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van den End A, Snoek A, Aarts I, Beekman ATF, Dekker J, Blankers M, Lommerse N, Thomaes K. Predictors of treatment attendance in patients with posttraumatic stress disorder and comorbid personality disorders. Compr Psychiatry 2024; 134:152516. [PMID: 38991291 DOI: 10.1016/j.comppsych.2024.152516] [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: 03/02/2024] [Revised: 06/25/2024] [Accepted: 07/05/2024] [Indexed: 07/13/2024] Open
Abstract
INTRODUCTION High dropout and low treatment attendance rates among patients with posttraumatic stress disorder (PTSD) and personality disorders (PDs) continue to pose a significant challenge. Despite numerous studies focusing on enhancing treatment attendance, the identification of consistent and reliable predictors in patients with PTSD and comorbid PDs remains limited. OBJECTIVES This study aims to investigate a wide range of potential predictors of treatment attendance, encompassing demographic, patient-severity, treatment, and therapist-related variables in patients with PTSD and comorbid borderline and/or cluster C PDs. METHODS Utilizing data from 255 patients participating in two randomized controlled trials comparing trauma-focused treatment with or without concurrent PD treatment, candidate predictors were individually analyzed in univariate regression models. Significant predictors were then combined in a multiple ordinal regression model. RESULTS In total, 40% of patients attended fewer trauma-focused treatment sessions than the minimum recommended in treatment guidelines. Out of the 38 candidate predictors examined, five significant, independent predictors of treatment attendance emerged in a multiple ordinal regression model. Higher baseline PTSD severity (OR = 1.04, p = .036), higher education level (OR = 1.22, p = .009) and a stronger patient-rated working alliance (OR = 1.72, p = .047) with the therapist predicted higher treatment attendance. Conversely, inadequate social support from friends (OR = 0.90, p = .042) and concurrent PD treatment and trauma-focused treatment (OR = 0.52, p = .022) were associated with lower treatment attendance. CONCLUSIONS In conclusion, this constitutes the first study investigating predictors of treatment attendance in patients with PTSD and comorbid PDs. The results highlight the complexity of pinpointing reliable predictors. Nevertheless, the identification of five predictors provides valuable insights, aiding clinicians in customizing treatment strategies for individual patients and enhancing overall treatment attendance.
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Affiliation(s)
- Arne van den End
- Arkin, Sinai Centrum, Laan van de Helende Meesters 2, 1186AM Amstelveen, the Netherlands; Amsterdam UMC, University of Amsterdam, Department of Psychiatry, Oldenaller 1, 1081HJ Amsterdam, the Netherlands.
| | - Aishah Snoek
- Arkin, Sinai Centrum, Laan van de Helende Meesters 2, 1186AM Amstelveen, the Netherlands; Amsterdam UMC, University of Amsterdam, Department of Psychiatry, Oldenaller 1, 1081HJ Amsterdam, the Netherlands.
| | - Inga Aarts
- Arkin, Sinai Centrum, Laan van de Helende Meesters 2, 1186AM Amstelveen, the Netherlands; Amsterdam UMC, University of Amsterdam, Department of Psychiatry, Oldenaller 1, 1081HJ Amsterdam, the Netherlands; Amsterdam UMC, University of Amsterdam, Department of Anatomy and Neurosciences, De Boelelaan 1085, 1081HV Amsterdam, the Netherlands.
| | - Aartjan T F Beekman
- Amsterdam UMC, University of Amsterdam, Department of Psychiatry, Oldenaller 1, 1081HJ Amsterdam, the Netherlands.
| | - Jack Dekker
- Arkin Mental Health Care, Klaprozenweg 111, 1033NN, Amsterdam, the Netherlands; Vrije Universiteit Amsterdam, Faculty of Behavioural and Movement Sciences, van der Boechorststraat 7, 1081BT Amsterdam, the Netherlands.
| | - Matthijs Blankers
- Arkin Mental Health Care, Klaprozenweg 111, 1033NN, Amsterdam, the Netherlands.
| | - Nick Lommerse
- Arkin Mental Health Care, Klaprozenweg 111, 1033NN, Amsterdam, the Netherlands.
| | - Kathleen Thomaes
- Arkin, Sinai Centrum, Laan van de Helende Meesters 2, 1186AM Amstelveen, the Netherlands; Amsterdam UMC, University of Amsterdam, Department of Psychiatry, Oldenaller 1, 1081HJ Amsterdam, the Netherlands; Arkin Mental Health Care, Klaprozenweg 111, 1033NN, Amsterdam, the Netherlands.
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Emmelkamp PMG, Meyerbröker K. Psychotherapies for the treatment of personality disorders: the state of the art. Curr Opin Psychiatry 2024:00001504-990000000-00140. [PMID: 39239878 DOI: 10.1097/yco.0000000000000968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/07/2024]
Abstract
PURPOSE OF REVIEW To provide an update of systematic reviews, meta-analyses and recent clinical outcome studies for personality disorder (PD) in order to investigate the state of the art of the evidence of psychotherapy for personality disorders. RECENT FINDINGS Few outcome studies in patients with Cluster A and Cluster C PD have been conducted, which limits the conclusions which can be drawn. Most recently published research has been conducted with borderline PD. There is limited evidence that dialectical behavior therapy (DBT), mentalization based therapy and schema therapy are more effective than treatment as usual. There is no convincing evidence that long and intensive therapy is more effective than short and less intensive therapy. Drop-out is rather high for patients with borderline PD. Group therapy results in more drop-outs than individual therapy. SUMMARY There is a clear need of studies evaluating whether psychotherapies developed for PDs are more effective than CBT for patients with Cluster C PD. Given that studies with patients with Cluster B PD suggest that longer treatment of DBT and mentalization-based treatment is not more effective than shorter treatment this needs to be studied with other evidence-based therapies as well. Serious efforts are needed to evaluate therapies for patients with Cluster A PDs.
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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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Culina I, Ranjbar S, Nadel I, Kramer U. Fluctuations in therapist responsiveness facing clients with borderline personality disorder: Starting therapy on the right foot. Psychother Res 2024:1-10. [PMID: 38943681 DOI: 10.1080/10503307.2024.2368784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 06/10/2024] [Indexed: 07/01/2024] Open
Abstract
OBJECTIVE The present paper focuses on therapist responsiveness during the initial therapy session with clients with borderline personality disorder (BPD), aiming to analyze therapist responsiveness at short intervals during the initial session and determine if it can predict therapeutic alliance from both therapist and client viewpoints. METHOD A sample of 47 clients participated in the study for 10 sessions of therapy. Therapeutic alliance from therapists' and clients' perspectives was rated after each session; external raters assessed therapist responsiveness during the initial session. Multiple linear regression models and linear mixed models with backward variable selection based on AIC were run to analyze whether specific therapist behaviors during session one predicted therapeutic alliance rated from therapists' and clients' perspectives. RESULTS The results indicate that therapists normalizing and validating clients' experiences during the first session are crucial for establishing therapeutic alliance for BPD clients; however, for therapists, the increase in variability of emotions verbalized by clients during the initial session negatively impacts therapeutic alliance. CONCLUSION The study contributes to further understand the impact of therapists' behavior at the beginning of therapy with BPD clients. Therapist responsiveness is crucial for therapy outcome but is methodologically challenging; therefore, efforts in this direction should be pursued.
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Affiliation(s)
- Ines Culina
- General Psychiatry Service, Department of Psychiatry, University Hospital Center and University of Lausanne, Lausanne, Switzerland
| | - Setareh Ranjbar
- Psychiatric Epidemiology and Psychopathology Research Center, Department of Psychiatry, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Isabella Nadel
- Department of Psychiatry, Williams College, Williamstown, MA, USA
| | - Ueli Kramer
- General Psychiatry Service, Department of Psychiatry, University Hospital Center and University of Lausanne, Lausanne, Switzerland
- Institute of Psychotherapy, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
- Department of Psychology, University of Windsor, Windsor, Canada
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Zopfs M, Jindrová M, Gurevitch G, Keynan JN, Hendler T, Baumeister S, Aggensteiner PM, Cornelisse S, Brandeis D, Schmahl C, Paret C. Amygdala-related electrical fingerprint is modulated with neurofeedback training and correlates with deep-brain activation: proof-of-concept in borderline personality disorder. Psychol Med 2024; 54:1651-1660. [PMID: 38131344 DOI: 10.1017/s0033291723003549] [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] [Indexed: 12/23/2023]
Abstract
BACKGROUND The modulation of brain circuits of emotion is a promising pathway to treat borderline personality disorder (BPD). Precise and scalable approaches have yet to be established. Two studies investigating the amygdala-related electrical fingerprint (Amyg-EFP) in BPD are presented: one study addressing the deep-brain correlates of Amyg-EFP, and a second study investigating neurofeedback (NF) as a means to improve brain self-regulation. METHODS Study 1 combined electroencephalography (EEG) and simultaneous functional magnetic resonance imaging to investigate the replicability of Amyg-EFP-related brain activation found in the reference dataset (N = 24 healthy subjects, 8 female; re-analysis of published data) in the replication dataset (N = 16 female individuals with BPD). In the replication dataset, we additionally explored how the Amyg-EFP would map to neural circuits defined by the research domain criteria. Study 2 investigated a 10-session Amyg-EFP NF training in parallel to a 12-weeks residential dialectical behavior therapy (DBT) program. Fifteen patients with BPD completed the training, N = 15 matched patients served as DBT-only controls. RESULTS Study 1 replicated previous findings and showed significant amygdala blood oxygenation level dependent activation in a whole-brain regression analysis with the Amyg-EFP. Neurocircuitry activation (negative affect, salience, and cognitive control) was correlated with the Amyg-EFP signal. Study 2 showed Amyg-EFP modulation with NF training, but patients received reversed feedback for technical reasons, which limited interpretation of results. CONCLUSIONS Recorded via scalp EEG, the Amyg-EFP picks up brain activation of high relevance for emotion. Administering Amyg-EFP NF in addition to standardized BPD treatment was shown to be feasible. Clinical utility remains to be investigated.
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Affiliation(s)
- Malte Zopfs
- Department of Psychosomatic Medicine and Psychotherapy, Central Institute of Mental Health Mannheim, Medical Faculty Mannheim/Heidelberg University, Mannheim, Germany
| | - Miroslava Jindrová
- Department of Psychosomatic Medicine and Psychotherapy, Central Institute of Mental Health Mannheim, Medical Faculty Mannheim/Heidelberg University, Mannheim, Germany
| | - Guy Gurevitch
- Sagol Brain Institute, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Jackob N Keynan
- Brain Stimulation Lab, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Talma Hendler
- Sagol Brain Institute, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
- School of Psychological Sciences and Sagol School of Neuroscience, Tel-Aviv University, Tel-Aviv, Israel
| | - Sarah Baumeister
- Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim/Heidelberg University, Mannheim, Germany
| | - Pascal-M Aggensteiner
- Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim/Heidelberg University, Mannheim, Germany
| | - Sven Cornelisse
- Department of Psychosomatic Medicine and Psychotherapy, Central Institute of Mental Health Mannheim, Medical Faculty Mannheim/Heidelberg University, Mannheim, Germany
| | - Daniel Brandeis
- Department of Child and Adolescent Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim/Heidelberg University, Mannheim, Germany
- Department of Child and Adolescent Psychiatry and Psychotherapy, University Hospital of Psychiatry, University of Zurich, Zurich, Switzerland
- Neuroscience Center Zurich, University of Zurich and ETH Zurich, Zurich, Switzerland
| | - Christian Schmahl
- Department of Psychosomatic Medicine and Psychotherapy, Central Institute of Mental Health Mannheim, Medical Faculty Mannheim/Heidelberg University, Mannheim, Germany
| | - Christian Paret
- Department of Psychosomatic Medicine and Psychotherapy, Central Institute of Mental Health Mannheim, Medical Faculty Mannheim/Heidelberg University, Mannheim, Germany
- Sagol Brain Institute, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
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Lucre K, Ashworth F, Copello A, Jones C, Gilbert P. Compassion Focused Group Psychotherapy for attachment and relational trauma: Engaging people with a diagnosis of personality disorder. Psychol Psychother 2024. [PMID: 38305507 DOI: 10.1111/papt.12518] [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: 06/20/2023] [Revised: 12/28/2023] [Accepted: 01/16/2024] [Indexed: 02/03/2024]
Abstract
OBJECTIVES The research aimed to evaluate an exploratory Compassion Focused Group Psychotherapy Programme and the impact on participants' experiences of self-criticism, usage of services and general wellbeing. Participants included patients with a history of complex attachment and relational trauma (A&RT), who might attract a diagnosis of personality disorder. DESIGN This study utilised a quasi-experimental non-randomised within subject controlled design for the evaluation of the efficacy of the programme. METHODS Participants were recruited from tertiary care services. The programme consisted of a 12-week Preparation and Engagement intervention (PEG) which was Compassionate Mind Training and Psychoeducation, followed by a 40-week Compassion Focused Trauma Group intervention. The cohort was then followed up after 12 months during which period they received treatment as usual. A comprehensive selection of self-report measures was administered at various points during the therapeutic process and following completion of the group interventions. RESULTS The results of the research showed that the provision of a long-term, slow-paced, Compassion Focused Group Psychotherapy intervention, resulted in significant changes across all measures which were maintained at 12-month follow-up. These significant results were maintained following intention to treat and reliable change analyses. These data were supported by a significant reduction in service usage and a significant increase in engagement in employment and education. CONCLUSIONS This study has identified that within Compassion Focused Group Psychotherapy, there is a therapeutic process of establishing group-based safeness as a necessary precursor to cultivating compassion and reworking early shame-based trauma memories.
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Affiliation(s)
- Kate Lucre
- Birmingham and Solihull Mental Health Foundation Trust, Birmingham, UK
| | | | - Alex Copello
- School of Psychology University of Birmingham & Birmingham and Solihull Mental Health NHS Foundation Trust, Birmingham, UK
| | - Chris Jones
- School of Psychology, University of Birmingham, Birmingham, UK
| | - Paul Gilbert
- Centre for Compassion Research and Training, College of Health, Psychology and Social Care, University of Derby, Derby, UK
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Leichsenring F, Fonagy P, Heim N, Kernberg OF, Leweke F, Luyten P, Salzer S, Spitzer C, Steinert C. Borderline personality disorder: a comprehensive review of diagnosis and clinical presentation, etiology, treatment, and current controversies. World Psychiatry 2024; 23:4-25. [PMID: 38214629 PMCID: PMC10786009 DOI: 10.1002/wps.21156] [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: 01/13/2024] Open
Abstract
Borderline personality disorder (BPD) was introduced in the DSM-III in 1980. From the DSM-III to the DSM-5, no major changes have occurred in its defining criteria. The disorder is characterized by instability of self-image, interpersonal relationships and affects. Further symptoms include impulsivity, intense anger, feelings of emptiness, strong abandonment fears, suicidal or self-mutilation behavior, and transient stress-related paranoid ideation or severe dissociative symptoms. There is evidence that BPD can be reliably diagnosed and differentiated from other mental disorders by semi-structured interviews. The disorder is associated with considerable functional impairment, intensive treatment utilization, and high societal costs. The risk of self-mutilation and suicide is high. In the general adult population, the lifetime prevalence of BPD has been reported to be from 0.7 to 2.7%, while its prevalence is about 12% in outpatient and 22% in inpatient psychiatric services. BPD is significantly associated with other mental disorders, including depressive disorders, substance use disorders, post-traumatic stress disorder, attention-deficit/hyperactivity disorder, bipolar disorder, bulimia nervosa, and other personality disorders. There is convincing evidence to suggest that the interaction between genetic factors and adverse childhood experiences plays a central role in the etiology of BPD. In spite of considerable research, the neurobiological underpinnings of the disorder remain to be clarified. Psychotherapy is the treatment of choice for BPD. Various approaches have been empirically supported in randomized controlled trials, including dialectical behavior therapy, mentalization-based therapy, transference-focused therapy, and schema therapy. No approach has proved to be superior to others. Compared to treatment as usual, psychotherapy has proved to be more efficacious, with effect sizes between 0.50 and 0.65 with regard to core BPD symptom severity. However, almost half of the patients do not respond sufficiently to psychotherapy, and further research in this area is warranted. It is not clear whether some patients may benefit more from one psychotherapeutic approach than from others. No evidence is available consistently showing that any psychoactive medication is efficacious for the core features of BPD. For discrete and severe comorbid anxiety or depressive symptoms or psychotic-like features, pharmacotherapy may be useful. Early diagnosis and treatment of BPD can reduce individual suffering and societal costs. However, more high-quality studies are required, in both adolescents and adults. This review provides a comprehensive update of the BPD diagnosis and clinical characterization, risk factors, neurobiology, cognition, and management. It also discusses the current controversies concerning the disorder, and highlights the areas in which further research is needed.
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Affiliation(s)
- Falk Leichsenring
- Department of Psychosomatics and Psychotherapy, University of Giessen, Giessen, Germany
- Department of Psychosomatics and Psychotherapy, University of Rostock, Rostock, Germany
| | - Peter Fonagy
- Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Nikolas Heim
- International Psychoanalytic University, Berlin, Germany
| | - Otto F Kernberg
- Personality Disorders Institute, Weill Cornell Medical College, New York, NY, USA
| | - Frank Leweke
- Department of Psychosomatics and Psychotherapy, University of Giessen, Giessen, Germany
| | - Patrick Luyten
- Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
- Faculty of Psychology and Educational Sciences, University of Leuven, Leuven, Belgium
| | - Simone Salzer
- International Psychoanalytic University, Berlin, Germany
| | - Carsten Spitzer
- Department of Psychosomatics and Psychotherapy, University of Rostock, Rostock, Germany
| | - Christiane Steinert
- Department of Psychosomatics and Psychotherapy, University of Giessen, Giessen, Germany
- International Psychoanalytic University, Berlin, Germany
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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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Sved Williams A, Hill R. The Management of Perinatal Borderline Personality Disorder. J Clin Med 2023; 12:6850. [PMID: 37959315 PMCID: PMC10650510 DOI: 10.3390/jcm12216850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 10/19/2023] [Accepted: 10/24/2023] [Indexed: 11/15/2023] Open
Abstract
Borderline personality disorder (BPD) is highly prevalent in clinical perinatal mental health settings, although there are few systematic programmes to identify BPD at this time. Retrospective studies show compromised birth outcomes for women with this condition, and several authors have highlighted a significant range of problem outcomes for offspring identifiable from early infancy through the adult years, including the intergenerational transfer of mental health problems from mother to child. A literature review identifies the varying prevalence rates found in non-clinical and clinical settings and the paucity of published studies on the management of perinatal BPD, in particular focused both on the mother and mother-infant relationships. A case study is presented to show both the potential benefits of inpatient mother-baby unit protocols and of specialised longer-term group therapy. Many knowledge gaps can be identified for further clinical research that could potentially benefit families with perinatal BPD, including systematic identification of perinatal BPD and intensive programmes that not only could perhaps improve birth outcomes but also provide skills to mothers to help with their emotional regulation and potentially improve mother-infant relationships and longer-term offspring developmental pathways.
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Affiliation(s)
- Anne Sved Williams
- Women’s and Children’s Health Network, North Adelaide 5006, Australia;
- Faculty of Psychiatry, University of Adelaide, Adelaide 5005, Australia
- School of Medicine and Psychology, Australian National University, Canberra 2601, Australia
| | - Rebecca Hill
- Women’s and Children’s Health Network, North Adelaide 5006, Australia;
- Faculty of Psychiatry, University of Adelaide, Adelaide 5005, Australia
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Setkowski K, Palantza C, van Ballegooijen W, Gilissen R, Oud M, Cristea IA, Noma H, Furukawa TA, Arntz A, van Balkom AJLM, Cuijpers P. Which psychotherapy is most effective and acceptable in the treatment of adults with a (sub)clinical borderline personality disorder? A systematic review and network meta-analysis. Psychol Med 2023; 53:3261-3280. [PMID: 37203447 PMCID: PMC10277776 DOI: 10.1017/s0033291723000685] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 02/11/2023] [Accepted: 02/27/2023] [Indexed: 05/20/2023]
Abstract
A broad range of psychotherapies have been proposed and evaluated in the treatment of borderline personality disorder (BPD), but the question which specific type of psychotherapy is most effective remains unanswered. In this study, two network meta-analyses (NMAs) were conducted investigating the comparative effectiveness of psychotherapies on (1) BPD severity and (2) suicidal behaviour (combined rate). Study drop-out was included as a secondary outcome. Six databases were searched until 21 January 2022, including RCTs on the efficacy of any psychotherapy in adults (⩾18 years) with a diagnosis of (sub)clinical BPD. Data were extracted using a predefined table format. PROSPERO ID:CRD42020175411. In our study, a total of 43 studies (N = 3273) were included. We found significant differences between several active comparisons in the treatment of (sub)clinical BPD, however, these findings were based on very few trials and should therefore be interpreted with caution. Some therapies were more efficacious compared to GT or TAU. Furthermore, some treatments more than halved the risk of attempted suicide and committed suicide (combined rate), reporting RRs around 0.5 or lower, however, these RRs were not statistically significantly better compared to other therapies or to TAU. Study drop-out significantly differed between some treatments. In conclusion, no single treatment seems to be the best choice to treat people with BPD compared to other treatments. Nevertheless, psychotherapies for BPD are perceived as first-line treatments, and should therefore be investigated further on their long-term effectiveness, preferably in head-to-head trials. DBT was the best connected treatment, providing solid evidence of its effectiveness.
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Affiliation(s)
- Kim Setkowski
- Research Department, 113 Suicide Prevention, Amsterdam, the Netherlands
- Department of Psychiatry, Amsterdam UMC, VU University, Amsterdam Public Health research institute, and GGZinGeest Specialized Mental Health Care, Amsterdam, the Netherlands
| | - Christina Palantza
- Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit, Amsterdam, the Netherlands
| | - Wouter van Ballegooijen
- Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit, Amsterdam, the Netherlands
- Department of Psychiatry, Amsterdam UMC, VU University, Amsterdam Public Health research institute, and GGZinGeest Specialized Mental Health Care, Amsterdam, the Netherlands
| | - Renske Gilissen
- Research Department, 113 Suicide Prevention, Amsterdam, the Netherlands
| | - Matthijs Oud
- Department of Treatment, Care and Reintegration, Trimbos Institute, Utrecht, the Netherlands
| | - Ioana A. Cristea
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- IRCCS Mondino Foundation, Pavia, Italy
| | - Hisashi Noma
- Department of Data Science, The Institute of Statistical Mathematics, Tokyo, Japan
| | - Toshi A. Furukawa
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan
| | - Arnoud Arntz
- Department of Clinical Psychological Science, Maastricht University, Maastricht, the Netherlands
- Department of Clinical Psychology, University of Amsterdam, Amsterdam, the Netherlands
| | - Anton J. L. M. van Balkom
- Department of Psychiatry, Amsterdam UMC, VU University, Amsterdam Public Health research institute, and GGZinGeest Specialized Mental Health Care, Amsterdam, the Netherlands
| | - Pim Cuijpers
- Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit, Amsterdam, the Netherlands
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11
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Bachrach N, Rijkeboer MM, Arntz A, Huntjens RJC. Schema therapy for Dissociative Identity Disorder: a case report. Front Psychiatry 2023; 14:1151872. [PMID: 37151967 PMCID: PMC10160656 DOI: 10.3389/fpsyt.2023.1151872] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 04/04/2023] [Indexed: 05/09/2023] Open
Abstract
Treatment for Dissociative Identity Disorder (DID) often follows a practice-based psychodynamic psychotherapy approach that is conducted in three phases: symptom stabilization, trauma processing, and identity integration and rehabilitation. The percentage of patients that reach the third phase is relatively low, treatment duration is long, and the effects of this treatment on the core DID symptoms have been found to be small or absent, leaving room for improvement in the treatment of DID. Schema Therapy (ST) is an integrative psychotherapy that has been proposed as a treatment for DID. This approach is currently being investigated in several studies and has the potential to become an evidence-based treatment for DID. This case report presents an overview of the protocol adaptations for DID ST treatment. The presented case concerns a 43-year-old female patient with DID, depressive disorder (recurrent type), PTSD, cannabis use disorder, and BPD. Functioning was very low. She received 220 sessions of ST, which included direct trauma processing through Imagery Rescripting (ImRs). The patient improved in several domains: she experienced a reduction of PTSD symptoms, as well as dissociative symptoms, there were structural changes in the beliefs about the self, and loss of suicidal behaviors. After treatment she was able to stop her punitive mode, to express her feelings and needs to others, and to participate adequately in social interaction. This case report indicates that ST might be a viable treatment for DID, adding to a broader scope of treatment options for this patient group.
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Affiliation(s)
- Nathan Bachrach
- Department of Medical and Clinical Psychology, Tilburg University, Tilburg, Netherlands
- GGZ-Oost Brabant, Department of Personality Disorders, Helmond, Netherlands
| | - Marleen M. Rijkeboer
- Department of Clinical Psychological Science, Maastricht University, Maastricht, Netherlands
- Department of Clinical Psychology, University of Amsterdam, Amsterdam, Netherlands
| | - Arnoud Arntz
- Department of Clinical Psychology, University of Amsterdam, Amsterdam, Netherlands
| | - Rafaële J. C. Huntjens
- Department of Experimental Psychotherapy and Psychopathology, University of Groningen, Groningen, Netherlands
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