Processes of change in a randomized clinical trial of radically open dialectical behavior therapy (RO DBT) for adults with treatment-refractory depression

The Path to Loneliness for Psychiatric Patients: A Qualitative Study of a Journey Marked by Pain, Hopelessness, Prosocial Signaling Deficits, and Coping Strategies That Are Not Effective

Enduring loneliness has serious physical and mental health implications. Patients with mental health problems are at risk of experiencing problems related to loneliness. Therefore, it is important to increase knowledge about how loneliness is experienced and managed in this particular group. The aim of the study was to explore (1) psychiatric patients' experiences of different forms of loneliness, (2) associated problems, including difficulties with prosocial signaling, and (3) strategies used to combat loneliness, to better understand how loneliness affects psychiatric patients and how patients manage their loneliness. A total of 110 psychiatric patients were recruited at eight outpatient clinics in Region Stockholm for a larger study of loneliness. The first fifteen patients who also agreed to participate in the present substudy were invited to meet a trainee psychologist who conducted a semi-structured interview. A reflexive thematic analysis with a codebook approach was used to analyze the transcripts. The described experiences of loneliness were primarily examples of social and emotional loneliness with one prominent theme: "Hopelessly lonely". Associated problems were summarized in two themes: "The inevitable road to loneliness" and "Social signals are confusing and push others away". Regarding patients' strategies for combating loneliness, one theme emerged: "Using strategies that focus on the current moment". The results also included a total of sixteen subthemes. Loneliness was described as something painful that is inevitable and unchangeable, with a self-reinforcing loneliness loop leading to social and emotional loneliness, and as something that is intertwined with mental health problems. These results are in accordance with research. In addition, patients described a variety of prosocial signaling deficits and feelings of being disconnected from others. They also reported using strategies that primarily alleviated their immediate suffering when they were alone, rather than focusing on approaches with long-term effects on reducing loneliness, such as participating in social activities combined with effective social signaling. Future research should investigate whether increased awareness of social signaling, as well as social activities combined with improved prosocial signaling and strengthened self-belief, would constitute effective steps for patients to combat enduring loneliness. It also seems important to help patients reduce hopelessness related to loneliness.

Evolutionary Systems Therapy for Obsessive-Compulsive Personality Disorder: A Five-Case Series

Obsessive-compulsive personality disorder is the most common personality disorder, with a prevalence of approximately 6.5% in the general population. However, little is known about the effective psychotherapy for this disorder. In this case series, we employed evolutionary systems therapy to support five adults diagnosed with obsessive-compulsive personality disorder. Evolutionary systems therapy is a novel form of psychotherapy that integrates evolutionary psychopathology, compassion-focused therapy, and metacognitively oriented treatments. Primary outcome (personality pathology) was assessed monthly from baseline to follow-up. Secondary outcomes (anxiety, depression, perfectionism, self-criticism, overcontrol) were assessed at initial and final sessions. Moreover, we evaluated the feasibility of intervention (completion, attendance, adverse events). At the end of 6 months of treatment, all the participants reported reliable changes and remitted from diagnosis. These outcomes were maintained at 1-month and 3-month follow-ups. Further research is needed to provide evidence about the acceptability of evolutionary systems therapy in the treatment of obsessive-compulsive personality disorder.

Applications and efficacy of radically open dialectical behavior therapy (RO DBT): A systematic review of the literature

Radically open dialectical behaviour therapy (RO DBT) is a transdiagnostic treatment, originally developed as a variant of dialectical behaviour therapy (DBT), that emerged as a novel treatment approach for those presenting with excessive or maladaptive overcontrol. Despite RO DBT's growing popularity among clinicians as a treatment for chronic depression, personality disorders and eating disorders, to date, no systematic review has been conducted to summarise the evidence on this therapy. Therefore, the aim of this study was to systematically review the literature to provide a current and comprehensive summary of the available evidence on the clinical applications and efficacy of RO DBT. Articles were included if they were original research studies that described the use of RO DBT in the treatment of any psychological disorder, condition or symptom, published in the English language in a peer-reviewed journal. Four electronic databases were searched, and screening, selection, risk of bias assessment and data extraction were all conducted by two independent reviewers. Fourteen articles were included in this review, including two qualitative articles, one case study, five case series studies, four quasi-experimental studies, and two articles describing one randomized control trial. Findings indicated there is emerging evidence for the use of RO DBT in both adolescents and adults, for disorders characterized by excessive self-control, such as anorexia nervosa and autism, as well as for treatment-resistant depression. While RO DBT shows promise as a treatment for disorders of overcontrol, further research is needed. This review outlines current gaps and identifies areas for future research.

Telehealth-Delivered Radically Open Dialectical Behavior Therapy for Adolescents (RO DBT-A): A Pilot Mixed-Methods Study

OBJECTIVE

Disorders related to overcontrol frequently first appear during adolescence, are highly comorbid, and show limited treatment response, necessitating the adaptation of radically open dialectical behavior therapy (RO DBT; a transdiagnostic treatment targeting overcontrol) for adolescents (RO DBT-A). This study tested the preliminary efficacy of telehealth-delivered RO DBT-A in a heterogeneous clinical sample of youths.

METHODS

The sample consisted of 20 female participants ages 13-21 with elevated overcontrol; most were White (75%) and non-Hispanic/Latino (80%). RO DBT-A was provided over 20 weeks via skills group and individual sessions (N=13 participants). Participants seeking other treatment or no treatment formed the control group (N=7). Outcomes included self-reported symptoms and overcontrol. Follow-up interviews were analyzed by using inductive, contextualist thematic analysis to examine participant perceptions and reasons for dropout.

RESULTS

The RO DBT-A group showed significant improvements in depression (t=-1.78, df=10, p=0.011) and quality of life (QOL; Wilcoxon W=75, p=0.021) compared with the control group. From baseline to posttreatment, youths receiving RO DBT-A demonstrated significant improvements in maladaptive overcontrol (t=2.76, df=12, p=0.043), anxiety (t=2.91, df=12, p=0.043), depression (Wilcoxon signed rank V=82.5, p=0.043), and QOL (t=-3.01, df=12, p=0.043). Qualitative analysis revealed themes related to treatment barriers, facilitators, and timing.

CONCLUSIONS

The findings provide preliminary evidence supporting telehealth-delivered RO DBT-A in targeting overcontrol, decreasing symptomatology, and improving QOL in a heterogeneous clinical sample of youths. Qualitative follow-ups highlighted that dropout was driven by barriers related to therapy (e.g., structure- and therapist-related issues) and the timing of RO DBT-A compared with other treatments.

Practitioner Review: Neurobiological consequences of childhood maltreatment - clinical and therapeutic implications for practitioners

BACKGROUND

Childhood maltreatment is one of the most important preventable risk factors for a wide variety of psychiatric disorders. Further, when psychiatric disorders emerge in maltreated individuals they typically do so at younger ages, with greater severity, more psychiatric comorbid conditions, and poorer response to established treatments, resulting in a more pernicious course with an increased risk for suicide. Practitioners treating children, adolescents, and young adults with psychiatric disorders will likely encounter the highest prevalence of clients with early-onset maltreatment-associated psychiatric disorders. These may be some of their most challenging cases.

METHOD

In this report, we explore key validated alterations in brain structure, function, and connectivity associated with exposure to childhood maltreatment as potential mechanisms behind their patients' clinical presentations.

RESULTS

We then summarize key behavioral presentations likely associated with neurobiological alterations and propose a toolkit of established trauma and skills-based strategies that may help diminish symptoms and foster recovery. We also discuss how some of these alterations may serve as latent vulnerability factors for the possible development of future psychopathology.

CONCLUSIONS

Research on the neurobiological consequences of childhood adversity provides a vastly enriched biopsychosocial understanding of the developmental origins of health and pathology that will hopefully lead to fundamental advances in clinical psychology and psychiatry.

Non-randomised feasibility study of training workshops for Talking Therapies service high-intensity therapists to optimise depression and anxiety outcomes for individuals with co-morbid personality difficulties: a study protocol

BACKGROUND

The NHS Talking Therapies for Anxiety and Depression programme ('TTad'; formerly Improving Access to Psychological Therapies 'IAPT') delivers high-intensity cognitive behavioural therapy (CBT) to over 200,000 individuals each year for common mental health problems like depression and anxiety. More than half of these individuals experience comorbid personality difficulties, who show poorer treatment outcomes. TTad therapists report feeling unskilled to work with clients with personality difficulties, and enhancing the training of TTad therapists may lead to improved treatment outcomes for individuals presenting with secondary personality difficulties alongside depression and anxiety.

METHODS

This is a pre-post non-randomised mixed-method feasibility study, exploring the feasibility and acceptability of a 1-day training workshop for high-intensity (HI) CBT therapists. The workshop is focused on understanding and assessing personality difficulties and adapting HICBT treatments for anxiety and depression to accommodate client needs. The feasibility and acceptability of the workshop and the evaluation procedures will be investigated. It will be examined to what extent the workshop provision leads to improvements in therapist skills and confidence and explored to what extent the training has the potential to enhance clinical outcomes for this client group.

DISCUSSION

This feasibility study will provide data on the acceptability and feasibility of delivering brief therapist training to adapt usual HICBT to optimise care for individuals with secondary personality difficulties seeking treatment in TTad services for a primary problem of depression and/or anxiety. The study will also evaluate proof of concept that such an approach has the potential to improve clinical outcomes for those with secondary personality difficulties and report any possible harms identified. The study will inform the design of a future randomised controlled trial designed to test the effectiveness and cost-effectiveness of the training.

TRIAL REGISTRATION

ISRCTN81104604 . Submitted on 6th June 2022. Registration date: 3rd January 2023.