Sequences of emotions in patients with borderline personality disorder

OBJECTIVE

To investigate sequences of emotions (temporal dependence of emotions) to identify specific patterns of borderline personality disorder (BPD).

METHOD

The perceived emotions of 50 BPD patients and 50 healthy controls (HC) were monitored by using a hand-held computer system for a 24-h period in a daily life setting. Participants were prompted four times per hour to assess their current perceived emotions. Differences between BPD patients and HC in terms of activation, persistence and down-regulation of emotions were analyzed.

RESULTS

Healthy controls in contrast to BPD patients more often activated joy and interest. BPD patients more often experienced persistence of anxiety and sadness. BPD patients more frequently switched from anxiety to sadness, from anxiety to anger and from sadness to anxiety. Anger was predominantly preceded by anxiety.

CONCLUSION

Persistence of sadness and anxiety, as well as emotional oscillating between anxiety, sadness and anger are important aspects of the emotional dysregulation in BPD patients.

Aversive tension in patients with borderline personality disorder: a computer-based controlled field study

OBJECTIVE

This study was designed to examine the subjective appraisal of aversive tension under conditions of daily life in patients with borderline personality disorder (BPD).

METHOD

A sample of 63 female subjects with BPD and 40 mentally healthy controls were each given a hand-held computer. For two consecutive days, participants were prompted at hourly intervals to record their current state of aversive tension and prompting events.

RESULTS

Compared with controls, states of aversive tension occurred significantly more frequently in BPD patients. The average levels of aversive tension were significantly higher, and the rate of increase in tension was markedly more rapid. Furthermore, states of aversive tension persisted for a longer period. Among BPD subjects three events (rejection, being alone, and failure) account for 39% of all events preceding states of tension.

CONCLUSION

The study provides support for the theory that patients with BPD experience more frequent, stronger, and longer-lasting states of aversive tension.

Dialectical behavior therapy for binge eating disorder

This study evaluated the use of dialectical behavior therapy (DBT) adapted for binge eating disorder (BED). Women with BED (N = 44) were randomly assigned to group DBT or to a wait-list control condition and were administered the Eating Disorder Examination in addition to measures of weight, mood, and affect regulation at baseline and posttreatment. Treated women evidenced significant improvement on measures of binge eating and eating pathology compared with controls, and 89% of the women receiving DBT had stopped binge eating by the end of treatment. Abstinence rates were reduced to 56% at the 6-month follow-up. Overall, the findings on the measures of weight, mood, and affect regulation were not significant. These results support further research into DBT as a treatment for BED.

Dialectical behavior therapy for binge eating disorder

This study evaluated the use of dialectical behavior therapy (DBT) adapted for binge eating disorder (BED). Women with BED (N = 44) were randomly assigned to group DBT or to a wait-list control condition and were administered the Eating Disorder Examination in addition to measures of weight, mood, and affect regulation at baseline and posttreatment. Treated women evidenced significant improvement on measures of binge eating and eating pathology compared with controls, and 89% of the women receiving DBT had stopped binge eating by the end of treatment. Abstinence rates were reduced to 56% at the 6-month follow-up. Overall, the findings on the measures of weight, mood, and affect regulation were not significant. These results support further research into DBT as a treatment for BED.

Dialectical behavior therapy for patients with borderline personality disorder and drug-dependence

A randomized clinical trial was conducted to evaluate whether Dialectical Behavior Therapy (DBT), an effective cognitive-behavioral treatment for suicidal individuals with borderline personality disorder (BPD), would also be effective for drug-dependent women with BPD when compared with treatment-as-usual (TAU) in the community. Subjects were randomly assigned to either DBT or TAU for a year of treatment. Subjects were assessed at 4, 8, and 12 months, and at a 16-month follow-up. Subjects assigned to DBT had significantly greater reductions in drug abuse measured both by structured interviews and urinalyses throughout the treatment year and at follow-up than did subjects assigned to TAU. DBT also maintained subjects in treatment better than did TAU, and subjects assigned to DBT had significantly greater gains in global and social adjustment at follow-up than did those assigned to TAU. DBT has been shown to be more effective than treatment-as-usual in treating drug abuse in this study, providing more support for DBT as an effective treatment for severely dysfunctional BPD patients across a range of presenting problems.

Dialectical behavior therapy for personality disorders

Interest in dialectical behavior therapy (DBT) as a treatment for personality disorders has increased dramatically in recent years. Although originally designed for the outpatient treatment of suicidal individuals with borderline personality disorder (BPD), DBT has been applied to many more diverse populations including comorbid substance dependence and BPD, inpatient treatment for BPD, as well as antisocial behaviors in juveniles and adults. This paper provides a brief overview of DBT, presents and evaluates the most recent literature on the application of DBT to the treatment of personality disorders, and highlights some of the current controversies surrounding the use of DBT.

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

Inpatient treatment of individuals with borderline personality disorder (BPD) is typically fraught with difficulty and failure. Patients and staff often become entangled in intense negative therapeutic spirals that obliterate the potential for focused, realistic, and effective treatment interventions. We describe an inpatient treatment approach to BPD patients which is an application of Dialectical Behavior Therapy (DBT), a cognitive-behavioral therapy for patients with BPD which has been shown to be effective in reducing suicidal behavior, hospitalization, and treatment dropout and improving interpersonal functioning and anger management. The inpatient DBT staff creates a validating treatment milieu and focuses on orienting and educating new patients and identifying and prioritizing their treatment targets. Inpatient DBT treatment techniques include contingency management procedures, skills training and coaching, behavioral analysis, structured response protocols to suicidal and egregious behaviors on the unit, and consultation team meetings for DBT staff.

Research on dialectical behavior therapy for patients with borderline personality disorder

Research evidence to date indicates that, although DBT was developed for the treatment of patients with suicidal behavior, it can be adapted to treat BPD patients with comorbid substance-abuse disorder and be extended to other patient populations and the treatment of other disorders. Across studies, DBT seems to reduce severe dysfunctional behaviors that are targeted for intervention (e.g., parasuicide, substance abuse, and binge eating), enhance treatment retention, and reduce psychiatric hospitalization. Evidence suggests that additional research is warranted to examine which components of DBT contribute to outcomes. Although preliminary, skills coaching seems to be a crucial ingredient in producing reductions in parasuicidal behavior, and specific strategies (e.g., validation, balance of change, and acceptance interventions) may play an important role in positive behavioral change. Several investigators are evaluating the efficacy of DBT. For example, Asberg et al at the Karolinska Institute in Sweden have begun a pilot study comparing DBT for women who have made multiple suicide attempts to transference focus psychotherapy, a psychodynamic therapy developed by Kernberg. They have planned a randomized clinical trial to compare DBT and transference focus psychotherapy with TAU in the community. van den Bosch has completed a randomized clinical trial for women who met criteria for BPD and substance abuse comparing DBT-S with TAU. Lynch is conducting a randomized clinical trial examining the efficacy of DBT skills training plus medication versus medication only for the treatment of moderate to severe depression in the elderly. Results from these studies should become available over the next several years, providing further empiric evidence by which to evaluate the efficacy of DBT. Additional development of DBT seems warranted to improve its efficacy, and additional investigation is needed to establish its effectiveness in public health settings. Analyses from existing data sets of factors that predict treatment response and elements of the treatment that contribute to outcome are needed. Also, longitudinal follow-up studies to determine suicide rates and maintenance of treatment gains are needed. Because DBT has been adopted in a variety of clinical settings, effectiveness studies are needed. Given the difficulty of conducting treatment research with chronically suicidal individuals, perhaps the largest challenge to further treatment development is recruiting young investigators who are willing to conduct research in this area. Nevertheless, in the 6 years since the treatment manuals were published, DBT seems to be a step toward more effective treatment for severely multidisordered patients.

Facial expression recognition ability among women with borderline personality disorder: implications for emotion regulation?

This study examined recognition of facial expressions of emotion among women diagnosed with borderline personality disorder (BPD; n = 21), compared to a group of women with histories of childhood sexual abuse with no current or prior diagnosis of BPD (n = 21) and a group of women with no history of sexual abuse or BPD (n = 20). Facial recognition was assessed by a slide set developed by Ekman and Matsumoto (Japanese and Caucasian Facial Expressions of Emotion and Neutral Faces, 1992), expanded and improved from previous slide sets, and utilized a coding system that allowed for free responses rather than the more typical fixed-response format. Results indicated that borderline individuals were primarily accurate perceivers of others' emotions and showed a tendency toward heightened sensitivity on recognition of fear, specifically. Results are discussed in terms of emotional appraisal ability and emotion dysregulation among individuals with BPD.

The Reasons for Living Inventory for Adolescents (RFL-A): development and psychometric properties

The role of adaptive beliefs and attitudes against suicide has not been given adequate attention in the clinical or assessment literature. This article reports on the development and initial psychometric properties of a 32-item self-report inventory, the Reasons for Living Inventory for Adolescents (RFL-A). In Phase 1, we used exploratory and confirmatory factor analyses to identify five correlated factors: Future Optimism, Suicide-Related Concerns, Family Alliance, Peer Acceptance and Support, and Self-Acceptance. In Phase 2, we cross-validated the 5-factor oblique model in a different group of adolescents recruited from two high schools. In addition, we examined evidence for convergent, discriminant, and construct validities. The coefficient alpha indices for the RFL-A total and scales were satisfactory. In Phase 3, we evaluated additional evidence of reliability and validity using samples of high school and psychiatric inpatient adolescents. The results suggest that the RFL-A is a short, reliable, and valid measure that is potentially useful in the assessment of adolescent suicidal behavior.

Special feature: theory and treatment development and evaluation: reflections on Benjamin's "models for treatment"

To make the final point of this commentary clear at the outset, I could not agree with Dr. L. S. Benjamin's comments more, on the one hand, and could not disagree more, on the other hand. I will first review the points that I not only agree with but also think are extremely important. I will then beg to differ with some of her conclusions (at least as I interpret then), and with her analysis of the outcomes of the one cognitive-behavioral treatment of a personality disorder she reviewed in some detail.

Behavioral treatments of suicidal behaviors. Definitional obfuscation and treatment outcomes

This chapter focuses on a review of randomized clinical trials of both psychosocial and behavioral interventions designed to directly reduce rates of suicide and parasuicidal behavior, including suicide attempts. It begins with an overview of the definitional difficulties in this field and then proceeds to an overview of treatment issues and a comprehensive review of treatment studies aiming to reduce suicidal behavior among suicidal individuals. Twenty studies are discussed. Eighteen studies randomly assigned subjects to the experimental and control condition; the other two studies assigned subjects in an alternating sequential fashion. Analyses showed that four psychosocial intervention studies and one pharmacotherapy study have reported efficacious results when compared to treatments-as-usual or placebo controls. From another perspective, when outpatient psychosocial interventions were examined, the strongest predictor of whether the experimental treatment would be more effective than the control was whether high-risk suicidal individuals were included. Psychosocial interventions appear to be most effective with the more high-risk individuals.

The Brief Reasons for Living Inventory for Adolescents (BRFL-A)

This study modified and evaluated the psychometric properties of the Reasons for Living Inventory (RFL) in samples of adolescents. Internal consistency reliability, corrected item-total scale correlation, and exploratory factor analysis procedures were used with a mixed sample of 260 adolescents to identify 14 items for the brief version of the RFL (BRFL-A). Confirmatory factor analyses provided support for the five-factor oblique structure of the BRFL-A in a psychiatric inpatient sample with a range of suicidal behaviors. Reliabilities of the BRFL-A subscales were satisfactory. Four of the five subscales differentiated between suicidal and nonsuicidal adolescents. Significant correlations were found between three BRFL-A subscales and several suicide indices. Convergent-discriminant validity was examined by correlating the BRFL-A subscales with the Minnesota Multiphasic Personality Inventory-Adolescents (MMPI-A) Content Scales. Limitations of the study are discussed.

Interpersonal outcome of cognitive behavioral treatment for chronically suicidal borderline patients

OBJECTIVE

This study reports the efficacy of a cognitive behavioral outpatient treatment on interpersonal outcome variables for patients diagnosed with borderline personality disorder.

METHOD

In a 1-year clinical trial, 26 female patients with borderline personality disorder were randomly assigned to either dialectical behavior therapy or a treatment-as-usual comparison condition. All subjects met criteria of DSM-III-R and Diagnostic Interview for Borderline Patients for borderline personality disorder and were chronically suicidal.

RESULTS

In both the intent-to-treat and treatment completion groups, dialectical behavior therapy subjects had significantly better scores on measures of anger, interviewer-rated global social adjustment, and the Global Assessment Scale and tended to rate themselves better on overall social adjustment than treatment-as-usual subjects.

CONCLUSIONS

These results suggest that dialectical behavior therapy is a promising psychosocial intervention for improving interpersonal functioning among severely dysfunctional patients with borderline personality disorder.

Dialectical behavior therapy for borderline personality disorder: theoretical and empirical foundations

Dialectical behavior therapy (DBT) is a cognitive-behavioral psychotherapy developed by Linehan for parasuicidal patients with a diagnosis of borderline personality disorder (BPD). DBT is based on a biosocial theory that views BPD as primarily a dysfunction of the emotion regulation system. The treatment is organized around a hierarchy of behavioral goals that vary in different modes of therapy. In two randomized trials, DBT has shown superiority in reducing parasuicide, medical risk of parasuicides, number of hospital days, dropout from treatment and anger while improving social adjustment. Most gains were maintained through a 1-year follow-up. In one process study testing DBT theory, dialectical techniques balancing acceptance and change were more effective than pure change or acceptance techniques in reducing suicidal behavior.

Naturalistic follow-up of a behavioral treatment for chronically parasuicidal borderline patients

BACKGROUND

A randomized clinical trial was conducted to evaluate whether the superior performance of dialectical behavior therapy (DBT), a psychosocial treatment for borderline personality disorder, compared with treatment-as-usual in the community, is maintained during a 1-year posttreatment follow-up.

METHODS

We analyzed 39 women who met criteria for borderline personality disorder, defined by Gunderson's Diagnostic Interview for Borderline Personality Disorder and DSM-III-R criteria, and who had a history of parasuicidal behavior. Subjects were randomly assigned either to 1 year of DBT, a cognitive behavioral therapy that combines individual psychotherapy with group behavioral skills training, or to treatment-as-usual, which may or may not have included individual psychotherapy. Efficacy was measured on parasuicidal behavior (Parasuicide History Interview), psychiatric inpatient days (Treatment History Interview), anger (State-Trait Anger Scale), global functioning (Global Assessment Scale), and social adjustment (Social Adjustment Scale--Interview and Social Adjustment Scale--Self-Report). Subjects were assessed at 6 and 12 months into the follow-up year.

RESULTS

Comparison of the two conditions revealed that throughout the follow-up year, DBT subjects had significantly higher Global Assessment Scale scores. During the initial 6 months of the follow-up, DBT subjects had significantly less parasuicidal behavior, less anger, and better self-reported social adjustment. During the final 6 months, DBT subjects had significantly fewer psychiatric inpatient days and better interviewer-rated social adjustment.

CONCLUSION

In general, the superiority of DBT over treatment-as-usual, found in previous studies at the completion of 1 year of treatment, was retained during a 1-year follow-up.

Cognitive-behavioral treatment of chronically parasuicidal borderline patients

A randomized clinical trial was conducted to evaluate the effectiveness of a cognitive-behavioral therapy, ie, dialectical behavior therapy, for the treatment of chronically parasuicidal women who met criteria for borderline personality disorder. The treatment lasted 1 year, with assessment every 4 months. The control condition was "treatment as usual" in the community. At most assessment points and during the entire year, the subjects who received dialectical behavior therapy had fewer incidences of parasuicide and less medically severe parasuicides, were more likely to stay in individual therapy, and had fewer inpatient psychiatric days. There were no between-group differences on measures of depression, hopelessness, suicide ideation, or reasons for living although scores on all four measures decreased throughout the year.

Modeling effects on suicidal behavior

Knowledge of suicidal behavior, i.e., psychiatric patients indicating that they have an acquaintance or relative who has attempted or committed suicide, has been cited as a risk factor in the assessment of suicide potential. The authors evaluated psychiatric patients hospitalized for a suicide attempt (N = 30), serious suicidal ideation (N = 26), or other non-suicide-related reasons (N = 20) and also a control group of 18 patients admitted for orthopaedic surgery. Information derived from a structured clinical interview revealed that suicide attempters have fewer suicidal models than individuals in the other patient groups, and they are more interpersonally distant from the models they do know. Depression level was not positively related to the recall and reporting of suicidal models. Measures assessing suicide-related beliefs revealed that suicide attempters rated suicide as an effective solution for problems to a greater extent that did patients in the remaining three groups. The implications of these results for social learning models of suicidal behavior are discussed.

Suicidal behaviors among clients at an outpatient psychology clinic versus the general population

The focus of this paper is on the comparison of suicidal behaviors among two populations in the same geographical area: clients at a psychology clinic vs. individuals from the general population sampled at an area shopping center. In both samples 10 percent of the individuals reported prior parasuicidal behavior; the two populations were also quite similar on reports of prior suicidal ideation: 31 percent in the clinical and 24 percent in the general population reported never, or only briefly, considering suicide at any point in their lives. Suicidal behavior was related to sex and income in the general population.

Suicide and attempted suicide: study of perceived sex differences

The study investigated social evaluations of suicidal behavior as a function of sex. A 2 × 2 × 2 factorial design was used with the following factors: sex of S, sex of concept, suicidal behavior of concept (suicide, attempted suicide). 202 evening school college students rated the concepts on evaluative, potency, activity, and masculinity semantic differential scales. Results support the hypothesis that suicide is considered more masculine than attempted suicide and partially support the hypothesis that suicide is considered more potent than attempted suicide.