[Dialectical Behaviour Therapy for adolescents (DBT-A)--a pilot study on the therapy of suicidal, parasuicidal, and self-injurious behaviour in female patients with a borderline disorder]

A clinical follow-up study of dialectical behavior therapy skills groups among female adolescents diagnosed with depressive disorder

Our aim was to evaluate longitudinal data for adolescents who were treated with Dialectical Behavior therapy (DBT) skills groups having been previously diagnosed with depressive disorder. Intervention with an observational cross-sectional design was implemented to evaluate the treatment outcome of a 10-week DBT skills groups with female adolescents with depression. After the patients were identified for enrollment, parents and adolescents were evaluated with psychometric measurements pre-, post-intervention, and at one-year follow-up. Repeated measures analysis was undertaken with the Child Depression Inventory (CDI), Pediatric Quality of Life Inventory (PedsQL) and Strengths and Difficulties Questionnaire (SDQ) for participants. Statistical significance was detected for self-report CDI scores and both self-report and parent SDQ and PedsQL scores. This study is the first DBT intervention in Turkish children, shows that a group DBT skills groups training can be adapted and put into practice successfully with depressed Turkish adolescents.

Maladaptive behaviours in adolescence and their associations with personality traits, emotion dysregulation and other clinical features in a sample of Italian students: a cross-sectional study

BACKGROUND

Emotion Dysregulation (ED), childhood trauma and personality are linked to the occurrence of maladaptive behaviours in adolescence which, in turn, may be related to increased risk for psychopathology in the life course. We sought to explore the relationship among the occurrence of different clusters of maladaptive behaviours and ED, clinical features (i.e. impulsivity, childhood maltreatment, anxiety, depressive symptoms) and personality traits that have been found to be associated to Borderline Personality Disorder (BPD), in a sample of 179 adolescent students.

METHODS

Multiple Correspondence Analysis (MCA) was applied to detect clustered types of maladaptive behaviours and groups of students were defined as individuals engaging in these clustered behaviours (non-suicidal self-injury-NSSI, binge eating, binge drinking, cannabis use, and sexual risk behaviours). Logistic models were used to evaluate the association among clinical scales, and student groups. Mediation analysis was used to evaluate whether clinical features affected the association between personality traits and student groups.

RESULTS

MCA analysis allowed to identify three student groups: NSSI/binge eating (NSSI-BE) behaviours, other maladaptive behaviours and "none". Higher scores in ED, impulsivity, childhood maltreatment, anxiety and depressive symptoms increased the risk of belonging to the cluster of NSSI-BE behaviours compared to the other two groups. ED, depression and anxiety symptoms were found to be mediators of the relationship between specific personality traits, mainly pertaining to the negative affectivity construct, and NSSI/BE.

CONCLUSIONS

Individuals engaging in NSSI-BE behaviours represent a vulnerable adolescent population. ED, depression and anxiety were mediators of the relationship between a variety of personality traits related to BPD and NSSI and binge eating behaviours. Findings have important clinical implications in terms of prevention and interventions among adolescents engaging in self-damaging behaviours.

Suicidality in Childhood and Adolescence

BACKGROUND

The suicide of minors in Germany is rare in absolute numbers: there were only 212 suicides among persons aged 10 to 20 in Germany in 2017. Nonetheless, in school surveys, 36.4-39.4% of those surveyed reported suicidal ideation, and 6.5-9% reported suicide attempts. Suicide among children and adolescents is thus a clinically and societally relevant problem.

METHODS

This review is based on pertinent articles retrieved by a selective literature search in the PubMed and PsycInfo databases (April 2019) employing the search terms "suicidality," "suicidal*," and "suicide," and on further information from several textbooks (1991-2017).

RESULTS

In children and adolescents with a mental illness, the risk of suicide is higher by a factor of 3 to 12. Mobbing experiences increase the suicide risk as well (odds ratio [OR] = 2.21, p <0.05). Non-suicidal self-injurious behavior (NSSB) is also a risk factor for both suicidal ideation (OR = 2.95) and suicide attempts (hazard ratio [HR] = 2.00). Intoxication with medications is the most common method of attempted suicide (67.7%). Most suicides are preceded by early warning signs. Psychiatric hospitalization is indicated for children and adolescents who are in acute danger of doing harm to themselves. Specific types of treatment, family-centered methods in particular, have been found to lessen the frequency of suicidal ideation and suicide attempts. The administration of antidepressant drugs to children and adolescents is controversial, as there is evidence of increased suicidality (but not mortality) for single medications. Antidepressant drugs should not, however, be withheld for this reason, if indicated. The prerequisite in all cases is close observation.

CONCLUSION

To prevent suicide and improve outcomes, risk factors for suicide must be considered, and the indications for primary and secondary preventive and therapeutic measures must be established. Online therapeutic modalities may become more widely used in the near future, particularly among young patients, who are well versed in the use of the Internet.

Psychopathology and Quality of Life in Traumatized or Victimized Underage Individuals as Factors for Forensic Multilevel Assessment-A Pilot Investigation

Background: Psychological sequels to criminal violence can be long lasting and severe. They are in many countries not sufficiently considered in court cases as an important circumstance that could be used to assess the severity of the crime, also guiding redress, compensation, and rehabilitation of the victim, and-in children-child custody considerations. So far, the focus of forensic assessment has often been limited to diagnostic categories, especially "posttraumatic stress disorder" (PTSD), a diagnosis that presently is subjected to rapidly changing definitions both in and between diagnostic systems. Other indicators such as quality of life (QoL) might be of equal importance as compared to clinical or research diagnostic categories to understand and evaluate the impact of a crime and the amount of help needed and, in the legal context, redress to be asked. Symptoms might differ depending on the crime encountered. Objective and Methods: QoL and general symptom patterns including a PTSD diagnosis were assessed in a group of 10- to 17-year-old minors with (n = 33) and without (n = 49) PTSD diagnosis who all had experienced sexual abuse, physical abuse, death of a parent, or their parents' divorce, using standardized diagnostic instruments. Results: PTSD patients reported a significantly lower QoL than non-PTSD controls. Reported symptom patterns with potential impact on life, such as intrusive thoughts, differed between the victims of different crime types, with the highest rates of both intrusive symptoms and combined symptom profile in victims of sexual abuse. Data indicate that the changes between older and present criteria and between DSM and recently published ICD 11 might help identify different groups and symptom profiles. Conclusion: Specific trauma-related symptom profiles integrating the type of crime encountered and its individual impact on QoL may help improve future forensic assessment and guide compensation and rehabilitation plans. Carefully designed studies are now needed to further explore the use and forensic usability of complex indicators and the impact of violence in different forensic settings.

Ambulante Dialektisch-Behaviorale Therapie für Adoleszente (DBT-A) mit impulsiven und selbstschädigenden Verhaltensweisen

Zusammenfassung. Die Dialektisch-Behaviorale Therapie für Adoleszente (DBT-A) zur Behandlung impulsiver und suizidaler Jugendlicher wird seit Februar 2005 in leicht abgeänderter Form ambulant im Kinder- und Jugendpsychiatrischen Dienst Zürich umgesetzt. Diese DBT-A umfasst Einzeltherapie, ein Gruppen- bzw. Skills-Training sowie einen Elternabend und dauert jeweils ein halbes Jahr. Der vorliegende Erfahrungsbericht zeigt die Umsetzung dieses Ansatzes und präsentiert eine Evaluation im Rahmen der klinikinternen Qualitätssicherung.

Die insgesamt 43 Teilnehmerinnen des Therapie-Programms waren weibliche Jugendliche im Alter von 14–19 Jahren, die impulsive und selbstschädigende Verhaltensweisen sowie Probleme in der Regulierung ihrer Emotionen und in der zwischenmenschlichen Beziehungsgestaltung aufwiesen. An einem Skills-Training nahmen jeweils 4–6 Jugendliche teil.

Unsere mehrheitlich positiven Erfahrungen mit diesem Ansatz in der Therapie wurden durch die Auswertungen der Daten aus der Qualitätssicherung von 19 Teilnehmerinnen bestätigt, welche sowohl Selbst- wie auch Fremdurteile umfassten. Es liegen Hinweise vor, dass die DBT-A mit zu einer Abnahme sowohl verschiedener Indikatoren der allgemeinen als auch der spezifischen Psychopathologie führt.

Diagnostik und Therapie von Suizidalität im Jugendalter: Das Wichtigste in Kürze aus den aktuellen Leitlinien

Zusammenfassung. Aufgrund der klinischen Relevanz von suizidalen Krisen, Suizidversuchen und Suiziden im Jugendalter wurde eine konsensusbasierte Leitlinie als Handlungsempfehlung erstellt. Jede Andeutung in Richtung Suizidalität muss ernst genommen werden. Suizidalität ist ein zentraler Bestandteil des psychopathologischen Befunds und Patienten sollten gezielt auf kurz- und langfristige Suizidgefährdung exploriert werden. Eine klinische Einschätzung des akuten Suizidrisikos ergibt sich aus einem vertrauensvollen anamnestischen Gespräch, der Erhebung von Risikofaktoren und dem Erfassen von psychischen Störungen sowie von Suchtmittelkonsum. Bei akuter Selbstgefährdung besteht eine Indikation zur stationären Behandlung, die zum Schutz des Patienten notfalls auch gegen dessen Willen umgesetzt werden muss. Eine adäquate Dokumentation ist unumgänglich. Nach einem Suizidversuch ist neben der fachärztlichen medizinischen Erstversorgung darauf zu achten, dass der Patient sich nicht schaden kann und rasch ein Konsil in der akutversorgenden Klinik erfolgt. Erstes therapeutisches Ziel ist die Reduktion der Suizidalität und ggf. das Wiedererreichen der Absprachefähigkeit. Für wiederkehrende Suizidgedanken ist ein Notfallplan zu erstellen. Zur Entlastung kann zusätzlich zu Gesprächsangeboten vorübergehend eine sedierende Medikation notwendig werden. Im Falle eines Suizids in einer Klinik sollte ein Handlungsleitfaden vorliegen, der die Zuständigkeiten und Abläufe genau regelt und festhält. Wirksame präventive Maßnahmen sind Schulungen von Multiplikatoren, Aufklärungskampagnen, Einschränkung der Verfügbarkeit von Suizidmethoden und die Einhaltung der Richtlinien zur Suizidberichterstattung.

Diagnostik und Behandlung nichtsuizidaler Selbstverletzungen im Kindes- und Jugendalter

Zusammenfassung. Theoretischer Hintergrund: Nichtsuizidales Selbstverletzendes Verhalten (NSSV) ist insbesondere im Jugendalter häufig und klinisch bedeutsam. Die Entwicklung einer konsensbasierten Leitlinie verfolgt das Ziel, die Diagnostik und die Behandlung von NSSV zu optimieren und Impulse für die Forschung zu geben. Als Leitlinie der Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Gesellschaften (AWMF) wurde diese erste Leitlinie zu NSSV verabschiedet und publiziert. Fragestellung und Methode: Die wichtigsten Empfehlungen zur Diagnostik und Behandlung von NSSV werden zusammengefasst und Forschungslücken aufgezeigt. Ergebnisse: In der Diagnostik von NSSV ist insbesondere die Einschätzung der Suizidalität zu berücksichtigen. Als erster Schritt ist die somatische Abklärung der Verletzungen und ggf. eine medizinische Erstversorgung zu nennen. Für die Evaluation des NSSV sind Häufigkeit, Methoden, Schmerzempfinden, Motive, Impulsivität als auch weitere familiäre und außerfamiliäre Einflussfaktoren zu erheben. Den Schwerpunkt der Behandlung bildet die Psychotherapie, insbesondere die kognitive Verhaltenstherapie, die Dialektisch-Behaviorale Therapie für Adoleszente und die Mentalisierungsbasierte Therapie für Adoleszente. Eine evidenzbasierte Indikation zur spezifischen Pharmakotherapie von NSSV existiert nicht. Schlussfolgerung: Die Leitlinie umfasst evidenz- und konsensusbasierte Empfehlungen zur Diagnostik und Therapie von NSSV. Die Implementierung soll zu einer Verbesserung der Versorgung von Patienten mit NSSV dienen.

Interventions for self-harm in children and adolescents

BACKGROUND

Self-harm (SH; intentional self-poisoning or self-injury) is common in children and adolescents, often repeated, and strongly associated with suicide. This is an update of a broader Cochrane review on psychosocial and pharmacological treatments for deliberate SH first published in 1998 and previously updated in 1999. We have now divided the review into three separate reviews; this review is focused on psychosocial and pharmacological interventions for SH in children and adolescents.

OBJECTIVES

To identify all randomised controlled trials of psychosocial interventions, pharmacological agents, or natural products for SH in children and adolescents, and to conduct meta-analyses (where possible) to compare the effects of specific treatments with comparison types of treatment (e.g., treatment as usual (TAU), placebo, or alternative pharmacological treatment) for children and adolescents who SH.

SEARCH METHODS

For this update the Cochrane Depression, Anxiety and Neurosis Group (CCDAN) Trials Search Co-ordinator searched the CCDAN Specialised Register (30 January 2015).

SELECTION CRITERIA

We included randomised controlled trials comparing psychosocial or pharmacological treatments with treatment as usual, alternative treatments, or placebo or alternative pharmacological treatment in children and adolescents (up to 18 years of age) with a recent (within six months) episode of SH resulting in presentation to clinical services.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected trials, extracted data, and appraised study quality, with consensus. For binary outcomes, we calculated odds ratios (OR) and their 95% confidence intervals (CI). For continuous outcomes measured using the same scale we calculated the mean difference (MD) and 95% CI; for those measured using different scales we calculated the standard mean difference (SMD) and 95% CI. Meta-analysis was only possible for two interventions: dialectical behaviour therapy for adolescents and group-based psychotherapy. For these analyses, we pooled data using a random-effects model.

MAIN RESULTS

We included 11 trials, with a total of 1,126 participants. The majority of participants were female (mean = 80.6% in 10 trials reporting gender). All trials were of psychosocial interventions; there were none of pharmacological treatments. With the exception of dialectical behaviour therapy for adolescents (DBT-A) and group-based therapy, assessments of specific interventions were based on single trials. We downgraded the quality of evidence owing to risk of bias or imprecision for many outcomes.Therapeutic assessment appeared to increase adherence with subsequent treatment compared with TAU (i.e., standard assessment; n = 70; k = 1; OR = 5.12, 95% CI 1.70 to 15.39), but this had no apparent impact on repetition of SH at either 12 (n = 69; k = 1; OR 0.75, 95% CI 0.18 to 3.06; GRADE: low quality) or 24 months (n = 69; k = 1; OR = 0.69, 05% CI 0.23 to 2.14; GRADE: low quality evidence). These results are based on a single cluster randomised trial, which may overestimate the effectiveness of the intervention.For patients with multiple episodes of SH or emerging personality problems, mentalisation therapy was associated with fewer adolescents scoring above the cut-off for repetition of SH based on the Risk-Taking and Self-Harm Inventory 12 months post-intervention (n = 71; k = 1; OR = 0.26, 95% CI 0.09 to 0.78; GRADE: moderate quality). DBT-A was not associated with a reduction in the proportion of adolescents repeating SH when compared to either TAU or enhanced usual care (n = 104; k = 2; OR 0.72, 95% CI 0.12 to 4.40; GRADE: low quality). In the latter trial, however, the authors reported a significantly greater reduction over time in frequency of repeated SH in adolescents in the DBT condition, in whom there were also significantly greater reductions in depression, hopelessness, and suicidal ideation.We found no significant treatment effects for group-based therapy on repetition of SH for individuals with multiple episodes of SH at either the six (n = 430; k = 2; OR 1.72, 95% CI 0.56 to 5.24; GRADE: low quality) or 12 month (n = 490; k = 3; OR 0.80, 95% CI 0.22 to 2.97; GRADE: low quality) assessments, although considerable heterogeneity was associated with both (I(2) = 65% and 77% respectively). We also found no significant differences between the following treatments and TAU in terms of reduced repetition of SH: compliance enhancement (three month follow-up assessment: n = 63; k = 1; OR = 0.67, 95% CI 0.15 to 3.08; GRADE: very low quality), CBT-based psychotherapy (six month follow-up assessment: n = 39; k = 1; OR = 1.88, 95% CI 0.30 to 11.73; GRADE: very low quality), home-based family intervention (six month follow-up assessment: n = 149; k = 1; OR = 1.02, 95% CI 0.41 to 2.51; GRADE: low quality), and provision of an emergency card (12 month follow-up assessment: n = 105, k = 1; OR = 0.50, 95% CI 0.12 to 2.04; GRADE: very low quality). No data on adverse effects, other than the planned outcomes relating to suicidal behaviour, were reported.

AUTHORS' CONCLUSIONS

There are relatively few trials of interventions for children and adolescents who have engaged in SH, and only single trials contributed to all but two comparisons in this review. The quality of evidence according to GRADE criteria was mostly very low. There is little support for the effectiveness of group-based psychotherapy for adolescents with multiple episodes of SH based on the results of three trials, the evidence from which was of very low quality according to GRADE criteria. Results for therapeutic assessment, mentalisation, and dialectical behaviour therapy indicated that these approaches warrant further evaluation. Despite the scale of the problem of SH in children and adolescents there is a paucity of evidence of effective interventions. Further large-scale trials, with a range of outcome measures including adverse events, and investigation of therapeutic mechanisms underpinning these interventions, are required. It is increasingly apparent that development of new interventions should be done in collaboration with patients to ensure that these are likely to meet their needs. Use of an agreed set of outcome measures would assist evaluation and both comparison and meta-analysis of trials.

[Inpatient Dialectical Behavioral Therapy for Adolescents (DBT-A) - 10 years of experience on the psychiatric inpatient unit "wellenreiter"]

In April 2004 the inpatient unit "Wellenreiter" at the Vorwerker Clinic for Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy in Lubeck (Germany) opened its doors. Despite reservations by the therapeutic community, we implemented a specialized treatment for female adolescents with symptoms of borderline personality disorder - the I;>ialectical Behavior Therapy for Adolescents (DBT-A). In this article we present the concept, our experiences, and data from the past 10 years of clinical work in this specialized unit.

[Psychotherapy of personality disorders in adolescence]

By the current state of knowledge adolescent personality disorders should be taken seriously due to their high prevalence and severe symptomatology. Personality disorders are characterized by a stable pattern of deviation concerning cognition, affectivity, impulse control, and interpersonal relationships and have negative repercussions in psychosocial functioning and subsequent development. There is emerging evidence that personality disorder diagnosis is reliable and valid during adolescence. It is essential to detect youth with personality pathology in order to refer them to specific psychotherapeutic interventions and consequently avoid further chronification and life-long functional impairment. This selective review will give an overview over personality disorders in adolescents as well as according psychotherapeutic interventions.

Predictors of treatment outcome of Inpatient Psychotherapy for Adolescents with personality pathology

Little is known about the effectiveness of treatment programmes for personality disordered adolescents. This study investigates the treatment outcome of Inpatient Psychotherapy for Adolescents (IPA), i.e. an intensive programme for treatment refractory adolescents with personality pathology. In addition, this study examines predictors of treatment outcome. One hundred and nine adolescents admitted for treatment of their personality problems were followed up during their stay in IPA. Axis I and Axis II disorders were measured using semi-structured interviews, and the adolescents completed several questionnaires to measure symptom severity (global indices of distress), personality styles and functioning, and quality of life at both start and 12 months after start of treatment. Patients showed improvement in level of symptom severity, personality functioning and quality of life (d ranging from 0.49 to 0.97). As for level of symptom severity, 29% of the adolescents moved into a normative range of symptom severity. Higher levels of self-criticism significantly predicted poorer outcome in terms of symptom severity. Type of personality disorder did not predict treatment outcome. IPA is a potentially effective treatment programme for (a subgroup of) treatment refractory adolescents with personality pathology.

Dialectical behaviour therapy with adolescents

BACKGROUND

  Dialectical behaviour therapy (DBT) is the first empirically validated treatment for chronically suicidal patients diagnosed with borderline personality disorder (BPD). Numerous randomised clinical trials conducted with adults with BPD have demonstrated that DBT is effective in reducing suicidal and non-suicidal self-injurious (NSSI) behaviours. Other research on the use of DBT for adults has shown that the treatment is effective in reducing a variety of problem behaviours in a range of therapeutic settings. In the last decade, a number of studies have evaluated DBT as a promising treatment for adolescents with different psychological disorders and behaviours, including borderline personality disorder (BPD), eating disorders, externalising disorders, and suicidal and NSSI behaviours. This article reviews the literature on the use of DBT with adolescents.

RESULTS

  Overall findings indicate some empirical support for the conclusion that DBT is a promising treatment for adolescents with BPD symptomatology, suicidal ideation and comorbid depression, bipolar disorder, disordered eating behaviours and aggressive and impulsive behaviours. Adolescents in these studies were also hospitalised less frequently when treated with DBT. Moreover, studies conducted with these populations suggest that DBT may be adapted for use in outpatient, inpatient, community, and residential treatment settings.

CONCLUSIONS

  The authors conclude that DBT may be effective in treating adolescents with additional disorders and dysfunctional behaviours not yet examined. Data from soon to be completed randomised controlled trials need to be published.

Treatment completion in psychotherapy for borderline personality disorder: a systematic review and meta-analysis

OBJECTIVE

Psychotherapy for borderline personality disorder (BPD) has been associated with problematically low treatment completion rates.

METHOD

PsycInfo and Medline were systematically searched to identify studies providing information on treatment completion in psychotherapy models that have been shown to be effective for BPD. A meta-analysis of treatment completion rates and a narrative analysis of factors predicting dropout were conducted.

RESULTS

Forty-one studies were included, with completion rates ranging from 36% to 100%- a substantial between-study heterogeneity. Random effects meta-analyses yielded an overall completion rate of 75% (95% CI: 68-82%) for interventions of <12 months duration, and 71% (95% CI: 65-76%) for longer interventions. Egger's test for publication bias was significant for both analyses (P ≤ 0.01). Study characteristics such as treatment model and treatment setting did not explain between-study heterogeneity. In individual studies, factors predicting dropout status included commitment to change, the therapeutic relationship and impulsivity, whilst sociodemographics were consistently non-predictive.

CONCLUSION

Borderline personality disorder should no longer be associated with high rates of dropout from treatment. However, the substantial variation in completion rates between studies remains unexplained. Research on the psychological processes involved in dropping out of treatment could further improve dropout rates.

Dialectical behavior therapy for suicidal adolescents with borderline personality disorder

Although research to date on dialectical behavior therapy (DBT) for adolescents has its limitations, growing evidence suggests that DBT is a promising treatment for adolescents with a range of problematic behaviors, including but not limited to suicidal and nonsuicidal self-injury. This article introduces dialectical behavior therapy's theoretical underpinnings, describes its adaptation for suicidal adolescents, and provides a brief review of the empirical literature evaluating DBT with adolescents.

A Preliminary Study of an Extension of a Community Dialectic Behaviour Therapy (DBT) Programme to Adolescents in the Looked After Care System

BACKGROUND

  Adolescents in the Looked After Care (LAC) system demonstrate high rates of psychiatric disorder and self-harm; however, there is little evidence for therapies reducing self-harm in this population.

METHOD

  An open evaluation of DBT for adolescents with repeated serious self-harm in the LAC system was undertaken.

RESULTS

  An intention-to-treat (ITT) analysis showed that DBT was successful at reducing the core elements of depression, hopelessness and self-harm; however, 35% (7/20) failed to engage.

CONCLUSION

  DBT is a useful treatment option; the failure, however, of some adolescents to engage in therapy may be due to their higher initial rates of depression and hopelessness.

Dialectical Behavioral Therapy for Adolescents (DBT-A): a clinical Trial for Patients with suicidal and self-injurious Behavior and Borderline Symptoms with a one-year Follow-up

BACKGROUND

To date, there are no empirically validated treatments of good quality for adolescents showing suicidality and non-suicidal self-injurious behavior. Risk factors for suicide are impulsive and non-suicidal self-injurious behavior, depression, conduct disorders and child abuse. Behind this background, we tested the main hypothesis of our study; that Dialectical Behavioral Therapy for Adolescents is an effective treatment for these patients.

METHODS

Dialectical Behavioral Therapy (DBT) has been developed by Marsha Linehan - especially for the outpatient treatment of chronically non-suicidal patients diagnosed with borderline personality disorder. The modified version of DBT for Adolescents (DBT-A) from Rathus & Miller has been adapted for a 16-24 week outpatient treatment in the German-speaking area by our group. The efficacy of treatment was measured by a pre-/post- comparison and a one-year follow-up with the aid of standardized instruments (SCL-90-R, CBCL, YSR, ILC, CGI).

RESULTS

In the pilot study, 12 adolescents were treated. At the beginning of therapy, 83% of patients fulfilled five or more DSM-IV criteria for borderline personality disorder. From the beginning of therapy to one year after its end, the mean value of these diagnostic criteria decreased significantly from 5.8 to 2.75. 75% of patients were kept in therapy. For the behavioral domains according to the SCL-90-R and YSR, we have found effect sizes between 0.54 and 2.14.During treatment, non-suicidal self-injurious behavior reduced significantly. Before the start of therapy, 8 of 12 patients had attempted suicide at least once. There were neither suicidal attempts during treatment with DBT-A nor at the one-year follow-up.

CONCLUSIONS

The promising results suggest that the interventions were well accepted by the patients and their families, and were associated with improvement in multiple domains including suicidality, non-suicidal self-injurious behavior, emotion dysregulation and depression from the beginning of therapy to the one-year follow-up.

Früh beginnende bipolare Störungen, ADHS oder Störung der Affektregulation?

Die Arbeit gibt einen Überblick über die Hintergründe der Kontroverse und leitet daraus konkrete Schlussfolgerungen für die klinische Praxis ab. Bei der Diagnostik früher bipolarer Störungen ist vorrangig auf das Auftreten von abgrenzbaren Episoden mit eindeutigen Stimmungsänderungen und Veränderungen von Verhalten und Kognition zu achten. Das Mischbild aus ADHS und begleitender affektiver Dysregulation sollte nicht im Sinne einer beginnenden bipolaren Störung interpretiert werden, bedarf aber stärkerer Beachtung, insbesondere bei der Entwicklung geeigneter psycho- und pharmakotherapeutischer Ansätze. Erläutert werden zudem Gemeinsamkeiten und Unterschiede von bipolaren Störungen mit Schizophrenie, Depression, ADHS, Borderline-Persönlichkeitsstörung und Substanzmissbrauch.

[Nonsuicidal self-injury in adolescence]

Nonsuicidal self-injury (NSSI) usually starts in adolescence. International studies report prevalence rates between 3 and 37% (for Germany between 15 and 26%) in adolescents. From a neurobiological perspective, there is evidence that primarily the serotonergic system is involved in the origin and maintenance of this behaviour. NSSI is often used by adolescents to influence aversive affective states, but sometimes serves other functions as well, such as self-punishment or anti-dissociation. To date there are many assessment instruments, some of which are available in a German translation. Regarding psychotherapeutic interventions there is evidence for a good efficacy of dialectical behavioral therapy for adolescents (DBT-A). There is little evidence for psychopharmacological interventions in childhood and adolescence; thus treatment should focus on psychotherapeutic interventions.

[Subjective evaluation of DBT treatment by adolescent patients with eating disorders and the correlation with evaluations by their parents and psychotherapists]

OBJECTIVE

The subjective evaluation of a psychotherapeutic treatment may be an essential aspect of the recovery from an eating disorder. Our study investigates the subjective treatment evaluation by patients with eating disorders and the accordance with their parents' and psychotherapist's evaluation.

METHOD

In a sample of 41 eating-disorder patients (M(Age) = 16.3; SD = 1.26), their parents and psychotherapists, we used a questionnaire (FBB) to assess satisfaction with Dialectical Behavioral Therapy treatment.

RESULTS

Our results show good ratings, as well as good correlations between patients and parents.

CONCLUSIONS

The findings implicate the importance of assessing a subjective therapy rating in addition to objective parameters.

Effectiveness of an emotion regulation group training for adolescents--a randomized controlled pilot study

Emotion Regulation Training (ERT) was developed for adolescents with symptoms of borderline personality disorder (BPD) and emotion dysregulation. ERT is an adaptation of the Systems Training for Emotional Predictability and Problem Solving (STEPPS) programme. This paper describes the background of the programme, and gives an outline of the treatment programme. The effectiveness of ERT was examined in a randomized controlled pilot study with 43 youth (aged 14-19 years) in five mental health centres in the Netherlands. Subjects were assessed before and after random assignment to ERT plus treatment as usual (TAU) (n = 23) or to TAU alone (n = 20). Outcome measures included assessment of BPD symptoms, locus of control, and internalizing and externalizing behaviour. Both groups showed equal reductions in BPD symptoms over time. The group receiving ERT plus TAU (and not the TAU-only group) had a significant increase in internal locus of control: ERT participants reported more sense of control over their own mood swings, and attributed changes in mood swings not only to external factors. The study was complicated by a high attrition. The implications of the findings are discussed, including the difficulties inherent in treating and researching an adolescent population, and the need for researchers to develop age-appropriate assessments.

Psychopharmakotherapie einer ambulanten und stationären Inanspruchnahmepopulation adoleszenter Patienten mit Borderline-Persönlichkeitsstörung

Fragestellung: Ein Großteil erwachsener Patienten mit Borderline-Persönlichkeitsstörung (BPS) wird mit Psychopharmaka behandelt. Über die Psychopharmakotherapie bei Adoleszenten mit BPS liegen bisher keine Daten vor. Ziel dieser Studie ist die Untersuchung der Häufigkeit des Störungsbildes und des Verschreibungsverhaltens bei adoleszenten ambulanten und stationären Patienten mit BPS. Methoden: 58 adoleszente Patienten mit BPS (16.7 ± 2.5 Jahre) einer Inanspruchnahmepopulation während eines 7-jährigen Beobachtungszeitraums wurden retrospektiv hinsichtlich der Medikation und verschiedener Risikovariablen in der Erstbehandlungsepisode untersucht. Ergebnisse: 37 Patienten wurden stationär und 21 ambulant behandelt, entsprechend einer Prävalenz von 2.1 %, bezogen auf die Inanspruchnahmepopulation. Stationäre Patienten waren insgesamt stärker durch Risikofaktoren belastet (ca. 68 % mit komorbiden Störungen, ca. 49 % mit selbstverletzendem Verhalten, signifikant (p < .001) mehr Suizidversuche in der Vorgeschichte) und wurden häufiger (p < .001) psychopharmakologisch behandelt. Am häufigsten wurden Antidepressiva verschrieben (SSRI und NaSSA), gefolgt von Neuroleptika. Über die Hälfte der medizierten Patienten erhielten mehrere Medikamente gleichzeitig. Schlussfolgerungen: Psychopharmakotherapie bei BPS hat inzwischen einen hohen Stellenwert, ist in erster Linie symptomorientiert und komorbide Störungen sollten gleichermaßen miteinbezogen werden. Auch für Adoleszente gewinnt die Medikation bei BPS an Bedeutung. Stationär behandelte Patienten sind durch psychiatrische Risikofaktoren stärker belastet und werden häufiger mediziert.

Dialektisch Behaviorale Therapie (DBT) und Kognitiv Behaviorale Therapie (CBT) für Jugendliche mit Anorexia und Bulimia nervosa im Vergleich

Ziel der vorliegenden randomisierten kontrollierten Studie war die Überprüfung der Wirksamkeit der Kognitiv Behavioralen Therapie (CBT) sowie der Dialektisch Behavioralen Therapie (DBT-AN/BN) bei Patienten mit einer Anorexia nervosa (AN) und Bulimia nervosa (BN). 50 weibliche Patienten (12;4 – 21;0 Jahre) nahmen an der Untersuchung teil. 19 Patientinnen absolvierten eine 25-wöchige CBT, 16 eine 25-wöchige DBT-AN/BN und 15 wurden für 3 Monate einer Wartekontrollgruppe (WKG) zugeordnet. Am Ende der Behandlung erfüllten in der CBT-Gruppe noch 42.1 %, in der DBT-AN/BN-Gruppe 37.5 % und in der WKG alle Patienten die Kriterien einer Essstörung nach DSM-IV. Sowohl die CBT als auch die DBT-AN/BN führten verglichen mit der WKG zu einer Reduktion der Kalorienvermeidung, der unregelmäßigen Nahrungsaufnahme und der aktuellen psychischen Belastung sowie zu einer Erhöhung des BMI. Bezogen auf die Körperbildstörung, die Autonomieentwicklung, die Emotionsregulation sowie den Perfektionismus konnten nur geringe positive Effekte erzielt werden.

[Treatment of an 11-year-old child with elements of the dialectical behavioral therapy for adolescents]

When a psychiatric disorder during childhood is on the verge of becoming chronic despite intensive early and guideline-based psychotherapy, the diagnostic classification according to research results ought to be reconsidered. By means of this case review it should be discussed which diagnostic and therapeutic procedure is appropriate, taking into account the stage of development and the pathology of the patient. This paper encourages sharpening the eye towards phenomena that--with respect to some disorders--can easily be ignored and be misinterpreted as typically conflict neurotic.

[Dialectical behavior therapy for adolescents with anorexia and bulimia nervosa (DBT-AN/ BN)--a pilot study]

Dialectical behavior therapy (DBT) was originally developed by Linehan (1993a, b) and modified by Miller et al. (1997) for suicidal adolescents with borderline personality features. Meanwhile, this therapy has also successfully applied in other adult clinical groups. The prior aim of the study is to evaluate the effectiveness of DBT for inpatient adolescents with anorexia and bulimia nervosa. In this pilot study (n=31) the efficacy of this treatment will be evaluated in a pre-post comparison. Different instruments will be used (SIAB, EDI-2, SCL-90-R, FBB). The first results are promising and we must hope that this new approach will improve the future treatment.

Selbstverletzendes Verhalten

Zusammenfassung. Selbstverletzendes Verhalten wie Sich-Schneiden und Kratzen kommt sowohl bei männlichen als auch bei weiblichen Jugendlichen verhältnismäßig häufig vor. Es handelt sich dabei in den meisten Fällen um den Ausdruck schwerwiegender psychischer und/oder sozialer Belastungen und sollte als Hinweis darauf gewertet werden, dass der oder die Jugendliche Hilfe und Unterstützung benötigt. Dieser Beitrag befasst sich vor allem mit den aktuellen Möglichkeiten der Diagnostik und Therapie selbstverletzenden Verhaltens. Beispielhaft werden Selbstbeurteilungsinstrumente vorgestellt, die verschiedene Aspekte selbstverletzenden Verhaltens detailliert erfassen. Sie können bei der Identifikation und Differenzialdiagnostik, aber auch zur Vorbereitung, Begleitung und Evaluation therapeutischer Maßnahmen eingesetzt werden. Als besonders vielversprechende Interventionsmöglichkeiten werden die DBT-A (Dialektisch-Behaviorale Therapie für Adoleszente) und das Eye Movement Desensitization and Reprocessing (EMDR) vorgestellt, wobei für die DBT-A bereits erste positive empirische Befunde vorliegen. Die Wirksamkeit dieser Verfahren sollte zukünftig möglichst in kontrolliert-randomisierten Studien geprüft werden.