DeViersprong Center of Psychotherapy, University of Amsterdam, Halsteren
Amsterdam Institute for Addiction Research
Erasmus University Medical Centre, Rotterdam
Amsterdam Institute for Addiction Research, Amsterdam, The Netherlands
Correspondence: Dr Roel Verheul, Psychotherapeutisch Centrum De Viersprong, Post Box 7, 4660 AA Halsteren, The Netherlands. Tel: +31 0 164 632200; fax: +31 0 164 632220; e-mail: roel.verheul{at}deviersprong.net
Declaration of interest None. This work was supported by ZAO Health Insurance Company, Amsterdam.
![]() |
ABSTRACT |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Aims To compare the effectiveness of DBT with treatment as usual for patients with BPD and to examine the impact of baseline severity on effectiveness.
Method Fifty-eight women with BPD were randomly assigned to either 12 months of DBT or usual treatment in a randomised controlled study. Participants were recruited through clinical referrals from both addiction treatment and psychiatric services. Outcome measures included treatment retention and the course of suicidal, self-mutilating and self-damaging impulsive behaviours.
Results Dialectical behaviour therapy resulted in better retention rates and greater reductions of self-mutilating and self-damaging impulsive behaviours compared with usual treatment, especially among those with a history of frequent self-mutilation.
Conclusions Dialectical behaviour therapy is superior to usual treatment in reducing high-risk behaviours in patients with BPD.
![]() |
INTRODUCTION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
In a randomised controlled trial, we compared the effectiveness of dialectical behaviour therapy with treatment as usual in terms of the therapy's primary targets (Linehan et al, 1999b): first, treatment retention and second, high-risk behaviours, including suicidal, self-mutilating and self-damaging impulsive behaviours. A further aim was to examine whether the efficacy of dialectical behaviour therapy is modified by baseline severity of parasuicide. This report describes the first 12 months of the trial.
![]() |
METHOD |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Randomisation procedure
Following the completion of the intake assessments, patients were randomly
assigned to treatment conditions. A minimisation method was used to ensure
comparability of the two treatment conditions on age, alcohol problems, drug
problems and social problems (as measured by the European version of the
Addiction Severity Index (Kokkevi &
Hartgers, 1995)).
Treatments
Patients assigned to dialectical behaviour therapy received 12 months of
treatment as specified in the manual
(Linehan, 1993). The treatment
combines weekly individual cognitivebehavioural psychotherapy sessions
with the primary therapist, weekly skills-training groups lasting 2-2.5 h per
session, and weekly supervision and consultation meetings for the therapists
(Linehan, 1993). Individual
therapy focuses primarily on motivational issues, including the motivation to
stay alive and to stay in treatment. Group therapy teaches self-regulation and
change skills, and skills for self-acceptance and acceptance of others. Among
its central principles is dialectical behaviour therapy's simultaneous focus
on both acceptance and validation strategies and change strategies to achieve
a synthetic (dialectical) balance in client functioning. The median adherence
score on a 5-point Likert scale was 3.8 (range 2.5-4.5), indicating
almost good dialectical behaviour therapy in terms of conformity
to the treatment manual.
Treatment as usual consisted of clinical management from the original referral source (addiction treatment centres n=11, psychiatric services n=20). Patients in this group attended generally no more than two sessions per month with a psychologist, a psychiatrist or a social worker.
Therapists
Extensive attention was paid to the selection, training and supervision of
the dialectical behaviour therapists, who included four psychiatrists and 12
clinical psychologists. Group training was conducted in three separate groups
led jointly by social workers and clinical psychologists. Training, regular
monitoring (using videotapes) and weekly individual and group supervision were
performed by the second author (L.M.C.B.), who received intensive training
from Professor Linehan in Seattle and is a member of the international
dialectical behaviour therapy training group.
Outcome assessments
Baseline assessments took place 1-16 weeks (median 6 weeks) before
randomisation. Therapy began 4 weeks after randomisation. Three clinical
psychologists (two with master's degrees and one a Doctor of Philosophy)
conducted all assessments. They were experienced diagnosticians who received
additional specific training in the administration of the instruments.
Recurrent parasuicidal and self-damaging impulsive behaviours were measured at baseline and at 11, 22, 33, 44 and 52 weeks after randomisation using the appropriate sections of the Borderline Personality Disorder Severity Index (BPDSI; Arntz et al, 2003), a semi-structured interview assessing the frequency of border-line symptoms in the previous 3-month period. The BPDSI consists of nine sections, one for each of the DSM-IV criteria for borderline personality disorder. The parasuicide section includes three items reflecting distinct suicidal behaviours (suicide threats, preparations for suicide attempts, and actual suicide attempts). The impulsivity section includes 11 items reflecting the manifestations of self-damaging impulsivity (e.g. gambling, binge eating, substance misuse, reckless driving). The parasuicide and impulsivity sections have shown reasonable internal consistencies (0.69 and 0.67, respectively), excellent interrater reliability (0.95 and 0.97, respectively) and good concurrent validity (Arntz et al, 2003). Three month testretest reliability for the total BPDSI score was 0.77.
Self-mutilating behaviours were measured using the Lifetime Parasuicide Count (LPC; Comtois & Linehan, 1999) at baseline and the adapted (3-month) version was administered 22 weeks and 52 weeks after randomisation. The LPC obtains information about the frequency and subsequent medical treatment of self-mutilating behaviours (e.g. cutting, burning and pricking).
Completeness of data
Of the five follow-up assessments, participants completed a mean of 3.7
assessments, with no significant difference between treatment conditions
(CochranMantelHaenszel test 23=1.51;
P=0.14). Forty-seven (81%) completed the assessment at week 52.
Statistical analysis
For the analysis of treatment retention, chisquared analysis was used. The
course of high-risk behaviours as measured with the LPC and BPDSI was analysed
using a general linear mixed model (GLMM) approach (Mixed
procedure from SAS version 6.12; SAS Institute, Cary, NC). Preliminary to the
GLMM analyses, examination of the variable characteristics revealed highly
skewed distributions of the BPDSI parasuicide and impulsivity and the LPC
total score. A shifted log transformation was performed on each of these
variables. A Bonferroni correction to the level of significance was applied,
resulting in an of 0.013 (0.05/4).
Within the GLMM approach, we used a two-step procedure: first, the covariance structure was fitted using restricted likelihood and a saturated fixed model, and second the fixed model was refined using maximum likelihood (Verbeke & Molenberghs, 1997). The main advantage of the GLMM approach over standard repeated-measurement multivariate analysis of variance is that it allows for inclusion of cases with missing values, thereby providing a better estimate of the true (unbiased) effect within the intention-to-treat sample. To examine the effect of dialectical behaviour therapy on the course of high-risk behaviours, we used a model with time, treatment, and time x treatment interaction. To correct for possible initial differences, baseline severity was added as a covariate. To examine the impact of initial severity on outcome, we implemented a model with time, baseline severity, treatment condition and the two-way and three-way interactions between these variables.
![]() |
RESULTS |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
|
|
Treatment retention
Significantly more patients who were receiving dialectical behaviour
therapy (n=17; 63%) than patients in the control group (n=7;
23%) continued in therapy with the same therapist for the entire year
(21=9.70; P=0.002). This difference was
maintained when two members of the control group who were assigned to other
therapists within the same institutes were included in the calculation
(
21=6.72; P=0.010).
High-risk behaviours
The frequency and course of suicidal behaviours were not significantly
different across treatment conditions: neither treatment condition
(t1,137=0.03; P=0.866) nor the interaction
between time and treatment condition (t1,166=0.22;
P=0.639) reached statistical significance. An additional analysis
revealed that, although fewer patients in the dialectical behaviour therapy
group (n=2; 7%) than in the control group (n=8; 26%)
attempted suicide during the year, this difference was not statistically
significant (21=3.24; P=0.064).
Self-mutilating behaviours of patients assigned to dialectical behaviour
therapy gradually diminished over the treatment year, whereas patients
assigned to treatment as usual gradually deteriorated in this respect: a
significant effect was observed for the interaction term time x
treatment condition (t1,44.4=10.24; P=0.003) but
not for treatment condition alone (t1,69.1=3.80;
P=0.055) (Fig. 2). The
most frequently reported self-mutilating acts were cutting, burning, pricking
and head-banging. At the week 52 assessment, 57% (n=13) of the
treatment-as-usual patients reported engaging in any self-mutilating behaviour
at least once in the previous 6-month period (median 13 times), against 35%
(n=8) of the dialectical behaviour therapy group (median 1.5 times);
median test 21=4.02; P=0.045.
|
In terms of self-damaging impulsive behaviour, patients assigned to dialectical behaviour therapy showed more improvement over time than patients in the control group: a significant effect was evident for the interaction term time x treatment condition (t1,164=2.60; P=0.010) but not for treatment condition alone (t1,122=1.02; P=0.315) (Fig. 3).
|
Confounding by medication use
Medication use was monitored by administration of the Treatment History
Interview (Linehan & Heard,
1987) at weeks 22 and 52. The greater improvement in the
dialectical behaviour therapy group could not be explained by greater or other
use of psychotropic medications by these patients. In both conditions,
three-quarters of the patients reported use of medication from one or more of
the following categories: benzodiazepines, selective serotonin reuptake
inhibitors (SSRIs), tricyclic antidepressants, mood stabilisers and
neuroleptics. Use of SSRIs was reported by 14 (52%) of the dialectical
behaviour therapy patients and 19 (61%) of treatment-as-usual patients
(21=0.44; P=0.509). These findings
eliminate the possibility of confounding by medication use.
Impact of baseline severity on effectiveness
The sample was divided according to a median split on the lifetime number
of self-mutilating acts. The number in the lower-severity group ranged from 0
to 14 (median 4.0) and in the higher-severity group from 14 to more than 1000
(median 60.5). The two groups did not differ with respect to the total score
on the BPDSI and the Addiction Severity Index. For suicidal behaviour an
almost significant effect was evident for the three-way interaction term time
x severity x treatment condition (t1,170=4.81;
P=0.029), indicating a trend towards greater effectiveness of
dialectical behaviour therapy in severely affected individuals. For
self-mutilating behaviours a significant effect was evident for the three-way
interaction term time x severity x treatment condition
(t1,404=16.82; P=0.000) and the interaction term
severity x treatment condition (t1,67.6=9.63;
P=0.003), indicating that dialectical behaviour therapy was superior
to treatment as usual for patients in the high-severity group but not for
their low-severity counterparts (Fig.
4). No differential effectiveness was found for self-damaging
impulsivity.
|
![]() |
DISCUSSION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Significance of findings
The current study results being highly concordant with previously
published studies are significant for several reasons. First, this is
the first clinical trial of dialectical behaviour therapy that was not
conducted by its developer and that was conducted outside the USA. This study
supports the accumulating evidence that mental health professionals outside
academic research centres can effectively learn and apply dialectical
behaviour therapy (Hawkins & Sinha,
1998), and that the therapy can be successfully disseminated in
other settings (Barley et al,
1993; Springer et al,
1996) and in other countries. Second, a relatively large sample
size allowed more rigorous statistical testing of the therapy's efficacy than
former trials, thereby countering some of the recently expressed concerns
about the status of dialectical behaviour therapy as the treatment of choice
for borderline personality disorder
(Scheel, 2000;
Tyrer, 2002). Third, our
findings indicated that patients receiving treatment as usual deteriorated
over time, suggesting that non-specialised treatment facilities might actually
cause harm rather than improvement. Finally, in contrast to the original trial
(Linehan et al,
1991), the sample was drawn from clinical referrals from both
addiction treatment and psychiatric services, and people with substance use
disorders were not excluded. Our study provides evidence that standard
dialectical behaviour therapy is suitable for patients with borderline
personality disorder regardless of the presence of substance use disorders
(cf. Bosch et al,
2002). This is consistent with a previous report showing that, in
borderline personality disorder, patients with substance use disorders are
largely similar to those without such disorders in terms of type and severity
of symptoms, treatment history, family history of substance use disorders and
adverse childhood experiences (Bosch et
al, 2001). Together these findings imply that addictive
behaviours in patients with borderline personality disorder can best be
considered as a manifestation of the borderline disorder rather than as a
condition that constitutes significant clinical heterogeneity and justifies
the exclusion of these patients from efficacy studies.
Clinical implications
Based upon multiple effectiveness studies, it is now well established that
dialectical behaviour therapy is an efficacious treatment of high-risk
behaviours in patients with borderline personality disorder. This is probably
due to some of this treatment's distinguishing features:
Across studies, however, dialectical behaviour therapy has not been effective in reducing depression and hopelessness, or in improving survival and coping beliefs or overall life satisfaction (Scheel, 2000). In addition, our study showed that, although dialectical behaviour therapy was effective in reducing self-harm in chronically parasuicidal patients, its impact on patients in the low-severity group was similar to that of treatment as usual. Together, these findings suggest that dialectical behaviour therapy should consistent with its original aims (Linehan, 1987) be the treatment of choice only for patients with borderline personality disorder who are chronically parasuicidal and should perhaps be extended or followed by another treatment, focusing on other components of the borderline personality disorder, as soon as the level of high-risk behaviour is sufficiently reduced. Alternatively, it could be argued that dialectical behaviour therapy is the treatment of choice for patients with severe, life-threatening impulse-control disorders rather than borderline personality disorder per se, implying that patients with other severe impulse-regulation disorders (e.g. substance use disorders or eating disorders) might benefit from the therapy. The latter interpretation is consistent with the development of modified versions of dialectical behaviour therapy for the treatment of patients with borderline personality disorder and a comorbid diagnosis of drug dependence (Linehan et al, 1999a), or patients with a binge eating disorder (Wiser & Telch, 1999).
Limitations
One limitation of our study is that dialectical behaviour therapy was
compared with treatment as usual or unstructured clinical management. This has
been recommended as a first step in establishing the efficacy of a treatment
(Teasdale et al,
1984; Linehan et al,
1991), but it allows no conclusion about the effect of the
experimental treatment compared with other manual-based treatment
programmes.
The observed effect size of dialectical behaviour therapy might be different from the true effect size because of a number of factors. First, although the research assessors were not informed about the treatment condition of their interviewees, it is unlikely that they remained masked throughout the project. Patients might have given them this information, or it could easily have been derived from some of the interviews. This concern is somewhat mitigated by the fact that the research focused on objective behaviours rather than subjective perceptions and experiences. Second, it is important to note that an effect of dialectical behaviour therapy was observed in spite of the potentially equalising impact of the attention paid to patients by the research assessors during multiple repeated measurements, including the substantial efforts made to contact patients for appointments. Third, because we selected patients in ongoing therapy who were willing to terminate the treatment, some of the patients might have perceived assignment to treatment as usual to be a less desirable randomisation outcome than assignment to dialectical behaviour therapy. Finally, the observed effect might be biased by a possible Hawthorne effect in terms of greater enthusiasm among the dialectical behaviour therapists compared with those providing conventional therapy.
Although the latter two factors could have favoured dialectical behaviour therapy in terms of patient satisfaction or the quality of the working alliance, additional analyses revealed that the two patient groups were highly similar in terms of scores on the three sub-scales of the Working Alliance Inventory (Horvath & Greenberg, 1989): development of bond, agreement on goals and agreement on tasks. This observed similarity is striking since the quality of the working alliance is often considered to be a prerequisite of efficacy in psychotherapy (e.g. Lambert & Bergin, 1994) and because a substantial feature of dialectical behaviour therapy is the establishment of a working alliance (Linehan, 1993). Perhaps the efficacy of dialectical behaviour therapy results from the persistent and enduring focus on certain target behaviours rather than an optimal working alliance.
Further directions
The participants in this study were followed up after 18 months to examine
whether the treatment results were maintained after discharge. The results
will be published elsewhere. Future research should focus on comparison with
concurrent therapies such as schema-focused cognitive therapy
(Young, 1990) and
psychoanalytically oriented partial hospitalisation
(Bateman & Fonagy, 2001), as well as on the effective mechanisms at work. Potential mediators of
favourable outcomes are, for example, reduced catastrophising, enhanced skills
for regulating affect and coping with life events, or an increase in reasons
for living (Rietdijk et al,
2001). Knowledge about the specific mechanisms that make
dialectical behavior therapy work might enable therapists to better direct the
focus in treatment, and possibly stimulate dismantling studies to investigate
the efficacy of the individual components of the therapy.
![]() |
Clinical Implications and Limitations |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
LIMITATIONS
![]() |
ACKNOWLEDGMENTS |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
REFERENCES |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
American Psychiatric Association (2001)
Practice guideline for the treatment of patients with borderline personality
disorder. American Journal of Psychiatry,
158(suppl.),
1-52.
Arntz, A., Hoorn, M., van den Cornelis, J., et al (2003) Reliability and validity of the Borderline Personality Disorder Severity Index. Journal of Personality Disorders, in press.
Barley, W. D., Buie, S. E., Peterson, E. W., et al (1993) The development of an inpatient cognitivebehavioral treatment program for borderline personality disorder. Journal of Personality Disorders, 7, 232-240.
Bateman, A. & Fonagy, P. (2001) Treatment
of borderline personality disorder with psychoanalytically oriented partial
hospitalization: an 18 month follow-up. American Journal of
Psychiatry, 156,
1563-1569.
Bosch, L. M. C. van den, Verheul, R. & Brink, W. van den (2001) Substance abuse in borderline personality disorder: clinical and etiological correlates. Journal of Personality Disorders, 15, 416-424.[Medline]
Bosch, L. M. C., van den, Verheul, R., Schippers, G. M., et al (2002) Dialectical behavior therapy of borderline patients with and without substance use problems: implementation and long-term effects. Addictive Behaviors, 27, 911-923.[CrossRef][Medline]
Comtois, K. A. & Linehan, M. M. (1999) Lifetime Parasuicide Count (LPC). Seattle, WA: University of Washington.
First, M. B., Spitzer, R. L., Gibbon, M., et al (1994) Structured Clinical Interview for DSMIV Axis II Personality Disorders (SCIDII, Version 2.0). New York: Biometrics Research Department, New York State Psychiatric Institute.
Hawkins, K. A. & Sinha, R. (1998) Can line clinicians master the conceptual complexities of Dialectical Behavior Therapy? An evaluation of a State Department of Mental Health training program. Journal of Psychiatric Research, 32, 379-384.[CrossRef][Medline]
Horvath, A. O. & Greenberg, L. S. (1989) The development and validation of the Working Alliance Inventory. Journal of Counseling Psychology, 36, 223-233.[CrossRef]
Hyler, S. E. (1994) Personality Diagnostic Questionnaire, DSMIV version (PDQ-4+). New York: New York State Psychiatric Institute.
Koerner, K. & Linehan, M. M. (2000) Research on Dialectical Behavior Therapy for patients with borderline personality disorder. Psychiatric Clinics of North America, 23, 151-167.[Medline]
Kokkevi, A. & Hartgers, C. (1995) EuropASI: European adaptation of a multidimensional assessment instrument for drug and alcohol dependence. European Addiction Research, 1, 208-210.
Lambert, M. J. & Bergin, A. E. (1994) The effectiveness of psychotherapy. In Handbook of Psychotherapy and Behavior Change (eds A. E. Bergin & S. L. Garfield), pp. 143-189. New York: Wiley.
Linehan, M. M. (1987) Dialectical Behavior Therapy: a cognitive behavioral approach to parasuicide. Journal of Personality Disorders, 1, 328-333.
Linehan, M. M. (1993) Cognitive Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press.
Linehan, M. M. & Heard, H. L. (1987) Treatment History Interview (THI). Seattle, WA: University of Washington.
Linehan, M. M., Armstrong, H. E., Suarez, A., et al (1991) Cognitivebehavioral treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry, 48, 1060-1064.[Abstract]
Linehan, M. M., Schmidt, H. I., Dimeff, L. A., et al (1999a) Dialectical Behavior Therapy for patients with borderline personality disorder and drug dependence. American Journal on the Addictions, 8, 279-292.[CrossRef]
Linehan, M. M., Kanter, J. & Comtois, K. A. (1999b) Dialectical Behavior Therapy for borderline personality disorder. In Psychotherapy Indications and Outcomes (ed. D. S. Janowsky), pp. 93-118. Washington, DC: American Psychiatric Press.
Rietdijk, E. A., Verheul, R., Bosch, W. van den, et al (2001) Predicting self-damaging and suicidal behaviors in female borderline patients: reasons for living, coping, and depressive personality disorder. Journal of Personality Disorders, 15, 512-520.[Medline]
Scheel, K. R. (2000) The empirical basis of
Dialectical Behavior Therapy: summary, critique, and implications.
Clinical Psychology: Science and Practice,
7, 68-86.
Springer, T., Lohr, N. E., Buchtel, H. H. A., et al (1996) A preliminary report of short-term cognitivebehavioral group therapy for inpatients with personality disorders. Journal of Psychotherapy Practice Research, 5, 57-71.
Teasdale, J. D., Fennell, M. J. V., Hibbert, G. A., et al (1984) Cognitive therapy for major depressive disorder in primary care. British Journal of Psychiatry, 144, 400-406.[Abstract]
Tyrer, P. (2002) Practice guideline for the treatment of borderline personality disorder: a bridge too far. Journal of Personality Disorders, 16, 113-118.[Medline]
Verbeke, G. & Molenberghs, G. (1997) Linear Mixed Models in Practice: A SAS Oriented Approach (section 3.12). New York: Springer.
Wiser, S. & Telch, C. F. (1999) Dialectical Behavior Therapy for binge-eating disorder. Journal of Clinical Psychology, 55, 755-768.[CrossRef][Medline]
Young, J. E. (1990) Cognitive Therapy for Personality Disorders: A Schema-focused Approach. Sarasota: Professional Resource Exchange.
Received for publication March 28, 2002. Revision received August 5, 2002. Accepted for publication October 15, 2002.
Related articles in BJP: