Eine Meta-Analyse zur Wirksamkeit der Dialektisch Behavioralen Therapie bei Borderline-Persönlichkeitsstörungen

One Year of Outpatient Dialectical Behavioral Therapy and Its Impact on Neuronal Correlates of Attachment Representation in Patients with Borderline Personality Disorder Using a Personalized fMRI Task

(1) Background: BPD is characterized by affect dysregulation, interpersonal problems, and disturbances in attachment, but neuroimaging studies investigating attachment representations in BPD are rare. No study has examined longitudinal neural changes associated with interventions targeting these impairments. (2) Methods: We aimed to address this gap by performing a longitudinal neuroimaging study on n = 26 patients with BPD treated with Dialectic Behavioral Therapy (DBT) and n = 26 matched healthy controls (HCs; post intervention point: n = 18 BPD and n = 23 HCs). For functional imaging, we applied an attachment paradigm presenting attachment related scenes represented in drawings paired with related neutral or personalized sentences from one's own attachment narratives. In a prior cross-sectional investigation, we identified increased fMRI-activation in the human attachment network, in areas related to fear response and the conflict monitoring network in BPD patients. These were especially evident for scenes from the context of loneliness (monadic pictures paired with individual narrative sentences). Here, we tested whether these correlates of attachment representation show a near-to-normal development over one year of DBT intervention. In addition, we were interested in possible associations between fMRI-activation in these regions-of-interest (ROI) and clinical scores. (3) Results: Patients improved clinically, showing decreased symptoms of borderline personality organization (BPI) and increased self-directedness (Temperament and Character Inventory, TCI) over treatment. fMRI-activation was increased in the anterior medial cingulate cortex (aMCC) and left amygdala in BPD patients at baseline which was absent after intervention. When investigating associations between scores (BPI, TCI) and functional activation, we found significant effects in the bilateral amygdala. In contrast, aMCC activation at baseline was negatively associated with treatment outcome, indicating less effective treatment effects for those with higher aMCC activation at baseline. (4) Conclusions: Monadic attachment scenes with personalized sentences presented in an fMRI setup are capable of identifying increased activation magnitude in BPD. After successful DBT treatment, these increased activations tend to normalize which could be interpreted as signs of a better capability to regulate intensive emotions in the context of "social pain" towards a more organized/secure attachment representation. Amygdala activation, however, indicates high correlations with pre-treatment scores; activation in the aMCC is predictive for treatment gain. Functional activation of the amygdala and the aMCC as a response to attachment scenes representing loneness at baseline might be relevant influencing factors for DBT-intervention outcomes.

Highly Structured Treatment Programs for Addicted Offenders: Comparing the Effects of the Reasoning & Rehabilitation Program and DBT-F

BACKGROUND

When treating addicted offenders in a forensic psychiatric setting, a primary concern is to decrease antisocial cognitions and behaviors. The cognitive style of offenders is often characterized by impulsiveness, egocentricity, irrational thinking, and rigidity. We examined the relative efficacy of Reasoning and Rehabilitation Program (R&R) and Dialectical Behavioral Therapy- Forensic (DBT-F) on the domains of underlying psychological constructs (e.g., mental flexibility, planning, and problem-solving).

MATERIALS AND METHODS

The R&R and DBT-F were introduced in a forensic-psychiatric hospital for offenders with substance addictions in Germany. We compared pre- and post-tests to measure the cognitive skills of addicted offenders having undergone R&R (N = 47), DBT-F (N = 34), or Treatment as Usual (TAU; N = 28). Participants' skills (cognitive flexibility, ability to inhibit cognitive interference, cognitive performance/mental speed, divergent and convergent reasoning/problem solving) were assessed using neuropsychological instruments. Analyses of variance were conducted to investigate whether there were significant improvements within groups and whether these differences were significant between groups. To examine the predictive power of treatment-program on outcomes, and diagnosis of personality disorder, a hierarchical regression model was used.

RESULTS

Both programs were associated with improvements in nearly all of the measured constructs. The only construct on which the R&R and DBT-F groups differed significantly was word fluency, with those receiving R&R improving more than those receiving DBT-F. A regression model showed no predictive power for age, IQ, or diagnosis of personality disorder. Treatment group explained 13.8% of variance in cognitive flexibility but did not predict variance in other outcomes.

CONCLUSION

Surprisingly, we did not find superiority for one intervention over TAU or differential effects between the two programs. Future research should use larger samples and additional outcomes, including recidivism, to identify possible effects of treatment programs. Additionally, qualitative methods might inform us about these programs are implemented as well as which outcomes may be relevant.

Meta-Analysis and Systematic Review Assessing the Efficacy of Dialectical Behavior Therapy (DBT)

OBJECTIVE

The objective was to quantitatively and qualitatively examine the efficacy of DBT (e.g., decreasing life-threatening suicidal and parasuicidal acts, attrition, and depression) explicitly with borderline personality disorder (BPD) and using conservative assumptions and criteria, across treatment providers and settings.

METHOD

Five randomized controlled trials (RCTs) were identified in a systematic search that examined the efficacy of DBT in reducing suicide attempts, parasuicidal behavior, attrition during treatment, or symptoms of depression, in adult patients with BPD.

RESULTS

Combining effect measures for suicide and parasuicidal behavior (five studies total) revealed a net benefit in favor of DBT (pooled Hedges' g -0.622). DBT was only marginally better than treatment as usual (TAU) in reducing attrition during treatment in five RCTs (pooled risk difference -0.168). DBT was not significantly different from TAU in reducing depression symptoms in three RCTs (pooled Hedges' g -0.896).

DISCUSSION

DBT demonstrates efficacy in stabilizing and controlling self-destructive behavior and improving patient compliance.

Borderline personality disorder features and history of childhood maltreatment in mothers involved with child protective services

This study examines the history of childhood maltreatment and Borderline Personality Disorder (BPD) symptoms in mothers whose children were removed from the home by Child Protective Services (CPS) to identify potential targets for future intervention efforts. Forty-one mothers of children removed from the home due to abuse and/or neglect and 58 community-control mothers without CPS involvement were assessed for history of childhood maltreatment, alcohol and drug use, and BPD features. CPS-involved mothers scored significantly higher on measures of childhood maltreatment history and BPD features than did control mothers. The highest BPD scores were associated with the most severe histories of mothers' childhood maltreatment. In total, 50% of CPS-involved mothers reported elevated BPD features, compared with 15% of control mothers. Further, 19% of CPS-involved mothers had self-reported scores consistent with a BPD diagnosis, compared with 4% of control mothers. BPD features rather than maltreatment history per se predicted maternal involvement with CPS, controlling for alcohol and drug use predictors. The present data suggest that evidence-based treatments to address BPD symptoms may be indicated for some CPS-involved parents.

Die Skala zur Erfassung der Impulsivität der Borderline-Persönlichkeitsstörung (IS-27)

Zusammenfassung. Um im Bereich von Psychotherapie eingesetzt zu werden, sollte die Skala zur Erfassung der Impulsivität (IS-27) bei der Borderline-Persönlichkeitsstörung (BPS) veränderungssensitiv sein und Personen mit BPS identifizieren können. Das Instrument wurde mit anderen Selbstbeurteilungsinstrumenten einer ambulanten Stichprobe (n = 147), einer gesunden Kontrollgruppe (n = 43) sowie einer Stichprobe von stationären Patienten mit BPS vor und nach einer dreimonatigen dialektisch behavioralen Behandlung (n = 62) vorgelegt. Das reliable und valide Instrument diskriminierte Patienten mit BPS von anderen Diagnosegruppen und konnte die Symptomreduktion infolge der Behandlung abbilden. Die „Receiver-Operating-Characteristic” (ROC)-Kurve zeigte eine hohe diskriminatorische Fähigkeit. Unterschiedliche Cut-Off-Werte wurden hinsichtlich ihrer diagnostischen Effizienz bewertet. Aufgrund der Kosten, die die BPD verursacht, wird ein Cut-off-Wert von ≥ 27 bei fast optimalem Youden-Index und hoher Sensitivität favorisiert. Mit der IS-27 liegt ein Verfahren mit guten teststatischen Kennwerten vor, das einen Beitrag zu einer störungsspezifischen Qualitätssicherung leisten kann.

Konstruktion eines störungsspezifischen Instruments zur Erfassung der Impulsivität der Borderline-Persönlichkeitsstörung

Zusammenfassung. Theoretischer Hintergrund: Impulsivität ist eines der zentralen Merkmale der Borderline-Persönlichkeitsstörung (BPS), das in der Behandlung als eines der ersten Ziele fokussiert wird. Bislang fehlt ein störungsorientiertes Selbstbeurteilungsinstrument, das impulsives Verhalten reliabel, valide und ökonomisch erfasst. Fragestellung: Welche Gütekriterien weist die Skala zur Erfassung der Impulsivität (IS-27) auf? Methode: Nach Voranalysen wurden 27 Items ausgewählt, die einer diagnostisch heterogenen Stichprobe (n1 = 115) und einer Stichprobe mit Patienten mit BPS (n2 = 149) zusammen mit anderen Selbstbeurteilungsinstrumenten vorgelegt wurden. Ergebnisse: Nach der Hauptkomponentenanalyse wird eine Ein-Faktor-Lösung favorisiert. Die Interne Konsistenz wie die Guttmans Split-Half-Koeffizienten betrugen über 0,92. Die IS-27 korreliert mit den Validierungsinstrumenten und diskriminiert zwischen Diagnosegruppen. Schlussfolgerungen: Mit der IS-27 liegt ein Verfahren mit guten teststatischen Kennwerten vor, das Impulsivität als verhaltensnahes Merkmal der BPS erheben kann. Das Verfahren sollte bezüglich seiner Veränderungssensitivität zukünftig untersucht werden.