Treating Co-Occurring Axis I Disorders in Recurrently Suicidal Women With Borderline

Personality Disorder: A 2-Year Randomized Trial of Dialectical

Behavior Therapy Versus Community Treatment by Experts

Melanie S. HarnedAlexander L. Chapman

Elizabeth T. Dexter-Mazzaet al.

Journal of Consulting and Clinical Psychology2008, Vol. 76, No. 6, 1068–1075

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Background

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• Numerous studies have showed patients with borderline personality disorder (BPD) have high rates of co-occurring Axis I disorders

• Patients with BPD also have more co-occurring Axis I disorders than do other diagnostic groups

• The co-occurring Axis I disorders, particularly substance use disorder (SUD) and PTSD, decreases the likelihood of attaining remission from BPD (Zanarini et al., 2004)

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• Except for the central disorders of BPD, such as suicide attempts, co-occurring Axis I disorders must also be the focus of treatments

• Many studies have shown that Dialectical behavior therapy (DBT) can efficiently treating BPD and Axis I disorders

• However, no studies have examined whether DBT leads to remission of co-occurring Axis I disorders among patients with BPD

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• The present study is part of a larger program of research comparing DBT with a rigorous control condition (community treatment by experts, or CTBE) designed to control for potential threats to internal validity (e.g., expertise, allegiance).

• Findings from the main outcome study indicate that DBT has unique effects that extend beyond those of general nonbehavioral expert therapy in reducing suicide attempts, medical severity of suicide attempts and NSSI acts, use of crisis services, inpatient hospitalizations, and treatment dropout (Linehan et al., 2006).

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• In the present study, we used data from the Linehan et al. study to examine the efficacy of DBT versus CTBE in treating co-occurring Axis I disorder among suicidal BPD patients.

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Objective

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• To examine the efficacy of DBT versus CTB

E in treating co-occurring Axis I disorders a

mong suicidal BPD patients.

• Based on previous study (Linehan et al., 2006):

Compared with those of general nonbehavioral ex

pert therapy, DBT has unique effects in reducing s

uicide attempts, inpatient hospitalizations and trea

tment dropout.

Methods

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• 101 women (age 18–45) who met criteria for BP

D

• reported at least two suicide attempts and/or N

SSI (nonsuicidal self-injury) acts in the past 5 ye

ars

• at least one act in the 8-week prestudy period.

Participants

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Exclusion criteria

• schizophrenia, schizoaffective disorder, bipolar

disorder, psychotic disorder not otherwise

specified, or mental retardation

• a seizure disorder requiring medication

• a mandate to treatment

• the need for primary treatment for another

debilitating condition

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Procedures

• Design: randomized control trial (RCT)

• Baseline assessments were made under the condition that the participants were not informed of their treatment assignment

• Outcome assessments occurred at 4-month intervals through the 1-year treatment and 1-year follow-up period

• Assessments were conducted blindly by independent clinical assessors.

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Treatment Conditions

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DBT

• DBT is a cognitive-behavioral treatment for suicidal individuals who meet criteria for BPD.

• DBT consists of (a) weekly individual psychotherapy (1 hr/wk); (b) group skills training (2.5 hr/wk); (c) phone consultation (as needed); and (d) weekly therapist consultation team meeting.

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CTBE• CTBE condition was developed as comparison

group to control for potential threats to the internal validity

• Therapists were nominated as experts at treating difficult clients with BPD without conducting DBT or any behavior treatment

• Expert treatment is the model used in most community mental health centers

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Assessment Measures

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• BPD was diagnosed with the Structured Clinical Interview for DSM–III–R Personality Disorders (SCID–II;) and the International Personality Disorders Examination (Loranger, 1995).

• The SCID–II was readministered at the 24-month point.

• The SCID–I assessed Axis I diagnoses at pretreatment

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• The Longitudinal Interval Follow-Up (LIFE) E

valuation was used to gather retrospective ratin

gs of Axis I disorders for each week of the study

(i.e.,104 weeks).

• psychological status ratings (PSRs) was assigne

d weekly for each disorder identified at pretrea

tment via the SCID–I.

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• PSRs range from 1 to 6 for MDD (1=usual self, 2= residual, 3=partial remission, 4=marked, 5= definite criteria, 6=definite criteria, severe) and from 1 to 3 for all other diagnoses (1=none, 2=moderate, 3=severe).

• High interviewer-observer reliability has been shown for the change points in diagnostic criteria as well as for the level of psychopathology (Keller et al., 1987).

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• DSM–IV–TR was used as the remission criteria

for substance dependence disorders (SDD)– (a) early partial remission (PSR=2 for at least 4 wee

ks)

– (b) early full remission (PSR=1 for at least 4 weeks).

• Remission criteria for mood, anxiety, and ED was used the conventional criteria LIFE

• For all disorders, relapse was defined as meetin

g full criteria for a disorder after having achiev

ed full remission.

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Statistical Methods

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• For group comparisons , t tests for continuous variables and chi-squares and Fisher’s exact tests for categorical variables.

• Kaplan–Meier and Cox regression survival analyses examined the time to first full remission.

• The study conducted on the intent-to-treat analysis

Results

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Baseline Sample Characteristics

The two groups did not differ significantly on any demographic characteristics or in rates of lifetime or current Axis I diagnoses at pretreatment

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Remission and Relapse for Co-Occurring Axis I Disorders

DBT and CTBE patients did not significantly differ in the proportion of Axis I disorders that reached full remission or that subsequently relapsed

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For specific Axis I disorders, DBT patients were significantly more likely to achieve full remission from SDD than were CTBE patients

Group comparisons of rates of full remission

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DBT patients spent significantly more time in partial remission and less time in no remission from SDD than did CTBE patients

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Survival analyses of the time to the first full remission did not indicate significant differences between treatments for any Axis I disorder

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DBT patients and CTBE patients did not significantly differ in rates of relapse for any Axis I disorder

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DBT patients with SDD reported a significantly greater proportion of drug andalcohol-abstinent days across time than did CTBE patients with SDD

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DBT and CTBE patients with SDD did not significantly differ in the number of BPD criteria met or in use of psychotropic medication

Discussion

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Superiority of DBT• DBT is superior to CTBE treating co-occurring SDD

among suicidal BPD patients

• DBT patients were more likely to achieve full

remission from SDD than CTBE patients (87.5% vs.

33.3%) and spent proportionally more time in partial

remission and less time in meeting full criteria for

SDD

• DBT patients with SDD also reported more drug and

alcohol abstinence days across time than did CTBE

patients with SDD

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One problem

If the superiority of DBT in decreasing SDD among patients with BPD was attributable to differences in BPD criterion behaviors or to psychotropic medication usage between treatment groups?

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Answer: maybe not • DBT targets substance use directly (via self-

monitoring, behavioral analyses, and problem-solving strategies) rather than indirectly (via other, related problems)

• several DBT skills are similar to those used in evidence-based SUD treatments

• specific attention has been paid to adapting

DBT to treat co-occurring SUD in patients with BPD

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General factors of DBT and CTBE

• The lack of significant differences between DBT

and CTBE for other Axis I disorders suggests that

general factors associated with expert therapy

may account for reductions in these disorders.

• Alternatively, given that many of the comparisons

yielded moderate-to-large effect sizes generally in

favor of DBT, the lack of significant differences

may be due to inadequate power.

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Notably high remission rates• 74% of DBT patients and 67% of CTBE patients achie

ved full remission from at least one Axis I disorder, and patients in both treatments fully remitted from approximately 50% of their co-occurring Axis I disorders.

• These rates, particularly for DBT, are comparable with those commonly found in psychological treatments for SDD (54%–71%; Crits-Christoph et al., 1999), MDD (47%–56%; de Mello, Mari, Bacaltchuk,Verdeli, & Neugebauer, 2005), and ED (50%; Fairburn & Brownell, 2001).

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Lower rates of remission from anxiety disorders

• Both DBT and CTBE achieved lower rates of remission from anxiety disorders

• Our lower remission rates support previous findings that anxiety disorder treatments are less efficacious among individuals with BPD.

• With severe, multiproblem patients, anxiety disorders may have been a lower treatment priority than suicidal behaviors

• In DBT, PTSD related to childhood abuse is not targeted until the second stage of treatment. Alternatively, anxiety disorders maybe particularly intractable among patients with BPD.

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Limitation

• Possible lack of power to detect between-groups differences due to small sample sizes for the specific Axis I disorders and primarily dichotomous outcomes.

• Although we validated all significant findings on the LIFE with a secondary measure of a similar outcome, there is a potential risk of Type I error.

• Further research on mechanisms of action in reducing Axis I disorders among patients with BPD is needed.

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Comments

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Strengths of the study

• Psychological treatments for BDP patients with Axis I Disorders is a challenging work. This carefully designed RCT study produced several outcomes that were significantly more positive for DBT than CTBE.

• This evidence-based study support that DBT has unique treatment elements that aren’t common with non-behavioral therapy that are related to significantly more positive outcomes

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Several problems

• There may had memory bias of retrospective ratings of psychological status for each week.

• Experts from CTBE group might conduct different nonbehavioral treatments, how to control the different treatment effects among these experts?

• Do the characteristics of patients involved in a DBT group influence the effectiveness of treatment? For example, treating chronically suicidal patients with those who are not

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Summary• In intervention study, indicators of efficacy should

be designed carefully.• Under the condition that China is quite lack of me

ntal health practitioners, how to train qualified therapists and popularized the treatments.

• Can DBT be developed as group therapy, it is need further explore.

• How about the feasibility of practicing DBT in the community setting?

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