The application of dialectical behavior therapy for patients with borderline personality disorder on inpatient units

Trauma-informed behavioral supports (TIBS) for inpatient treatment of individuals who experience BPD

Trauma-Informed Behavioral Supports (TIBS) is a novel treatment approach targeting aggression against self or against others in individuals who experience borderline personality disorder (BPD). It is based on applied behavior analysis and uses a person-centered and trauma-informed framework. People with BPD hospitalized because of concerning behaviors, [aggression to others, verbal aggression (e.g., defined as aggression in the forms of verbal threats, etc.), physical aggression, and self-injury, etc.] may experience exacerbations of such behavior in the hospital. Individuals diagnosed with BPD were treated with TIBS to diminish the frequency of concerning behaviors in the context of a pilot study. Functioning during a three-month pre-treatment phase was compared with a six-month treatment phase. The TIBS intervention resulted in statistically significant and clinically meaningful decreases in physical and verbal aggression. The results of this pilot investigation approach suggests that TIBS can promote behavior change in the inpatient setting.

A Review of Transdiagnostic Mechanisms in Cognitive Behavior Therapy

Cognitive behavior therapies (CBTs) are the gold standard treatment for many psychiatric conditions. However, relatively little is known about how CBTs work. By characterizing these mechanisms, researchers can ensure CBTs retain their potency across diagnoses and delivery contexts. We review 3 classes of putative mechanisms: CBT-specific skills (eg, cognitive restructuring, behavioral activation), transtheoretical mechanisms (eg, therapeutic alliance, treatment expectancies, self-efficacy beliefs), and psychopathological mechanisms (aversive reactivity, positive affect, attachment style). We point to future research within each class and emphasize the need for more intensive longitudinal designs to capture how each class of mechanisms interacts with the others to improve outcomes.

Comparison of 8-vs-12 weeks, adapted dialectical behavioral therapy (DBT) for borderline personality disorder in routine psychiatric inpatient treatment-A naturalistic study

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.

Effective management of patients with borderline personality disorder in a busy acute inpatient ward using dialectical behaviour therapy principles

OBJECTIVE

The study aimed to highlight principles of Dialectical Behaviour Therapy (DBT) that can provide a framework in the management of patients with borderline personality disorder (BPD) and outline some guiding principles in the effective management of these patients on a busy acute inpatient ward.

CONCLUSIONS

The inpatient environment is often a place where invalidating experiences can occur. These include feeling ignored, misunderstood and where private experiences are trivialised or denied. Patients with BPD are extremely sensitive to these experiences and are likely to decompensate if strategies are not in place to facilitate a more validating experience during admission. The proposed guidelines are feasible to implement and support a cohesive treatment team and collaborative patient-centred care which is likely to improve patient outcomes.

Acceptance and Commitment Therapy for Destructive Experiential Avoidance (ACT-DEA): A Feasibility Study

This study is a preliminary study on an acceptance and commitment therapy (ACT) program that mitigates destructive experiential avoidance (DEA) behaviors, including self-harm behavior and addiction; Methods: Twenty participants aged 15-25 years who had confirmed DEA behavior within the last month participated in a total of six sessions of ACT. Demographic characteristics, history of psychiatric illness, and TYPES and patterns of DEA behavior were confirmed in the baseline survey. The severity of clinical symptoms, frequency of DEA behavior and impulsivity, characteristics of experiential avoidance (EA) behavior, depression, and quality of life (QOL) were measured before and after the program for comparative statistical tests using the intention-to-treat method. Furthermore, the severity of clinical symptoms was evaluated after each program, along with the frequency of DEA behavior and trends in impulsivity, which were investigated based on the behavior log; Results: After the ACT program, both the frequency of DEA behavior and impulsivity and the severity of clinical symptoms, depression, and anxiety decreased significantly. Furthermore, among the EA characteristics, pain aversion, distraction and inhibition, and delayed behavior significantly improved. Moreover, the overall QOL, psychological and social relationships, and QOL regarding the environment also improved; Conclusions: The results of this feasibility study demonstrate the potential of the ACT program as an effective intervention in DEA behavior. The results of this study may be used as preliminary data for future large-scale randomized studies.

Drawing the borderline: Predicting treatment outcomes in patients with borderline personality disorder

BACKGROUND

A routinely collected big data set was analyzed to determine the effectiveness of naturalistic inpatient treatment and to identify predictors of treatment outcome and discontinuation.

METHODS

The sample included 878 patients with borderline personality disorder who received non-manualized dialectic behavioral therapy in a psychosomatic clinic. Effect sizes (Hedge's g) were calculated to determine effectiveness. A bootstrap-enhanced regularized regression with 91 potential predictors was used to identify stable predictors of residualized symptom- and functional change and treatment discontinuation. Results were validated in a holdout sample and repeated cross validation.

RESULTS

Effect sizes were small to medium (g = 0.28-0.51). Positive symptom-related outcome was predicted by low affect regulation skills and no previous outpatient psychotherapy. Lower age, absence of work disability, high emotional and physical role limitations and low bodily pain were associated with greater improvement in functional outcome. Higher education and comorbid recurrent depressive disorder were the main predictors of treatment completion. The predictive quality of the models varied, with the best being found for symptom-related outcome (R2 = 18%).

CONCLUSION

While the exploratory process of variable selection replicates previous findings, the validation results suggest that tailoring treatment to the individual patient might not be based solely on sociodemographic, clinical and psychological baseline data.

Effectiveness of a 5-Week Inpatient Dialectical Behavior Therapy for Borderline Personality Disorder

OBJECTIVE

The goal of this study was to evaluate whether symptoms are reduced and emotion regulation improves when patients with borderline personality disorder (BPD) receive a 5-week course of inpatient dialectical behavioral therapy (DBT) and if changes in emotion regulation are associated with changes in symptoms.

METHODS

Forty-four patients with BPD receiving a 5-week course of DBT in a German psychiatry clinic participated. The short version of the "Borderline Symptom List" (BSL-23) was the patient-reported outcome. To measure emotion regulation, the "Self-Report Measure for the Assessment of Emotion Regulation Skills" (SEK-27) was administered. Wilcoxon tests were performed to evaluate whether pre-post changes in the BSL-23 and SEK-27 reached statistical significance. Effect sizes (d) were calculated and correlations between the pre-post differences for both measures were computed to test associations between changes in emotion regulation and changes in symptoms. Completer (n=33) and intention-to-treat (n=43) analyses were performed.

RESULTS

Symptoms (BSL-23) were reduced and emotion regulation (SEK-27) improved during the 5-week inpatient DBT treatment (completer and intention-to-treat analysis: P<0.001). Effect sizes reached d=0.47 for the BSL-23 and d=0.84 for the SEK-27 in the completer analysis, and d=0.38 for the BSL-23 and d=0.68 for the SEK-27 in the intention-to-treat analysis. Improvements in emotion regulation (SEK-27) were correlated with reductions in symptoms (BSL-23) in both the completer (r=0.54; P=0.001) and the intention-to-treat (r=0.59; P<0.001) analyses.

CONCLUSIONS

These findings indicate that a 5-week course of inpatient DBT can effectively reduce symptoms in patients with BPD and that the more patients' emotion regulation improves, the more the patients benefit from the therapy.

A naturalistic longitudinal study of extended inpatient treatment for adults with borderline personality disorder: An examination of treatment response, remission and deterioration

BACKGROUND

Experts express reluctance to hospitalize patients with borderline personality disorder (BPD) for more than a few days, arguing that extended inpatient care leads to deterioration and adverse events. To date, there is no empirical support for these assertions.

AIMS

The current study examined the assumption of iatrogenic effects among BPD adults.

METHODS

Clinically significant and reliable change in symptoms, functional capacities, and adverse events were quantified for both inpatients with BPD (n = 245) and a well-matched inpatient reference (n = 220) sample. Latent growth curve (LGC) models were used to evaluate moderators of the trajectory of PHQ-9 depression scores over the course of hospitalization.

RESULTS

Large effect size improvements were observed in depression, anxiety, suicidal ideation and functional disability among patients with BPD (Cohen's d ≥ 1.0) and those in the reference sample (Cohen's d ≥ .80). Clinical deterioration and adverse events were rare (occurring in no more than 1.1% of BPD and reference patients on any outcome) with no difference across patient cohorts. BPD diagnosis failed to influence the trajectory of continuous depression severity. Rather, trait emotion dysregulation was associated with initial depression severity.

CONCLUSIONS

Twenty-five years ago it was assumed that adults with BPD could not benefit from psychiatric treatment. Today there are a number of effective evidence-based outpatient treatments for BPD, but beliefs about extended inpatient treatment have changed little. Current results indicate that extended inpatient treatment can result in significant and clinically meaningful symptomatic and functional improvement in BPD patients without iatrogenic effects.

Suicidal Ideation and Skill Use During In-patient Dialectical Behavior Therapy for Borderline Personality Disorder. A Diary Card Study

Associations between suicidal ideation and skill use were investigated during in-patient dialectical behavior therapy (DBT) for borderline personality disorder (BPD). Participants were N = 44 patients with BPD undergoing a 5-week in-patient DBT program in a psychiatric clinic. They filled in a diary card each treatment day resulting in 1,334 skill use ratings and 1,364 suicidal ideation ratings. Treatment days were categorized as days with successful skill use (using skills and perceiving them as effective), days with no skill use, days with unsuccessful skill use (using skills but perceiving them as ineffective). Multilevel models were performed to account for the nested data structure. The results showed that suicidal ideation improved more for patients who applied skills successfully more often during treatment (p < 0.05). Moreover, suicidal ideation was lower on treatment days with successful skill use compared to treatment days with no skill use and compared to treatment days with unsuccessful skill use (p < 0.05). When treatment days with no skill use were compared to treatment days with unsuccessful skill use, suicidal ideation was higher on treatment days with unsuccessful skill use (p < 0.05). To conclude, using skills successfully on as many treatment days as possible is associated with lower suicidal ideation.

Staff nurse perceptions of the impact of mentalization-based therapy skills training when working with borderline personality disorder in acute mental health: a qualitative study

People diagnosed with borderline personality disorder (BPD) are highly prevalent in acute mental health wards, with staff nurses identifying a challenge in working with people who can be significantly distressed. This has contributed to a negative stereotype verging on stigmatization. Mentalization-based therapy (MBT) is a psychological therapy which has been shown to be of benefit to people with a diagnosis of BPD, yet it has been utilized and evaluated only in partial hospitalization and outpatient settings. Despite this, most people diagnosed with BPD will continue to be treated in generic inpatient settings such as acute mental health. Mentalization-based therapy skills training (MBT-S) is a new and cost-effective 2-day workshop aiming to provide generalist practitioners with MBT skills for use in generic settings. This study aimed to capture staff perceptions of the impact of MBT-S on their practice when working with people with a diagnosis of BPD in acute mental health. Through two focus groups, this study assessed the perceptions of nine staff nurses. An interpretive phenomenological approach was utilized in data analysis. Participants found the approach easy to grasp, improving of consistency between staff and flexible in its use in planned or 'off the cuff' discussions. MBT-S promoted empathy and humane responses to self-harm, impacted on participants ability to tolerate risk and went some way to turning the negative perception of BPD through changing the notion of patients as 'deliberately difficult'. Staff felt empowered and more confident in working with people with a diagnosis of BPD. The positive implication for practice was the ease in which the approach was adopted and participants perception of MBT-S as an empowering skill set which also contributed to attitudinal change. In acute mental health environments, which may not have the resources to provide long-term structured treatments to patients, MBT-S could be viewed as ideal as participants applauded its flexibility. The promotion of empathy also sees a move away from iatrogenic damage caused by unhelpful responses to self-harm. In the context of wider research, this study shows that staff nurses find the MBT-S skill set valuable in the generic inpatient setting of acute mental health.

Reasons for premature termination of dialectical behavior therapy for inpatients with borderline personality disorder

Although one of the main aims of dialectical behavior therapy (DBT) for borderline personality disorder (BPD) is to increase the retention rates, premature termination rates for DBT inpatient programs were found to be over 30%. The aim of the study was to identify the reasons for, and to analyze, patient characteristics that are associated with premature termination. We studied 541 inpatients with BPD, who were consecutively admitted for an open-door 3-month DBT inpatient treatment in Berlin, Germany. All participants completed several self-rating measures and participated in clinical interviews. Fourteen percent, who did not complete the full 84 days of assigned treatment, were expelled, mainly due to treatment-disturbing behaviors, or substance abuse or possession. Nearly 19% dropped out of treatment, mostly due to lack of motivation, arguments with others, and poor tolerance of emotional distress. Using non-parametric conditional inference trees, expulsion was associated with anorexia nervosa and alcohol abuse, whereas more than 9 suicide attempts, antisocial personality disorders, and more than 86 weeks in a psychiatric hospital were risk factors for dropout. We discussed measures and interventions that might lead to an adaptation of DBT inpatient programs. Future research should examine the symptom course and utilization of health-care services of non-completers.

A Service Evaluation of a 1-Year Dialectical Behaviour Therapy Programme for Women with Borderline Personality Disorder in a Low Secure Unit

Background: Previous studies about the effectiveness of Dialectical Behaviour Therapy for the treatment of Borderline Personality Disorder have had promising results. However, no previous studies have examined its effectiveness when delivered in low secure inpatient services for women. Aims: To evaluate clinical outcomes during and after a 1-year period of admission within a low secure unit for women offering a Dialectical Behaviour Therapy programme. Method: A naturalistic, within subjects study of clinical data collected as part of routine practice was conducted. Participants were18 consecutively admitted women who met the diagnostic criteria for Borderline Personality Disorder and had completed at least 1 year of treatment. Measures covered: risk behaviours; self-reported symptoms of Borderline Personality Disorder, and current mood and symptom experience; staff reports of clinical problems, needs and social functioning. Scores were compared between admission and at 6 months and 1 year. Results: There was a statistically significant improvement on all 13 measures over the year's treatment. Most improvement was demonstrated between admission and 6 months. Conclusions: Engagement in1-year's treatment was associated with significant reduction in risk behaviours and both staff-rated and self-rated outcome measures. Some significant questions remain about which elements of the programme are most effective but the results are encouraging.

A preliminary follow-up study of patients treated at an inpatient psychotherapy unit

Inpatient psychotherapeutic services for patients experiencing high levels of psychological distress are scarce in South Africa. Furthermore, follow-up research with patients receiving this type of mental health care is also limited. This study focuses on patients treated at an inpatient psychotherapeutic unit offering individual and group psychotherapies to adults, by assessing their experiences following admission to the unit. Patients’ experiences during their admission and since discharge from the unit, mental health status since admission, compliance in terms of outpatient mental health care, current quality of relationships with family and friends, and the impact of the patients’ mental illness on their work situation are examined. The challenges encountered in such research are also explored.

Effectiveness, response, and dropout of dialectical behavior therapy for borderline personality disorder in an inpatient setting

To examine the effectiveness of dialectical behavior therapy for inpatients with borderline personality disorder (BPD), small sample sizes and, predominantly, tests of statistical significance have been used so far. We studied 1423 consecutively admitted individuals with BPD, who were seeking a 3-month inpatient treatment. They completed the Borderline Symptom List (BSL) as the main outcome measure, and other self-rating measures at pre- and post-treatment. Therapy outcome was defined in three ways: effect size (ES), response based on the reliable change index, and remission compared to the general population symptom level. Non-parametric conditional inference trees were used to predict dropouts. In the pre-post comparison of the BSL, the ES was 0.54 (95% CI: 0.49-0.59). The response rate was 45%; 31% remained unchanged, and 11% deteriorated. Approximately 15% showed a symptom level equivalent to that of the general population. A further 10% of participants dropped out. A predictive impact on dropout was demonstrated by substance use disorders and a younger age at pre-treatment. In future research, follow-up assessments should be conducted to investigate the extent to which response and remission rates at post-treatment remain stable over time. A consistent definition of response appears to be essential for cross-study and cross-methodological comparisons.

Remission, Response und deren Prädiktion nach einer Dialektisch-Behavioralen Therapie der Borderline-Persönlichkeitsstörung im stationären Setting

Theoretischer Hintergrund: Bislang wurde die Wirksamkeit der Dialektisch-Behavioralen Therapie (DBT) für die Borderline-Persönlichkeitsstörung (BPS) im stationären Bereich überwiegend anhand von gruppenstatistischen Kennwerten aufgezeigt. Fragestellung: Wie hoch fallen die Remissions- und Responseraten aus? Lassen sich Prädiktoren hinsichtlich der Responserate finden? Methode. Soziodemographische und klinische Merkmale von 366 stationären, konsekutiven Patienten mit einer BPS wurden erhoben. Der Therapieerfolg wurde durch den Global Severity Index (GSI) des Brief Symptom Inventory erfasst und auf vier verschiedene Arten (Effektstärke [ES], Remission, Response anhand des Reliable Change Index [RCI] bzw. der prozentualen Symptomverbesserung [PSV]) definiert. Ergebnisse: Es ergab sich im Prä-Post-Vergleich des GSI eine ES von 0.52 (95 %-KI: 0.48 – 0.56). Die Responseraten betrug 42 % nach dem Kriterium des RCIs bzw. 33 % nach der PSV. Etwa 33 % erreichten ein Belastungsniveau, das dem einer ambulanten Stichprobe entspricht. Unverändert blieben 47 %, verschlechtert haben sich 11 %. Einen prädiktiven Einfluss auf die Response zeigten eine höhere Ausprägung der allgemeinen Symptombelastung und Depressivität zu Therapiebeginn und eine höhere Schulbildung. Schlussfolgerungen: Zukünftig sollten Nachbefragungen durchgeführt werden, um zu untersuchen, inwiefern die Response- bzw. Remissionsraten nach der Behandlung über die Zeit hinweg stabil bleiben. Um studien- und verfahrensübergreifende Vergleiche durchführen zu können, erscheinen einheitliche Definitionen notwendig.

Living through distress: a skills training group for reducing deliberate self-harm

BACKGROUND

Dialectical Behaviour Therapy (DBT) is an evidence-based treatment effective in reducing deliberate self-harm. However, DBT is resource and time intensive, and few services are able to sustain a programme faithful to all aspects. Thus, modified or adapted versions of DBT have been developed, particularly for delivery in inpatient hospital settings.

AIMS

This study presents a description of the "Living Through Distress" (LTD) Group, which is based on the group skills training component of DBT.

METHOD

Participants (n = 114) were patients of a psychiatric hospital who attended the LTD group. The main inclusion criterion for the LTD group was a history of deliberate self-harm. The outcome measures were frequency of incidents of deliberate self-harm, levels of distress tolerance, and mean numbers of bed days per year.

RESULTS

Upon completion of the group, there were significant reductions in participants' reports of deliberate self-harm and significant increases in their distress tolerance levels, which were maintained at 3-month follow-up. There was also a reduction in participants' mean number of inpatient days at 1-year and 2-year follow-up. Over 50% of participants had no admissions in the year subsequent to completing the group.

CONCLUSIONS

As this study was not a randomized controlled trial, results must be interpreted with caution. However, the findings presented here are promising, and suggest that a briefer, less resource intense version of the group skills training component of DBT may be effective in reducing deliberate self-harm.

The physician's unique role in preventing violence: a neglected opportunity?

BACKGROUND

Episodes of explosive rage and violence comprise a symptom complex which can have a devastating effect on a person's life. In the community this behavior is seen as workplace violence, domestic abuse and road rage, while in the clinical setting, this behavior is rarely mentioned by patients, despite evidence that it can signify an important biological disorder that may afflict more than three percent of the population.

DISCUSSION

Patients are often reluctant to seek help for episodic attacks of rage, especially attacks which are accompanied by physical violence. Although, in the past, clinicians have had few treatment options to offer, recent neuroscience advances have created new possibilities to understand and help patients with this neglected problem. No formal medical guidelines for treating violence exist; however, many patients can be helped by diagnosis, referral and treatment. Treatment can include pharmaceuticals and nutrients, as well as referral for anger management or behavioral therapy.

SUMMARY

The astute clinician has an opportunity to positively impact an important problem through the diagnosis and treatment of patients with symptoms of intermittent explosive disorder.

Borderline personality disorder and depression: an update

To review the literature related to recent temperamental and biological findings on borderline personality disorder (BPD) and major depression, the close link between the two disorders, and the latest therapeutical findings on BPD, focusing on the conditions of co-morbidity between depression and BPD. The National Institutes of Health's PubMed database was used to identify indexed studies on BPD, depression and the co-morbidity between the two. Only studies published between 2000 and 2011 were assessed. Similar temperamental features have been demonstrated in BPD and depression. The strong link between the two disorders seems to be widely recognized by scientific community. Psychotherapy and new antipsychotics are the topics of current major interest of research. The therapeutic targets in the case of co-morbidity are BPD features associated with depressive symptoms, thus influencing prognosis. A global assessment is, in fact, fundamental for a successful therapy for the treatment of the several aspects of a complex psychopathological phenomenon.

Beliefs about emotions as a metacognitive construct: initial development of a self-report questionnaire measure and preliminary investigation in relation to emotion regulation

Metacognitive theory, amongst other theories, gives an important role to beliefs about mental states, including beliefs about emotions, in the maintenance of distress. Mentalization theory as well as the dialectical behaviour therapy and emotion-focused therapy literature specifies particular beliefs thought to be related to emotion dysregulation and therefore to a label of borderline personality disorder. The current study aimed to develop a questionnaire to measure the beliefs about emotions as specified by this literature and to test the relationship of this new measure to various aspects of emotion regulation in a non-clinical sample of 289 participants. A factor analysis extracted six factors, which described beliefs about emotions as (a) overwhelming and uncontrollable; (b) shameful and irrational; (c) invalid and meaningless; (d) useless; (e) damaging; and (f) contagious. The final measure showed some promising psychometric properties. All of the questionnaire subscales were related to aspects of emotion dysregulation including distress, borderline personality disorder symptoms and behaviours associated with dysregulation of emotion, suggesting that beliefs about emotions could be an important metacognitive construct involved in the ability to regulate emotions. Beliefs about emotions may be a useful direct or indirect target for treatment of difficulties regulating emotions, and this could be achieved through the use of various therapeutic modalities.

Dialectical behaviour therapy and an added cognitive behavioural treatment module for eating disorders in women with borderline personality disorder and anorexia nervosa or bulimia nervosa who failed to respond to previous treatments. An open trial with a 15-month follow-up

There is evidence from case studies suggesting that adapted dialectical behavior therapy (DBT) for borderline personality disorder (BPD) and eating disorders (ED) might improve disorder related complaints. Twenty-four women with BPD (9 with comorbid anorexia nervosa [AN] and 15 with bulimia nervosa [BN]), who already had failed to respond to previous eating-disorder related inpatient treatments were consecutively admitted to an adapted inpatient DBT program. Assessment points were at pre-treatment, post-treatment, and 15-month follow-up. At follow-up, the remission rate was 54% for BN, and 33% for AN. Yet 44% of women with AN crossed over to BN and one woman additionally met the criteria of AN. For women with AN, the mean weight was not significantly increased at post-treatment, but had improved at follow-up. For women with BN, the frequency of binge-eating episodes was reduced at post-treatment as well as at follow-up. Self-rated eating-related complaints and general psychopathology, as well as ratings on global psychosocial functioning, were significantly improved at post-treatment and at follow-up. Although these findings support the assumption that the adapted DBT inpatient program is a potentially efficacious treatment for those who failed to respond to previous eating-disorder related inpatient treatments, remission rates and maintained eating-related psychopathology also suggest that this treatment needs further improvement.

The Development of an Effective Occupational Therapy Assessment and Treatment Pathway for Women with a Diagnosis of Borderline Personality Disorder in an Inpatient Setting: Implementing the Model of Human Occupation

This article describes the implementation of a comprehensive occupational therapy graded assessment and treatment pathway within an inpatient specialist unit for women with borderline personality disorder. It was developed after a review concluded that treatment sessions lacked an occupational evidence base. The Model of Human Occupation was therefore used to ensure the delivery of an optimum, consistent programme that could meet the occupational needs of this specific group of patients.

Predictors of dropout from inpatient dialectical behavior therapy among women with borderline personality disorder

Inpatient dialectical behavior therapy (DBT) is an effective treatment for borderline personality disorder (BPD), but often treatment is ended prematurely and predictors of dropout are poorly understood. We, therefore, studied predictors of dropout among 60 women with BPD during inpatient DBT. Non-completers had higher experiential avoidance and trait anxiety at baseline, but fewer life-time suicide attempts than completers. There was a trend for more anger-hostility and perceived stigma among non-completers. Experiential avoidance and anxiety may be associated with dropout in inpatient DBT. Low life-time suicidality and high anger could reflect a subtype at risk for discontinuation of inpatient treatment.

Under-identification of personality disorder among in-patient mental health service users: implications for CBT therapists

The identification of personality disorder among mental health service users is problematic but important because it is associated with high levels of comorbidity and possibly ineffective service delivery. This study assessed the prevalence of personality disorder using the Millon Clinical Multiaxial Inventory – 3rd edition (MCMI-III) compared with prevalence using frequency of assignment of diagnosis in people referred to an in-patient CBT clinical psychology service. Prevalence rates differed from 85% (MCMI-III) to 16% (diagnosis) using these different measures. Reasons for this difference and implications for CBT therapists' practice are discussed.

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

Zusammenfassung. Theoretischer Hintergrund: Die Dialektisch Behaviorale Therapie (DBT) gilt inzwischen als empirisch bewährte Behandlungsform für die Borderline-Persönlichkeitsstörung im ambulanten wie stationären Setting. Fragestellung: Wie groß ist die durchschnittliche Wirksamkeit in den bisherigen Studien? Gibt es Hinweise auf eine differenzielle Effektivität? Unterscheidet sich die Wirksamkeit im ursprünglich ambulanten Konzept von der stationären Adaptation? Methode: Eine Literaturrecherche erbringt zehn Primärstudien, die in die Meta-Analyse eingehen. Berechnet werden neben summarischen Effektstärken (ES) über alle Maße spezifische ES für die Bereiche Impulsivität, Soziale Anpassung und allgemeine Symptombelastung. Ergebnisse: Die globale Wirksamkeit der DBT liegt bei ES = 0,62. Verbesserungen der Sozialen Anpassung fallen mit einer ES von 1,09 noch höher aus. Zwischen ambulantem und stationärem Setting ergaben sich keine Unterschiede. Schlussfolgerungen: DBT kann als wirksames Behandlungsverfahren gelten. Notwendig erscheinen weitere kontrollierte Studien besonders im stationären Bereich.

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.

Dialectical behavior therapy: current status, recent developments, and future directions

Dialectical behavior therapy (DBT) was developed as a treatment for parasuicidal women with borderline personality disorder and has been adapted for several other populations. This article describes standard DBT and several adaptations of it and reviews outcome studies with borderline patients in outpatient, inpatient, and crisis intervention settings, borderline patients with substance use disorders, suicidal adolescents, patients with eating disorders, inmates in correctional settings, depressed elders, and adults with attention-deficit/hyperactivity disorder. This treatment outcome review is followed by discussion of predictors of change in DBT, possible mechanisms of change, and current developments in theory, practice, and research.