Integrating empirically supported therapies for treating personality disorders: a synthesis of psychodynamic and cognitive-behavioral group treatments

Abstract This paper describes the theoretical foundations and components of an intensive group treatment program for individuals diagnosed with personality disorders. The Chrysalis Community Day Treatment Program integrates aspects of three empirically supported therapies: Transference-Focused Psychotherapy and Mentalization-Based Therapy, both psychodynamic psychotherapies, and Dialectical Behavior Therapy, a cognitive-behavioral therapy. Each of these modalities is structured for the treatment of individuals suffering from the symptoms of borderline personality disorder, and each of the treatments addresses problems that occur across a wide spectra of beliefs, capacities, and behaviors. The program is comprised of expressive, psycho-educational and skills-training groups, and participants attend three days per week, for 15 weeks. Preliminary evaluation is promising, reflecting decreases in self-injurious behavior, suicide attempts, psychiatric hospitalizations, and psychiatric symptoms at a one-year follow-up.     

Effectiveness of inpatient dialectical behavioral therapy for borderline personality disorder: a controlled trial

Dialectical Behavioral Therapy (DBT) was initially developed and evaluated as an outpatient treatment program for chronically suicidal individuals meeting criteria for borderline personality disorder (BPD). Within the last few years, several adaptations to specific settings have been developed. This study aims to evaluate a three-month DBT inpatient treatment program. Clinical outcomes, including changes on measures of psychopathology and frequency of self-mutilating acts, were assessed for 50 female patients meeting criteria for BPD. Thirty-one patients had participated in a DBT inpatient program, and 19 patients had been placed on a waiting list and received treatment as usual in the community. Post-testing was conducted four months after the initial assessment (i.e. four weeks after discharge for the DBT group). Pre-post-comparison showed significant changes for the DBT group on 10 of 11 psychopathological variables and significant reductions in self-injurious behavior. The waiting list group did not show any significant changes at the four-months point. The DBT group improved significantly more than participants on the waiting list on seven of the nine variables analyzed, including depression, anxiety, interpersonal functioning, social adjustment, global psychopathology and self-mutilation. Analyses based on Jacobson's criteria for clinically relevant change indicated that 42% of those receiving DBT had clinically recovered on a general measure of psychopathology. The data suggest that three months of inpatient DBT treatment is significantly superior to non-specific outpatient treatment. Within a relatively short time frame, improvement was found across a broad range of psychopathological features. Stability of the recovery after one month following discharge, however, was not evaluated and requires further study.     

A Psychodynamic Treatment for Severe Personality Disorders: Issues in Treatment Development

We describe a psychodynamic treatment modified for patients with severe personality disorders identified as borderline personality disorder in DSM-IV, Axis II, and understood as borderline personality organization from a psychoanalytic perspective. This treatment is labeled transference-focused psychotherapy (TFP) in order to highlight the centrality of working with these patients in the here-and-now treatment interaction. The empirical development of TFP is described, including the generation of a treatment manual, the utility of various methods to teach the treatment, and preliminary data on efficacy. The latest step in the development of this treatment is an ongoing randomized clinical trial comparing the efficacy of TFP to a cognitive-behavioral and a supportive treatment.     

My subdued ego: A psychodynamic case study of borderline personality disorder following relational trauma

Recent advances in the conceptualisation of borderline personality disorder (BPD) have highlighted the role of relational trauma as central to the onset of the disorder, whilst observing deficits in the structure of the self-concept as a result of developmental adversity. Understanding borderline states within a psychiatric framework alone has attracted significant criticism due to the lack of the medical model’s explanatory properties, which fail to account for the complexity and variation of borderline symptomatology. A reliance on psychodynamic formulation instead, can provide an aetiological framework where BPD can be understood as a disorder of the sense of self, originating in the client’s relational matrix. The purpose of the current paper is to discuss a borderline case study with a focus on formulation rather than diagnosis, in an attempt to shed light on the relational and unconscious processes underpinning the disorder and thus inform treatment interventions.     

The role of emotion reactivity and gender in the relationship between psychopathology and self-injurious behavior

The goal of the present study was to examine emotion reactivity, a broad construct that consists of an individual’s sensitivity, intensity, and persistence of emotional reactions, as a mediator of the relationship between two types of psychopathology (depression symptoms and borderline personality disorder (BPD) symptoms) and history of self-injurious behavior (non-suicidal self-injury (NSSI) and suicide attempts (SA)). We also examined gender as a potential moderator of this relationship. Participants (N = 1914) completed measures of emotion reactivity, psychopathology, and self-injurious behavior. Results using a series of mediated path analyses indicated that emotion reactivity mediated the relationship between (1) depressive symptoms and NSSI in females only, (2) depressive symptoms and SA in females only, and (3) probable BPD diagnosis and NSSI in both genders. Emotion reactivity did not mediate the relationship between probable BPD diagnosis and SA in either gender. Our findings suggest that emotion reactivity is a possible pathway through which depression and self-injurious behavior relate, especially in women. We temper these findings, however, within the context of relatively modest observed effects.     

Transference Focused Psychotherapy for Patients with Comorbid Narcissistic and Borderline Personality Disorder

Clinical experience involving the treatment of patients with comorbid borderline and narcissistic personality disorders suggests that this patient population is among the more difficult to treat within the personality disorder spectrum. In this article, we present refinements of Transference Focused Psychotherapy (TFP) based on our clinical experience with and research data on patients with comorbid narcissistic personality disorder/borderline personality disorder (NPD/BPD). We briefly review object relations formulations of severe narcissistic pathology, as well as recent research in attachment and the allied concept of mentalization, which have provided a new lens through which to view narcissistic disorders. The research findings from two randomized clinical trials demonstrating the efficacy and effectiveness of TFP are presented. The data from the two Randomized Clinical Trials (RCT) allowed for the study of the characteristics of the subgroup of borderline personality disorder patients who have comorbid NPD/BPD. Findings on comorbidity, attachment status, capacity for mentalization, and level of personality organization of borderline patients with comorbid NPD/BPD, compared with borderline patients without comorbid narcissistic pathology (BPD), are presented. Clinical implications of the observed group differences are discussed, with a focus on refinements in the technique of TFP. Clinical case material is presented to illustrate the specific challenges posed by narcissistic patients to carrying out TFP in each phase of treatment.     

Brief Communications

Abstract

This paper describes the theoretical foundations and components of an intensive group treatment program for individuals diagnosed with personality disorders. The Chrysalis Community Day Treatment Program integrates aspects of three empirically supported therapies: Transference-Focused Psychotherapy and Mentalization-Based Therapy, both psychodynamic psychotherapies, and Dialectical Behavior Therapy, a cognitive-behavioral therapy. Each of these modalities is structured for the treatment of individuals suffering from the symptoms of borderline personality disorder, and each of the treatments addresses problems that occur across a wide spectra of beliefs, capacities, and behaviors. The program is comprised of expressive, psycho-educational and skills-training groups, and participants attend three days per week, for 15 weeks. Preliminary evaluation is promising, reflecting decreases in self-injurious behavior, suicide attempts, psychiatric hospitalizations, and psychiatric symptoms at a one-year follow-up.     

Changes in schemas of patients with severe borderline personality disorder: The Oulu BPD study

Borderline personality disorder (BPD) is a relatively common and severe psychiatric disorder that can impair quality of life in many ways. The aim of this study was to determine whether a combined treatment model for BPD patients, utilising major principles from schema‐focused therapy (SFT) and dialectical behavioral therapy (DBT), could be more effective in relieving early maladaptive schemas of BPD patients, compared to treatment as usual (TAU). This study is a part of the Oulu BPD study conducted at mental health care services run by Oulu city social and health care services. The study is a multisite, randomized controlled trial conducted over a one year period, involving two groups of patients with severe BPD: (1) Community Treatment By Experts (CTBE) patients (n = 18) receiving the combined treatment model, and 2) TAU patients (n = 27). The patients' schemas were assessed using the Young Schema Questionnaire (YSQ‐L3a) before and after one year of treatment. The results reveal that CTBE patients who attended the combined treatment model showed a statistically significant reduction in eight out of 18 early maladaptive schemas, while patients receiving treatment as usual did not demonstrate any significant changes in schemas. The cognitive therapeutic treatment model can be applied for clinical use in public mental health settings using existing professionals, and appears to produce positive changes in patients with BPD.     

The effectiveness of dialectical behaviour therapy in routine public mental health settings: An Australian controlled trial

Randomised controlled studies in research environments have demonstrated dialectical behaviour therapy (DBT) to be more efficacious than treatment as usual in reducing suicidal behaviour in patients with borderline personality disorder (BPD). Limited evidence exists for the effectiveness of DBT in the treatment of BPD within routine clinical settings. This study examines the clinical and cost effectiveness of providing DBT over treatment as usual in a routine Australian public mental health service. Forty-three adult patients with BPD were provided with outpatient DBT for six months with patient outcomes compared to those obtained from patients in a wait list group receiving treatment as usual (TAU) from the same service. After six months of treatment the DBT group showed significantly greater reductions in suicidal/non-suicidal self-injury, emergency department visits, psychiatric admissions and bed days. Self-report measures were administered to a reduced sample of patients. With this group, DBT patients demonstrated significantly improved depression, anxiety and general symptom severity scores compared to TAU at six months. Average treatment costs were significantly lower for those patients in DBT than those receiving TAU. Therapists who received intensive DBT training were shown to produce significantly greater improvements in patients’ suicidal and non-suicidal self-injury than therapists who received only 4 day basic training. Further clinical improvements were achieved in patients offered an additional six months of DBT. This study demonstrates that providing DBT to patients within routine public mental health settings can be both clinically effective and cost effective.     

Prospective predictors of suicide attempts in borderline personality disorder at one, two, and two-to-five year follow-up

Efforts to identify reliable predictors of suicidal behavior in Borderline Personality Disorder have been confounded by the marked dimensional heterogeneity of the disorder, frequent comorbidity with other high risk disorders, debilitating social and vocational consequences of BPD over time. Using survival analyses, we assessed the predictive association between risk factors in each of these symptom domains and suicide attempts in BPD subjects followed for 12 months, 18-24 months and 2-5 years. The suicide attempt rate was 19% in the first year, 24.8% through the second year. The risk of suicidal behavior among 137 BPD subjects completing the first 12 months was increased by comorbid MDD and poor social adjustment. Outpatient treatment decreased short-term risk. Among 133 subjects completing 18-24 months in the study, the relative risk of a suicide attempt was increased by hospitalization (prior to any attempt), and poor social adjustment. Among 122 subjects followed for 2-5 years, increased risk was associated with hospitalization and medication visits (prior to any attempt), an attempt in the first year, and a low GAS score at baseline. Long term risk was decreased by "any outpatient treatment." Predictors of suicidal behavior in BPD change over time. MDD has a short-term effect on suicide risk, while poor social adjustment may increase risk throughout each follow-up interval. Assessing and supporting family, work, and social relationships may decrease suicidal behavior in BPD, and should be a principal focus of long-term treatment.     

Religious Conversion in a Psychotic Individual

The authors describe the case of a man who appeared to have psychotic symptoms, including self-injurious behavior, but who understood his own experience as a religious conversion. The symptoms, clinical course, and treatment response are described with reference to the works of Kurt Schneider and William James. Empirical studies of the attitudes of psychiatrists, psychiatric patients, and clergypersons about the relationship between religious belief and psychiatric illness are described, and various theoretical models used to understand this relationship are articulated.     

Schizophrene Patienten der forensischen Psychiatrie im Vergleich zu schizophrenen Patienten der Allgemeinpsychiatrie

Background

The number of schizophrenic patients admitted to forensic hospitals according to section 63 of the German Criminal Code has increased continuously over the past years. Some researchers assume that these forensic patients form a group of patients with very complex mental disorders, a number of risk factors and insufficient pretreatment in general psychiatry. This study aimed to identify differences regarding the history of treatment of forensic and general psychiatric patients diagnosed with schizophrenia.

Method

The matched samples included 72 male patients from forensic wards and 72 male patients from general psychiatric institutions diagnosed with schizophrenia. The history of psychiatric treatment was reconstructed by interviewing the patients as well as outpatient psychiatrists and patients’ legal custodians and by analyzing patient medical records.

Results

In contrast to the general psychiatric patients, prior to admission forensic patients were less integrated into psychiatric care and showed a lower rate of treatment compliance. They also showed a higher rate of previous compulsory treatment because of aggressive behavior towards other persons as well as higher rates of treatment difficulties and violent behavior during previous inpatient treatment. Furthermore, forensic patients had a higher number of previous criminal convictions and had been convicted more often for violent offences. With regard to other relevant risk factors (e.g. comorbid substance abuse disorder, age, education, conduct disorder, antisocial personality disorder, previous exposure to violent and abusive behavior) the two patient groups were, however, comparable.

Conclusions

Regarding schizophrenic patients with comorbid substance abuse disorders, previous violent delinquency and violent behavior during previous inpatient treatment, an intensive outpatient aftercare should be arranged before they are discharged from general psychiatric institutions.     

Sustained efficacy of dialectical behaviour therapy for borderline personality disorder

Dialectical Behaviour Therapy (DBT) is considered one of the most promising treatments for borderline personality disorder (BPD). Recently, we reported significantly positive effects of 12 months DBT on parasuicidal behaviour and impulsivity in a mixed group of female BPD patients with and without substance abuse. Fifty-eight women with BPD were randomly assigned to either 52 weeks of DBT or treatment as usual (TAU). Follow-up assessment took place at 78 weeks, i.e., 6 months after discontinuation of DBT. Participants were clinical referrals from addiction treatment and psychiatric services. Outcome measures included parasuicidal behaviour, impulsivity and substance abuse. Six months after treatment discontinuation, the benefits of DBT over TAU in terms of lower levels of parasuicidal and impulsive behaviours, and in alcohol use, sustained. No differences between the treatment conditions were found for drug abuse. In conclusion, DBT seems to have a sustained effect on some of the core symptoms of BPD and on alcohol problems in a mixed population of female borderline patients with and without substance abuse problems.     

Stress regulation and incision in borderline personality disorder-a pilot study modeling cutting behavior

Emotion dysregulation in Borderline Personality Disorder (BPD) is characterized by high baseline negative intensity, high reactivity, and slow return to baseline. Patients with BPD often engage in self-injurious behavior because it leads to immediate relief of stress levels. We aimed to assess stress regulation as well as the influence of tissue damage on subjective (aversive tension) and objective (heart rate) stress correlates in BPD. In 14 unmedicated patients with BPD and 18 healthy controls, a stress induction was followed by an incision into the forearm conducted by an investigator. For aversive tension, we found elevated baseline levels as well as slower return to baseline in BPD. In controls, incision resulted in a short-term increase of aversive tension, whereas tension and heart rate decreased in the BPD group. Our preliminary results support the hypothesis that tissue damage may play a role in disturbed stress regulation in BPD.     

Effects of the dialectical behavioral therapy-mindfulness module on attention in patients with borderline personality disorder

It is known that patients with borderline personality disorder (BPD) show attention deficits and impulsivity. The main aim of this study was to explore the effects of Dialectical Behavioral Therapy-Mindfulness training (DBT-M), used as an adjunct to general psychiatric management (GPM), on attention variables in patients diagnosed with BPD. A second objective was to assess the relation of mindfulness formal practice on clinical variables. A sample of 60 patients with BPD was recruited. Forty of them were allocated to GPM + DBT-M treatment and the other 20 received GPM alone. At the termination of the mindfulness training, DBT-M + GPM group showed a significant improvement on commissions, hit reaction time, detectability scores from the CPT-II neuropsychological test, and also on the composite scores of inattention and impulsivity. Further, the more minutes of mindfulness practice were correlated to greater improvement in general psychiatric symptoms and affective symptomatology, but not in CPT-II measures. This is probably the first study so far assessing the effects of this single DBT module in patients with BPD. The results suggest a positive effect of such intervention on attention and impulsivity variables.     

Can negative attitudes toward patients with borderline personality disorder be changed? The effect of attending a STEPPS workshop

We sought to determine whether negative attitudes toward patients with borderline personality disorder (BPD) can be modified through education. Mental health clinicians attended a 1-day workshop on the Systems Training for Emotional Predictability and Problem Solving (STEPPS) group treatment program for BPD. A questionnaire to assess attitudes towards BPD was given to 271 clinicians before and after the workshop. Following the workshop, clinicians endorsed having significantly greater empathy toward patients with BPD, and having greater awareness of the distress and low self-esteem associated with the disorder. Significant improvement was seen in the clinicians' attitudes toward patients with BPD and their desire to work with them. Clinicians were significantly less likely to express dislike for BPD patients. They also reported feeling more competent in their ability to treat these patients. The study offers preliminary evidence that negative attitudes toward patients with BPD can be modified through education.     

Treatment Outcome of 18-Month, Day Hospital Mentalization-Based Treatment (MBT) in Patients with Severe Borderline Personality Disorder in the Netherlands

Psychoanalytically oriented day hospital therapy, later manualized and named mentalization-based treatment (MBT), has proven to be a (cost-) effective treatment for patients with severe borderline personality disorder and a high degree of psychiatric comorbidity (BPD) in the United Kingdom (UK). As to yet it has not been shown whether manualized day hospital MBT would yield similar results when conducted by an independent institute outside the UK. We investigated the applicability and treatment outcome of 18-month, manualized day hospital MBT in the Netherlands by means of a prospective cohort study with 45 Dutch patients with severe BPD and a high degree of comorbid Axis I and Axis II disorders. Outcomes were assessed each six months. Symptom distress, social and interpersonal functioning, and personality pathology and functioning all improved significantly, with effect sizes between 0.7 and 1.7. Suicide attempts, acts of self-harm, and care consumption were also significantly reduced. The results indicate that MBT can effectively be implemented in an independent treatment institute outside the UK. This study also supports the clinical effectiveness of manualized day hospital MBT in patients with severe BPD and a high degree of psychiatric comorbidity.     

The Personality Disorders Institute/Borderline Personality Disorder Research Foundation randomized control trial for borderline personality disorder: rationale, methods, and patient characteristics

The Personality Disorder Institute/Borderline Personality Disorder Research Foundation randomized control trial (PDI/BPDRF RCT) is a controlled outcome study for borderline personality disorder (BPD), in which 90 participants were randomized to one of three manualized and monitored, active psychosocial treatment conditions. These treatments are: (a) Transference-Focused Psychotherapy (TFP; Clarkin, Yeomans, & Kernberg, 1999), a treatment for BPD based on object-relational and psychoanalytic principles first applied to BPD by Kernberg (1996), notable for its particular emphasis on interpretation of object relations activated in the ongoing therapeutic relationship; (b) Dialectical Behavior Therapy (DBT; Linehan, 1993), a popular treatment for BPD, with evidence of efficacy (Linehan, Armstrong, Suarez, Allmon, & Heard, 1991) that emphasizes a balance between acceptance and change in its combination of cognitive-behavioral and Zen principles; and (c) supportive psychotherapy (Rockland, 1992), another object-relational and psychoanalytically based treatment for BPD which, in contrast to TFP, eschews transference interpretation and places primary emphasis on development of a collaborative engagement with the patient to foster identity development. Patients received medication, if clearly indicated, according to the treatment algorithm developed by Soloff (2000). This article describes the significance and rationale of the study and the overall design, methods, plan of analysis, and demographic characteristics of the recruited sample of patients.     

Nonsuicidal self-injury: relationship to behavioral and self-rating measures of impulsivity and self-aggression

Previous research using self-report measures has shown an association between nonsuicidal self-injurious behavior (NSSI) and impulsive tendencies. However, self-injurers have not been shown to be different from comparison groups on laboratory tasks putatively assessing impulsive behavior. One explanation for these contradictory findings is that self-report and laboratory measures of impulsive behavior tap into distinct but related constructs. Moreover, performance on laboratory measures of impulsive behavior can be influenced by myriad contextual and affective factors not present during past self-reported NSSI events. Accordingly, a relationship between behavioral tasks of impulsivity and self-injurious behavior could emerge if both are assessed relatively close in time under controlled laboratory conditions. To test this possibility, both self-ratings and laboratory task measures of self-injurious and impulsive behavior were employed in the current study. This multi-modal assessment approach revealed that self-rated impulsivity was associated with both self-report and behavioral measures of self-injurious behavior. Moreover, behavioral measures of impulsivity were associated with self-injurious behavior, but not NSSI history. These results provide support for the notion that a multi-modal approach to assessing self-injurious behavior is important for better understanding the correlates of nonsuicidal self-injury.     

EXPERIMENTAL ANALYSIS AND EXTINCTION OF SELF-INJURIOUS ESCAPE BEHAVIOR

Three studies are presented in which environmental correlates of self-injurious behavior were systematically examined and later used as the basis for treatment. In Study 1, 7 developmentally disabled subjects were exposed to a series of conditions designed to identify factors that maintain self-injurious behavior: attention contingent on self-injurious behavior (positive reinforcement), escape from or avoidance of demands contingent on self-injurious behavior (negative reinforcement), alone (automatic reinforcement), and play (control). Results of a multielement design showed that each subject's self-injurious behavior occurred more frequently in the demand condition, suggesting that the behavior served an avoidance or escape function. Six of the 7 subjects participated in Study 2. During educational sessions, “escape extinction” was applied as treatment for their self-injurious behavior in a multiple baseline across subjects design. Results showed noticeable reduction or elimination of self-injurious behavior for each subject and an increase in compliance with instructions in all subjects for whom compliance data were taken. The 7th subject, whose self-injurious behavior during Study 1 occurred in response to medical demands (i.e., physical examinations), participated in Study 3. Treatment was comprised of extinction, as in Study 2, plus reinforcement for tolerance of the examination procedure, and was evaluated in a multiple baseline across settings design. Results showed that the treatment was successful in eliminating self-injurious behavior and that its effects transferred across eight new therapists and three physicians. General implications for the design, interpretation, and uses of assessment studies are discussed.