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van den End A, Beekman ATF, Dekker J, Aarts I, Snoek A, Blankers M, Vriend C, van den Heuvel OA, Thomaes K. Trauma-focused and personality disorder treatment for posttraumatic stress disorder and comorbid cluster C personality disorder: a randomized clinical trial. Eur J Psychotraumatol 2024; 15:2382652. [PMID: 39087734 DOI: 10.1080/20008066.2024.2382652] [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: 12/08/2023] [Revised: 03/15/2024] [Accepted: 07/12/2024] [Indexed: 08/02/2024] Open
Abstract
Background: Posttraumatic stress disorder (PTSD) is associated with high rates of cluster C personality disorders (PD), which may negatively affect PTSD treatment. It is unknown whether concurrent treatment for PTSD and comorbid PD leads to superior treatment effects, compared to standard trauma-focused treatment.Objective: The objective was to test the efficacy of adding personality disorder treatment (group schema therapy; GST) to individual trauma-focused treatment (imagery rescripting; ImRs).Method: A two-arm randomized clinical trial (1:1 allocation ratio) was conducted between 2018 and 2023 at two sites of a mental health institution in the Netherlands. Raters were blind to treatment allocation. Adult outpatients with PTSD and comorbid cluster C personality disorders were randomized to receive either ImRs (12-18 sessions) or ImRs + GST (12-18 ImRs + 52-58 GST). The main outcome was PTSD severity one year after start of treatment measured with the Clinician-Administered PTSD Scale for DSM-5.Results: Of 130 patients (mean [SD] age = 40.6 [11.2], 110 [85%] females), 66 were assigned to ImRs and 64 to ImRs + GST. At 12 months, there were large decreases in PTSD severity (dImRs = 2.42, 95%CI = 1.97-2.87; dImRs + GST = 2.44, 95%CI = 1.99-2.90), but there was no significant difference between conditions (d = 0.02, 95%CI = -0.33-0.36, p = .944). Reductions in personality disorder symptoms and all other secondary outcomes were observed in both conditions. There were no significant differences between conditions on any of the secondary outcomes at 12 months.Conclusion: The more intensive concurrent trauma-focused and personality disorder treatment (ImRs + GST) was not superior to trauma-focused treatment alone (ImRs) for patients with PTSD and comorbid CPD. This suggests that trauma-focused treatment is the preferred primary treatment in patients presenting with both internalizing personality disorder and PTSD, reserving the stepping up to more intensive psychotherapy aimed at the personality disorder as a second line of treatment.Trial registration: ClinicalTrials.gov identifier: NCT03833531.
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Affiliation(s)
- Arne van den End
- Psychiatry, Amsterdam UMC, Amsterdam, The Netherlands
- Sinai Centrum, Amstelveen, The Netherlands
| | | | - Jack Dekker
- Arkin Mental Health Care, Amsterdam, The Netherlands
- Clinical Psychology, VU University, Amsterdam, The Netherlands
| | - Inga Aarts
- Sinai Centrum, Amstelveen, The Netherlands
- Anatomy and Neurosciences, Amsterdam UMC, Amsterdam, The Netherlands
| | - Aishah Snoek
- Psychiatry, Amsterdam UMC, Amsterdam, The Netherlands
- Sinai Centrum, Amstelveen, The Netherlands
| | | | - Chris Vriend
- Psychiatry, Amsterdam UMC, Amsterdam, The Netherlands
- Anatomy and Neurosciences, Amsterdam UMC, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Compulsivity Impulsivity & Attention Program, Amsterdam, The Netherlands
| | - Odile A van den Heuvel
- Psychiatry, Amsterdam UMC, Amsterdam, The Netherlands
- Anatomy and Neurosciences, Amsterdam UMC, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Compulsivity Impulsivity & Attention Program, Amsterdam, The Netherlands
| | - Kathleen Thomaes
- Psychiatry, Amsterdam UMC, Amsterdam, The Netherlands
- Sinai Centrum, Amstelveen, The Netherlands
- Anatomy and Neurosciences, Amsterdam UMC, Amsterdam, The Netherlands
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Links PS, Aslam H, Brodeur J. Assessing and managing patients with borderline personality disorder requesting medical assistance in dying. Front Psychiatry 2024; 15:1364621. [PMID: 38919634 PMCID: PMC11196780 DOI: 10.3389/fpsyt.2024.1364621] [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: 01/02/2024] [Accepted: 06/03/2024] [Indexed: 06/27/2024] Open
Abstract
Background When physician assisted dying (referred to as Medical Assistance in Dying or MAiD in this article) is available for individuals with mental disorders as the sole underlying medical condition (MD-SUMC), patients with borderline personality disorder (BPD) frequently request MAiD. Psychiatrists and other clinicians must be prepared to evaluate and manage these requests. Objectives The purposes of this paper are to define when patients with BPD should be considered to have an irremediable, treatment resistant disorder and provide clinicians with an approach to assess and manage their patients with BPD making requests for MAiD. Methods This perspective paper developed the authors' viewpoint by using a published, authoritative definition of irremediability and including noteworthy systematic and/or meta-analytic reviews related to the assessment of irremediability. Results The clinician must be aware of the eligibility requirements for granting MAiD in their jurisdiction so that they can appropriately prepare themselves and their patients for the assessment process. The appraisal of the intolerability of the specific person's suffering comes from having an extensive dialogue with the patient; however, the assessment of whether the patient has irremediable BPD should be more objectively and reliably determined. A systematic approach to the assessment of irremediability of BPD is reviewed in the context of the disorder's severity, treatment resistance and irreversibility. Conclusion In addition to characterizing irremediability, this paper also addresses the evaluation and management of suicide risk for patients with BPD undergoing the MAiD assessment process.
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Affiliation(s)
- Paul S. Links
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada
| | - Hira Aslam
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Jonah Brodeur
- Department of Family Medicine, University of Toronto, Toronto, ON, Canada
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Blay M, Nicot P, Durpoix A, Leaune E, Poulet E, Ulm J, Perroud N. Evaluation of the level of training of French psychiatrists on borderline personality disorder: An online survey. L'ENCEPHALE 2024; 50:257-264. [PMID: 37604716 DOI: 10.1016/j.encep.2023.06.014] [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: 05/02/2023] [Revised: 06/04/2023] [Accepted: 06/08/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND Borderline personality disorder is a common and treatable personality disorder that is often underdiagnosed and untreated, mainly due to a lack of training of psychiatrists and to a lack of accessibility to specialized therapies. However, no study has been conducted in France regarding this issue. Thus, we aimed to evaluate on a national scale the level of training, knowledge, and general attitude toward BPD diagnosis of French psychiatrists. METHODS We conducted an online survey in an unselected population of residents and senior French psychiatrists between January and March 2022, the results of which are presented descriptively. RESULTS 228 psychiatrists fully answered the questionnaire, and 21 more psychiatrists answered it partially. We found that most of the responders were unsatisfied with the residency training or the continuing medical education offered regarding BPD, a lack of training resulting in a low level of self-confidence regarding BPD management, in a low number of evidence-based therapies trained psychiatrists in issues regarding diagnostic disclosure, and in misconceptions regarding some aspects of the disorder. CONCLUSIONS These results underlie a clear lack of training of French psychiatrists, as well as a request from the latter for more opportunities to learn. This calls for a rethinking of the teaching system to incorporate more knowledge and tools related to BPD.
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Affiliation(s)
- Martin Blay
- ADDIPSY, Addictology and Psychiatry Outpatient Center, Santé Basque Development group, Lyon, France.
| | - Pierre Nicot
- Université Claude Bernard Lyon 1, CNRS, INSERM, Centre de Recherche en Neurosciences de Lyon CRNL U1028 UMR5292, PSYR2, 69500 Bron, France
| | - Amaury Durpoix
- University Hospital of Strasbourg, Strasbourg, France; University of Strasbourg, Strasbourg, France
| | - Edouard Leaune
- Suicide Prevention Center, Vinatier Hospital Center, Bron, France; Université Claude Bernard Lyon 1, CNRS, INSERM, Centre de Recherche en Neurosciences de Lyon CRNL U1028 UMR5292, PSYR2, 69500 Bron, France
| | - Emmanuel Poulet
- Psychiatry Crisis Unit, Edouard Herriot Hospital, Lyon, France; Université Claude Bernard Lyon 1, CNRS, INSERM, Centre de Recherche en Neurosciences de Lyon CRNL U1028 UMR5292, PSYR2, 69500 Bron, France
| | - Justin Ulm
- Percy Army Instruction Hospital, Clamart, France; Val de Grâce School, Paris, France
| | - Nader Perroud
- Service of Psychiatric Specialties, Department of Mental Health and Psychiatry, University Hospitals of Geneva, Geneva, Switzerland; University of Geneva, Geneva, Switzerland
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Kujovic M, Benz D, Riesbeck M, Mollamehmetoglu D, Becker-Sadzio J, Margittai Z, Bahr C, Meisenzahl E. Comparison of 8-vs-12 weeks, adapted dialectical behavioral therapy (DBT) for borderline personality disorder in routine psychiatric inpatient treatment-A naturalistic study. Sci Rep 2024; 14:11264. [PMID: 38760498 PMCID: PMC11101618 DOI: 10.1038/s41598-024-61795-9] [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: 10/20/2023] [Accepted: 05/09/2024] [Indexed: 05/19/2024] Open
Abstract
Dialectical behavior therapy (DBT) is widely acknowledged as an effective treatment for individuals with borderline personality disorder (BPD). However, the optimal treatment duration within DBT remains a topic of investigation. This retrospective, naturalistic non-randomized study aimed to compare the efficacy of 8 week and 12 week DBT interventions with equivalent content, focusing on the change of BPD-specific symptomatology as the primary outcome and depressive symptoms as the secondary outcome. Overall, 175 patients who participated in DBT and received either 8 week or 12 week intervention were included in the analysis. Routine inpatient treatment was adapted from standard DBT with the modules: skill training, interpersonal skills, dealing with feelings, and mindfulness. Measurements were taken at baseline, mid-point, and endpoint. The borderline symptom list-23 (BSL-23) was used for the assessment of borderline-specific symptoms, while the Beck depression inventory-II (BDI-II) was used for the assessment of depressive symptoms. Statistical analysis was conducted using linear mixed models. Effect sizes were calculated for both measures. The results of the analysis indicated an improvement in both groups over time. Effect sizes were d = 1.29 for BSL-23 and d = 1.79 for BDI-II in the 8 week group, and d = 1.16 for BSL-23 and d = 1.58 for BDI-II in the 12 week group. However, there were no differences in the change of BPD-specific symptoms or the severity of depressive symptoms between the 8 week and 12 week treatment duration groups. Based on these findings, shorter treatment durations, like 8 weeks, could be a viable alternative, offering comparable therapeutic benefits, potential cost reduction, and improved accessibility. However, further research is needed to explore factors influencing treatment outcomes and evaluate the long-term effects of different treatment durations in DBT for BPD.Trial registration: drks.de (DRKS00030939) registered 19/12/2022.
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Affiliation(s)
- Milenko Kujovic
- Department of Psychiatry and Psychotherapy, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany.
| | - Daniel Benz
- Department of Psychiatry and Psychotherapy, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Mathias Riesbeck
- Department of Psychiatry and Psychotherapy, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Devin Mollamehmetoglu
- Department of Psychiatry and Psychotherapy, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Julia Becker-Sadzio
- University Hospital for Psychiatry and Psychotherapy, Neurophysiology & Interventional Neuropsychiatry, Tübingen Center for Mental Health, University Hospital Tübingen, Tübingen, Germany
| | - Zsofia Margittai
- Department of Psychiatry and Psychotherapy, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Christian Bahr
- Department of Psychiatry and Psychotherapy, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Eva Meisenzahl
- Department of Psychiatry and Psychotherapy, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
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Luyten P, Campbell C, Moser M, Fonagy P. The role of mentalizing in psychological interventions in adults: Systematic review and recommendations for future research. Clin Psychol Rev 2024; 108:102380. [PMID: 38262188 DOI: 10.1016/j.cpr.2024.102380] [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: 03/08/2023] [Revised: 12/20/2023] [Accepted: 01/05/2024] [Indexed: 01/25/2024]
Abstract
Mentalizing is the human capacity to understand actions of others and one's own behavior in terms of intentional mental states, such as feelings, wishes, goals and desires. Mentalizing is a transtheoretical and transdiagnostic concept that has been applied to understanding vulnerability to psychopathology and has attracted considerable research attention over the past decades. This paper reports on a pre-registered systematic review of evidence concerning the role of mentalizing as a moderator and mediator in psychological interventions in adults. Studies in adults were reviewed that address the following questions: (a) does pre-treatment mentalizing predict treatment outcome; (b) do changes in mentalizing across treatment predict outcome; (c) does adherence to the principles or protocol of mentalization-based treatment predict outcome; and (d) does strengthening in-session mentalizing impact the therapeutic process via improved alliance, alleviated symptoms, or improved interpersonal functioning? Results suggest that mentalizing might be a mediator of change in psychotherapy and may moderate treatment outcome. However, the relatively small number of studies (n = 33 papers based on 29 studies, totaling 3124 participants) that could be included in this review, and the heterogeneity of studies in terms of design, measures used, disorders included, and treatment modalities, precluded a formal meta-analysis and limited the ability to draw strong conclusions. Therefore, theoretical and methodological recommendations for future research to improve the quality of existing research in this area are formulated.
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Affiliation(s)
- Patrick Luyten
- Faculty of Psychology and Educational Sciences, KU Leuven, Tiensestraat 102, Pobox 3722, Leuven 3000, Belgium; Research Department of Clinical, Educational and Health Psychology, University College London, 1-19 Torrington Place, London WC1E 7HB, UK.
| | - Chloe Campbell
- Research Department of Clinical, Educational and Health Psychology, University College London, 1-19 Torrington Place, London WC1E 7HB, UK
| | - Max Moser
- Research Department of Clinical, Educational and Health Psychology, University College London, 1-19 Torrington Place, London WC1E 7HB, UK
| | - Peter Fonagy
- Research Department of Clinical, Educational and Health Psychology, University College London, 1-19 Torrington Place, London WC1E 7HB, 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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Hultsjö S, Appelfeldt Å, Wärdig R, Cederqvist J. Don´t set us aside!Experiences of families of people with BPD who have access to Brief admission:a phenomenological perspective. Int J Qual Stud Health Well-being 2023; 18:2152943. [PMID: 36476045 PMCID: PMC9733683 DOI: 10.1080/17482631.2022.2152943] [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: 12/12/2022] Open
Abstract
AIM To highlight the experiences of family members of people with borderline personality disorder (BPD) and self-harming behaviour who have access to brief admission. METHODS To understand the families lived experience a phenomenological lifeworld perspective was adopted to this study. Twelve in-depht interviews were performed in November and December 2021 with family members of people with BPD and self-harming behaviour who have accessed BA. The phenomenological life-world perspective guided the analysis. RESULTS Families' life-world was characterized by anxiety and constant protection of their loved one. They live with constant fear of how their loved ones are feeling and whether they will injure themselves. When access to BA was available this gave hope and provided conditions for families to maintain everyday routines and also enhanced relationships among family members. When families' loved ones were denied BA, they felt betrayed which contributed to negative feelings towards the medical profession, and the families lost confidence in psychiatry. CONCLUSION By interviewing families of people with BPD and self-harming behaviour who had access to BA, it emerged they possess valuable knowledge. BA can be developed if the needs of families are taken into consideration, and if families are given the opportunity to share emotions and the high burden of responsibility with staff or families in similar situations. If health care staff gives family members a more central role in care and makes their shared life-world visible it could thereby hopefully increase well-being and benefits for the whole family.
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Affiliation(s)
- Sally Hultsjö
- Department of Psychiatry, Ryhov County Hospital. Jönköping, Sweden and Department of Health, Medicine and Caring Sciences. Division of Nursing and Reproductive Health, Linköping University, Linköping, Sweden,CONTACT Sally Hultsjö House N2, Department of Psychiatry, Ryhov County Hospital. 551 85 Jönköping, Sweden
| | - Åsa Appelfeldt
- Department of Psychiatry, Ryhov County Hospital. Jönköping, Sweden and Department of Health, Medicine and Caring Sciences. Division of Nursing and Reproductive Health, Linköping University, Linköping, Sweden
| | - Rikard Wärdig
- Department of Health, Medicine and Caring Sciences. Division of Nursing and Reproductive Health, Linköping University, Linköping, Sweden
| | - Jessica Cederqvist
- Department of Psychiatry, Ryhov County Hospital. Jönköping, Sweden and Department of Health, Medicine and Caring Sciences. Division of Nursing and Reproductive Health, Linköping University, Linköping, Sweden
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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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Blay M, Cohen S, Jan M, Perroud N, Speranza M, Charbon P. [Towards a pragmatic cohabitation of theoretical and clinical models: The example of "Good Psychiatric Management" in the treatment of borderline personality disorder]. L'ENCEPHALE 2023:S0013-7006(23)00042-8. [PMID: 37088579 DOI: 10.1016/j.encep.2023.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 01/16/2023] [Accepted: 01/31/2023] [Indexed: 04/25/2023]
Abstract
Borderline personality disorder (BPD) is a common disorder in general and clinical populations and is related to potentially severe medical and socio-professional consequences. Treatment of BPD is based on evidence-based psychotherapies (such as Dialectical Behavioral Therapy, Mentalization-Based Therapy, Schema-Focused Therapy or Transference Focused Psychotherapy), which have been shown effective but are poorly available in France. Pharmacological treatments, which are more easily available, are not effective in treating symptoms of the disorder but can be useful in management of comorbidities. In this context, recently called "generalist" models have been developed, which every well-trained psychiatrist can implement in their daily practice, combining practical elements from evidence-based psychotherapies and elements of pharmacological management of symptoms and comorbidities. The purpose of this article is to present one of these models, the Good Psychiatric Management (GPM) and its basic principles and its applications, and to provide one of the first French-speaking resources about this model. In addition, beyond the practical elements proposed by the GPM, we discuss the deeper question that it raises, namely the question of a pragmatic integration of different theoretical and clinical models. Indeed, the treatment of BPD patients is at the junction of different conceptualizations of mental pathology (psychopathological, neurobiological) and different modalities of practice (psychotherapy, biological psychiatry). In a French context, that sometimes separates these two models, and in our opinion GPM constitutes an example of clinical collaboration which shows the interest of the combined role of psychiatrist-psychotherapist.
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Affiliation(s)
- Martin Blay
- ADDIPSY, Centre ambulatoire d'addictologie et de psychiatrie, Groupe santé basque développement, 164, avenue Jean-Jaurès, 69007 Lyon, France; Université Claude-Bernard Lyon 1, Lyon, France.
| | - Satchel Cohen
- Centre hospitalier de Versailles, Service universitaire de psychiatrie de l'enfant et de l'adolescent, Le Chesnay, France
| | - Marlène Jan
- Centre hospitalier de Versailles, Service universitaire de psychiatrie de l'enfant et de l'adolescent, Le Chesnay, France
| | - Nader Perroud
- Service des spécialités psychiatriques, Département de psychiatrie, Hôpitaux universitaires de Genève, Genève, Suisse; Département de psychiatrie, Université de Genève, Genève, Suisse
| | - Mario Speranza
- Centre hospitalier de Versailles, Service universitaire de psychiatrie de l'enfant et de l'adolescent, Le Chesnay, France; Université Paris-Saclay, UVSQ, Inserm, Centre de recherche en épidémiologie et santé des populations Team "DevPsy", 94807 Villejuif, France
| | - Patrick Charbon
- Service des spécialités psychiatriques, Département de psychiatrie, Hôpitaux universitaires de Genève, Genève, Suisse; Cabinet de groupe « D'un Monde à l'Autre », Lausanne, Suisse
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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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11
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Arntz A, Mensink K, Cox WR, Verhoef REJ, van Emmerik AAP, Rameckers SA, Badenbach T, Grasman RPPP. Dropout from psychological treatment for borderline personality disorder: a multilevel survival meta-analysis. Psychol Med 2023; 53:668-686. [PMID: 36453183 PMCID: PMC9975988 DOI: 10.1017/s0033291722003634] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 10/28/2022] [Accepted: 11/02/2022] [Indexed: 12/05/2022]
Abstract
BACKGROUND Dropout from psychotherapy for borderline personality disorder (BPD) is a notorious problem. We investigated whether treatment, treatment format, treatment setting, substance use exclusion criteria, proportion males, mean age, country, and other variables influenced dropout. METHODS From Pubmed, Embase, Cochrane, Psycinfo and other sources, 111 studies (159 treatment arms, N = 9100) of psychotherapy for non-forensic adult patients with BPD were included. Dropout per quarter during one year of treatment was analyzed on participant level with multilevel survival analysis, to deal with multiple predictors, nonconstant dropout chance over time, and censored data. Multiple imputation was used to estimate quarter of drop-out if unreported. Sensitivity analyses were done by excluding DBT-arms with deviating push-out rules. RESULTS Dropout was highest in the first quarter of treatment. Schema therapy had the lowest dropout overall, and mentalization-based treatment in the first two quarters. Community treatment by experts had the highest dropout. Moreover, individual therapy had lowest dropout, group therapy highest, with combined formats in-between. Other variables such as age or substance-use exclusion criteria were not associated with dropout. CONCLUSION The findings do not support claims that all treatments are equal, and indicate that efforts to reduce dropout should focus on early stages of treatment and on group treatment.
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Affiliation(s)
- Arnoud Arntz
- Department of Clinical Psychology, University of Amsterdam, Amsterdam, The Netherlands
| | - Kyra Mensink
- Department of Clinical Psychology, University of Amsterdam, Amsterdam, The Netherlands
| | - Wouter R. Cox
- Department of Clinical Psychology, University of Amsterdam, Amsterdam, The Netherlands
| | - Rogier E. J. Verhoef
- Department of Clinical Psychology, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Sophie A. Rameckers
- Department of Clinical Psychology, University of Amsterdam, Amsterdam, The Netherlands
| | - Theresa Badenbach
- Department of Clinical Psychology, University of Amsterdam, Amsterdam, The Netherlands
| | - Raoul P. P. P. Grasman
- Department of Psychological Methods, University of Amsterdam, Amsterdam, The Netherlands
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12
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Simonsen S, Hestbæk E, Juul S. Adapting Short-Term Mentalization-Based Therapy to ICD-11 Personality Disorder in Adolescents. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10010093. [PMID: 36670644 PMCID: PMC9857296 DOI: 10.3390/children10010093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 12/23/2022] [Accepted: 12/24/2022] [Indexed: 01/15/2023]
Abstract
Following the introduction of the 11th revision of the International Classification of Diseases (ICD-11), adolescents can now be diagnosed with a personality disorder based on severity ranging from mild to moderate to severe. This dimensional model has potential implications for treatment, as it allows clinicians and researchers to search for effective treatments targeting adolescents at different severity levels rather than offering all patients the same treatment. In this conceptual paper, we propose that the short-term mentalization-based therapy (MBT) program, originally developed to treat adults with borderline personality disorder (BPD), has potential clinical advantages for adolescents with ICD-11 personality disorder at the mild to moderate severity level. The short-term MBT program is a 5-month structured treatment approach including individual therapy, combined psychotherapy with the individual therapist also being one of the group therapists, and closed-group therapy to enhance cohesion and a feeling of security. The purpose of this paper is to make a case for the use of this format, as opposed to the traditional long-term MBT format, for adolescents with BPD. Future research should include large-scale randomized clinical trials powered to assess patient-important outcomes.
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Affiliation(s)
- Sebastian Simonsen
- Stolpegaard Psychotherapy Centre, Mental Health Services in the Capital Region of Denmark, 2820 Gentofte, Denmark
- Correspondence:
| | - Emilie Hestbæk
- Stolpegaard Psychotherapy Centre, Mental Health Services in the Capital Region of Denmark, 2820 Gentofte, Denmark
| | - Sophie Juul
- Stolpegaard Psychotherapy Centre, Mental Health Services in the Capital Region of Denmark, 2820 Gentofte, Denmark
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region of Denmark, Copenhagen University Hospital–Rigshospitalet, 2820 Copenhagen, Denmark
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13
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Vuijk R, Deen M, Geurts HM, Arntz A. Schema therapy for personality disorders in autistic adults: Results of a multiple case series study. Clin Psychol Psychother 2022; 30:458-472. [PMID: 36522138 DOI: 10.1002/cpp.2817] [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: 08/30/2022] [Revised: 11/16/2022] [Accepted: 12/09/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND To our knowledge, treatment of personality disorder (PD) comorbidity in autistic adults is understudied and is still in its infancy. We investigated the effectiveness of schema therapy (ST) for autistic adults with PD. METHOD A multiple case series design with 12 adults (aged 19-62 years) was used with baseline, exploration, ST (with cognitive behavioural and experiential techniques) and follow-up conditions. Participants rated dysfunctional core beliefs (primary outcome) weekly during baseline and treatment and monthly during follow-up. Schema modes, general mental health symptoms, social responsiveness, PD traits and common Axis-I mental disorders were assessed. RESULTS Mixed model analyses indicated significant effects of ST with medium to large effect sizes for dysfunctional core beliefs, functional schema modes, PD traits, general mental health symptoms and social responsiveness. Results remained stable during follow-up. CONCLUSION The results of this study indicate that ST might be effective in decreasing dysfunctional core beliefs, PD traits and general mental health symptoms and in increasing functional schema modes and social responsiveness. Improvements persisted over time. ST seems effective in treating PD in autistic individuals.
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Affiliation(s)
- Richard Vuijk
- Sarr Autism Rotterdam (Parnassia Psychiatric Institute), Rotterdam, The Netherlands
| | - Mathijs Deen
- Parnassia Psychiatric Institute, The Hague, The Netherlands.,Institute of Psychology, Methodology and Statistics Unit, Leiden University, Leiden, The Netherlands
| | - Hilde M Geurts
- University of Amsterdam, Amsterdam, The Netherlands.,Leo Kanner Huis (Youz; Parnassia Psychiatric Institute), Amsterdam, The Netherlands
| | - Arnoud Arntz
- University of Amsterdam, Amsterdam, The Netherlands
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14
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Fung HW, Ross CA, Lam SKK, Hung SL. Recent research on the interventions for people with dissociation. EUROPEAN JOURNAL OF TRAUMA & DISSOCIATION 2022. [DOI: 10.1016/j.ejtd.2022.100299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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15
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Stoffers-Winterling JM, Storebø OJ, Simonsen E, Sedoc Jørgensen M, Pereira Ribeiro J, Kongerslev MT, Lieb K. Perspectives on Dialectical Behavior Therapy and Mentalization-Based Therapy for Borderline Personality Disorder: Same, Different, Complementary? Psychol Res Behav Manag 2022; 15:3179-3189. [PMID: 36329713 PMCID: PMC9624210 DOI: 10.2147/prbm.s342257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 09/11/2022] [Indexed: 11/16/2022] Open
Abstract
Current evidence suggests that individuals with borderline personality disorder (BPD) are likely to benefit from specialized, or BPD-specific, treatments. Dialectical behavior therapy (DBT) and mentalization-based treatment (MBT) are currently the most intensively researched BPD treatments. Reviewing the current research, this paper highlights similarities and differences between the two treatments, and discusses possible ways they could complement each other. As the effectiveness of specialized treatments for BPD in general has been determined with some certainty, research now tends towards individualized approaches, identifying predictors of optimal treatment response. However, it is still to be settled who might profit from a combination of or sequential treatment with DBT and MBT.
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Affiliation(s)
- Jutta M Stoffers-Winterling
- Department of Psychiatry and Psychotherapy, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Ole Jakob Storebø
- Psychiatric Research Unit, Psychiatry Region Zealand, Slagelse, Denmark,Department of Psychology, University of Southern Denmark, Odense, Denmark,Correspondence: Ole Jakob Storebø, Psychiatric Research Unit, Psychiatry Region Zealand, Fælledvej 6, Slagelse, 4200, Denmark, Tel +45 24965917, Email
| | - Erik Simonsen
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark,Mental Health Services East, Psychiatry Region Zealand, Roskilde, Denmark
| | | | - Johanne Pereira Ribeiro
- Psychiatric Research Unit, Psychiatry Region Zealand, Slagelse, Denmark,Department of Psychology, University of Southern Denmark, Odense, Denmark
| | - Mickey T Kongerslev
- Psychiatric Research Unit, Psychiatry Region Zealand, Slagelse, Denmark,Department of Psychology, University of Southern Denmark, Odense, Denmark,Mental Health Services East, Psychiatry Region Zealand, Roskilde, Denmark
| | - Klaus Lieb
- Department of Psychiatry and Psychotherapy, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
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16
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Wu Y, Zheng Y, Wang J, Zhang T. Specific type of childhood trauma and borderline personality disorder in Chinese patients. Front Psychiatry 2022; 13:936739. [PMID: 35958646 PMCID: PMC9360314 DOI: 10.3389/fpsyt.2022.936739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 06/27/2022] [Indexed: 11/30/2022] Open
Abstract
Background Childhood maltreatment (CM) is a known risk factor for the development of mental disorders. An extensive body of literature about CM and mental health has been developed in wealthy countries, but information about this connection is lacking in developing countries including China. Aims To explore the possible relationship between specific types of CM and borderline personality disorder (BPD) in patients with mental disorders in China. Methods A survey was conducted in 2006, involving over 3,402 Chinese individuals aged 18-60 years who were randomly selected from the outpatients in the Shanghai Mental Health Center. The patients were screened with the Personality Diagnostic Questionnaire and CM was assessed using the Childhood Trauma Questionnaire. The final sample comprised 178 patients with BPD, 178 patients with other personality disorders (PDs), and 178 patients without PDs. Results In Chinese patients, compared to other PDs, patients with BPDs are more likely to have experienced CM. Emotional maltreatment (emotional abuse and neglect) was the strongest predictor of BPD. Female gender and sexual abuse are significant predictors of the self-harm/suicidal risk of BPD patients. Conclusion This is a pioneering study conducted on a large set of Chinese clinical samples with paired controls to establish and compare the associations between specific CM and BPD. Further studies in this field are necessary to elucidate the mechanism of how various types of childhood trauma have influenced PDs.
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Affiliation(s)
| | | | - Jijun Wang
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Tianhong Zhang
- Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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17
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Snacken S, Devynck C, Uzieblo K. Dignity, Social Reintegration of Prisoners, and the New Penal Power: European Human Rights, Experiences of Belgian Prisoners, and Professional Practices. INTERNATIONAL JOURNAL OF OFFENDER THERAPY AND COMPARATIVE CRIMINOLOGY 2022; 66:980-1000. [PMID: 35583110 DOI: 10.1177/0306624x221099489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Over the last 30 years, prisoners' dignity and fundamental rights have increasingly been protected by European human rights bodies such as the European Court of Human Rights and the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment. This protection is aimed particularly at the traditional power relations between prisoners and uniformed staff. More recently, social reintegration of prisoners has also been recognized by these European human rights standards as a fundamental element of human dignity and an equally important aim of imprisonment as retribution and deterrence. However, it is also accepted that some offenders may be too dangerous to be returned back to society. Psychiatric/psychological assessments are a major element in this decision-making. This "new penal power" receives much less attention in human rights protection. This article compares three intertwining perspectives on this issue: the European human rights perspective on dignity and social reintegration; the experiences and mental suffering of Belgian prisoners who find themselves being stuck in prison as a result of structural problems in the risk assessment and risk management practices; and the professional perspective on how professional standards and good practices based on scientific insights might alleviate some of these threats to human dignity.
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Affiliation(s)
- Sonja Snacken
- Department of Criminology, Vrije Universiteit Brussel, Belgium
| | | | - Kasia Uzieblo
- Department of Criminology, Vrije Universiteit Brussel, Belgium
- The Forensic Care Specialists, Utrecht, The Netherlands
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18
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Chanen AM, Betts JK, Jackson H. Further Considerations on Early Intervention for Borderline Personality Disorder-Reply. JAMA Psychiatry 2022; 79:631-632. [PMID: 35385056 DOI: 10.1001/jamapsychiatry.2022.0485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Andrew M Chanen
- Orygen, Melbourne, Australia.,Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia
| | - Jennifer K Betts
- Orygen, Melbourne, Australia.,Centre for Youth Mental Health, The University of Melbourne, Melbourne, Australia
| | - Henry Jackson
- Melbourne School of Psychological Sciences, The University of Melbourne, Melbourne, Australia
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19
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Krause-Utz A. Dissociation, trauma, and borderline personality disorder. Borderline Personal Disord Emot Dysregul 2022; 9:14. [PMID: 35440020 PMCID: PMC9020027 DOI: 10.1186/s40479-022-00184-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 04/01/2022] [Indexed: 11/10/2022] Open
Abstract
Dissociation is a complex phenomenon, which occurs in various clinical conditions, including dissociative disorders, (complex) post-traumatic stress disorder (CPTSD, PTSD), and borderline personality disorder (BPD). Traumatic stress is considered an important risk factor, while the etiology of dissociation is still debated. Next to traumatic experiences, temperamental and neurobiological vulnerabilities seem to contribute to the development of dissociation. Stress-related dissociation is a prevalent symptom of BPD, which may interfere with psychosocial functioning and treatment outcome. More research in the field is strongly needed to improve the understanding and management of this complex phenomenon. This article collection brings together research on dissociation and trauma, with a special focus on BPD or sub-clinical expressions of BPD. In this editorial, recent conceptualizations of dissociation and relevant previous research are introduced in order to provide a framework for this novel research.
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Affiliation(s)
- Annegret Krause-Utz
- Department of Clinical Psychology, Institute of Psychology, Leiden University, Leiden, The Netherlands. .,Leiden Institute for Brain and Cognition, Leiden University, Leiden, The Netherlands.
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20
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De Hert M, Loos S, Sterckx S, Thys E, Van Assche K. Improving control over euthanasia of persons with psychiatric illness: Lessons from the first Belgian criminal court case concerning euthanasia. Front Psychiatry 2022; 13:933748. [PMID: 35928783 PMCID: PMC9343580 DOI: 10.3389/fpsyt.2022.933748] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 06/30/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Belgium is one of very few countries that legally allow euthanasia for suffering caused by psychiatric illness. In the first criminal trial in Belgium of physicians involved in euthanasia, three physicians recently faced the accusation of "murder by poisoning," for allegedly having failed to comply with several requirements of the Belgian Euthanasia Law in granting the euthanasia request a woman suffering from psychiatric illness. Although all three physicians were acquitted, the case generated much debate among policy makers, medical professionals, and the general public. METHOD We use this trial as the starting point for a critical analysis of the adequacy of the three-level control system established in the Euthanasia Law, as it is applied in the evaluation of euthanasia requests from persons who suffer unbearably from a psychiatric illness. This analysis is based on information presented during the criminal trial as well as information on the euthanasia that was published in the press. RESULTS Our analysis highlights substantial problems in the assessment and granting of the euthanasia request. The patient was euthanized without it having been substantiated that her psychiatric illness had no prospect of improvement and that her suffering could not be alleviated. The three-step control system enshrined in the Law and promoted by the Federal Control and Evaluation Commission for Euthanasia appears to have failed at each level. CONCLUSION To evaluate requests for euthanasia for mental suffering caused by psychiatric illness, the requirements of the Belgian Euthanasia Law should be complemented by mandating the advice of two psychiatrists, and face-to-face discussions between all physicians involved. In parallel with the process of evaluating the euthanasia request, a treatment track should be guaranteed where reasonable evidence-based treatments and recovery-oriented options are tried.
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Affiliation(s)
- Marc De Hert
- University Psychiatric Centre, Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Neurosciences, Centre for Clinical Psychiatry, Katholieke Universiteit Leuven, Leuven, Belgium.,Leuven Brain Institute, Katholieke Universiteit Leuven, Leuven, Belgium.,Antwerp Health Law and Ethics Chair, University of Antwerp, Antwerp, Belgium
| | - Sien Loos
- Research Group Personal Rights and Property Rights, Faculty of Law, University of Antwerp, Antwerp, Belgium.,Leuven Institute for Healthcare Policy, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Sigrid Sterckx
- Bioethics Institute Ghent, Department of Philosophy and Moral Sciences, Ghent University, Ghent, Belgium
| | - Erik Thys
- University Psychiatric Centre, Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Neurosciences, Centre for Clinical Psychiatry, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Kristof Van Assche
- Antwerp Health Law and Ethics Chair, University of Antwerp, Antwerp, Belgium.,Research Group Personal Rights and Property Rights, Faculty of Law, University of Antwerp, Antwerp, Belgium
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