeesterstraatweg 13-C, 2342 AN Oegstgeest, The Netherlands.,Present address: Scelta, Deventerstraat 459, 7323 PT Apeldoorn, The Netherlands
| | - Leona Hakkaart-van Roijen
- 2Erasmus School of Health Policy and Management (ESPHM) and institute for Medical Technology Assessment (iMTA), Erasmus University Rotterdam, Postbus 1738, 3000 DR Rotterdam, The Netherlands
| | - Kristof Vansteelandt
- 3Z.org KU Leuven, University of Leuven, Leuvensesteenweg 517, 3070 Kortenberg, Belgium
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Kröger C, del Pozo MA, Kosfelder J, Allroggen M, Grabowski G, Legenbauer T. Erfassung von Impulsivität und emotionaler Dysregulation bei Jugendlichen mit Borderline-Persönlichkeitsstörung. DIAGNOSTICA 2017. [DOI: 10.1026/0012-1924/a000184] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Zusammenfassung. Die Skala zur Erfassung der Impulsivität und emotionalen Dysregulation (IES-27) bei der Borderline-Persönlichkeitsstörung (BPS) hat sich in Forschung und Praxis bei Erwachsenen bewährt. In adaptierter Form soll das Instrument auch bei Jugendlichen (IES-27-J) sowie deren Angehörigen (IES-27-A) eingesetzt werden können. Ziel der vorliegenden Studie war die Evaluation dieser Selbst- und Fremdbeurteilungsskalen. Die psychometrischen Kennwerte der IES-27-J wurden anhand von zwei unabhängigen psychiatrischen Stichproben (n = 109 und n = 170) und die der IES-27-A von Angehörigen (n = 31) überprüft. Die Itemanalyse zeigt für beide Instrumente gute Ergebnisse. Die interne Konsistenz beträgt für die IES-27-J in beiden Stichproben α = .95 sowie α = .92 für die IES-27-A. Die Test-Retest-Reliabilität fiel sehr gut aus (ρ = .97). Für die IES-27-J ergaben sich in der exploratorischen Hauptkomponentenanalyse Hinweise auf eine einfaktorielle Struktur. Jugendliche mit einer BPS erzielten signifikant höhere Summenwerte als Patientinnen und Patienten mit depressiver Störung und Störung des Sozialverhaltens, was als Hinweis auf die diskriminative Validität der IES-27-J gewertet werden kann. Die IES-27-J weist einen moderaten Zusammenhang zur IES-27-A auf. Beide Instrumente können für die Forschung und Praxis eingesetzt werden. Zukünftig sollte eine Normierung mithilfe einer Stichprobe von gesunden Jugendlichen erfolgen.
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Affiliation(s)
- Christoph Kröger
- Technische Universität Braunschweig, Institut für Psychologie, Abteilung für Klinische Psychologie, Psychotherapie und Diagnostik
| | - Melina Andrea del Pozo
- Technische Universität Braunschweig, Institut für Psychologie, Abteilung für Klinische Psychologie, Psychotherapie und Diagnostik
| | | | - Marc Allroggen
- Universitätsklinikum Ulm, Klinik für Kinder- und Jugendpsychiatrie / Psychotherapie
| | | | - Tanja Legenbauer
- LWL-Universitätsklinikum Hamm, Klinik für Kinder- und Jugendpsychiatrie, Psychotherapie und Psychosomatik
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49
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Baczkowski BM, van Zutphen L, Siep N, Jacob GA, Domes G, Maier S, Sprenger A, Senft A, Willenborg B, Tüscher O, Arntz A, van de Ven V. Deficient amygdala-prefrontal intrinsic connectivity after effortful emotion regulation in borderline personality disorder. Eur Arch Psychiatry Clin Neurosci 2017; 267:551-565. [PMID: 28039553 PMCID: PMC5561271 DOI: 10.1007/s00406-016-0760-z] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 12/13/2016] [Indexed: 02/05/2023]
Abstract
Emotion instability in borderline personality disorder (BPD) has been associated with an impaired fronto-limbic inhibitory network. However, functional connectivity (FC) underlying altered emotion regulation in BPD has yet to be established. Here, we used resting-state fMRI to investigate enduring effects of effortful emotion regulation on the amygdala intrinsic FC in BPD. In this multicenter study, resting-state fMRI was acquired before and after an emotion regulation task in 48 BPD patients and 39 non-patient comparison individuals. The bilateral amygdalae were used as a seed in the whole-brain FC analysis and two-way mixed ANOVA to test whether BPD patients exhibited weaker post-task increase in the amygdala intrinsic FC with the prefrontal cortex (PFC), compared to non-patients. Subsequently, we explored whether the results are common for personality disorders characterized by emotional problems, using additional data of 21 cluster-C personality disorder patients. In contrast to non-patients, BPD patients failed to show increased post-task amygdala resting-state FC with the medial, dorsolateral, ventrolateral PFC, and superior temporal gyrus, but surprisingly exhibited decreased FC with the posterior cingulate cortex and increased FC with the superior parietal lobule. In BPD patients, the emotion regulation task failed to increase resting-state amygdala FC with brain regions essential for effortful emotion regulation, which suggests: (a) altered cognitive control typically used to indirectly alleviate distress by reinterpreting the meaning of emotional stimuli; (b) impaired direct regulation of emotional responses, which might be common for personality disorders;
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Affiliation(s)
- Blazej M Baczkowski
- Department of Clinical Psychological Science, Faculty of Psychology and Neuroscience, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, The Netherlands
- Max Planck Research Group for Neuroanatomy & Connectivity, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany
| | - Linda van Zutphen
- Department of Clinical Psychological Science, Faculty of Psychology and Neuroscience, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, The Netherlands.
| | - Nicolette Siep
- Department of Clinical Psychological Science, Faculty of Psychology and Neuroscience, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, The Netherlands
| | - Gitta A Jacob
- Department of Clinical Psychology and Psychotherapy, University of Freiburg, Freiburg, Germany
| | - Gregor Domes
- Department of Psychology, Laboratory for Biological and Personality Psychology, University of Freiburg, Freiburg, Germany
- Freiburg Brain Imaging Center, University Medical Center, University of Freiburg, Freiburg, Germany
- Department of Biological and Clinical Psychology, University of Trier, Trier, Germany
| | - Simon Maier
- Freiburg Brain Imaging Center, University Medical Center, University of Freiburg, Freiburg, Germany
- Department of Psychiatry and Psychotherapy, Medical Center, University of Freiburg, Freiburg, Germany
| | - Andreas Sprenger
- Departments of Neurology and Psychology, University of Lübeck, Lübeck, Germany
| | - Alena Senft
- Department of Psychiatry and Psychotherapy, University of Lübeck, Lübeck, Germany
| | - Bastian Willenborg
- Department of Psychiatry and Psychotherapy, University of Lübeck, Lübeck, Germany
| | - Oliver Tüscher
- Department of Clinical Psychology and Psychotherapy, University of Freiburg, Freiburg, Germany
- Department of Psychiatry and Psychotherapy, University Medical Center Mainz, Mainz, Germany
| | - Arnoud Arntz
- Department of Clinical Psychological Science, Faculty of Psychology and Neuroscience, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, The Netherlands
- Department of Clinical Psychology, University of Amsterdam, Amsterdam, The Netherlands
| | - Vincent van de Ven
- Department of Cognitive Neuroscience, Maastricht University, Maastricht, The Netherlands
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50
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Peter M, Arntz AR, Klimstra T, Vingerhoets AJJM. Different aspects of emotional intelligence of borderline personality disorder. Clin Psychol Psychother 2017; 25:e51-e59. [PMID: 28857328 DOI: 10.1002/cpp.2126] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Revised: 07/11/2017] [Accepted: 07/18/2017] [Indexed: 11/08/2022]
Abstract
OBJECTIVES The present study investigated deficiencies in different components of emotional intelligence in borderline personality disorder (BPD). METHOD The Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT) and the Emotional Quotient Inventory (EQ-i) were used to assess EI dimensions. BPD patients (N = 85; 69 women; M = 33.6 years) were compared with Cluster C personality disorder (PD) patients (N = 39; 23 women; M = 36.6 years) and nonpatients (N = 69; 44 women; M = 35.6 years). RESULTS Compared to the Cluster C PD patients and the nonpatient group, BPD patients displayed only deficits in their ability to understand emotions as measured with the Mayer-Salovey-Caruso Emotional Intelligence Test. The Emotional Quotient Inventory only revealed deficits in stress management in BPD patients compared to Cluster C PD patients. CONCLUSIONS Our findings suggest that BPD patients have the ability to regulate emotions effectively, but they subjectively experience deficits in emotion regulation and therefore may not use this ability when they need it.
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Affiliation(s)
- Mathell Peter
- Department of Personality Disorders, GGz Breburg, Tilburg, The Netherlands
| | - Arnoud R Arntz
- Department of Clinical Psychology, University of Amsterdam, Amsterdam, The Netherlands
| | - Theo Klimstra
- Department of Developmental Psychology, Tilburg University, The Netherlands
| | - Ad J J M Vingerhoets
- Department of Medical and Clinical Psychology, Tilburg University, The Netherlands
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