Borderline personality disorder, substance abuse, and dialectical behavior therapy van den Bosch, L.M.C.

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1 UvA-DARE (Digital Academic Repository) Borderline personality disorder, substance abuse, and dialectical behavior therapy van den Bosch, L.M.C. Link to publication Citation for published version (APA): van den Bosch, L. M. C. (2003). Borderline personality disorder, substance abuse, and dialectical behavior therapy General rights It is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), other than for strictly personal, individual use, unless the work is under an open content license (like Creative Commons). Disclaimer/Complaints regulations If you believe that digital publication of certain material infringes any of your rights or (privacy) interests, please let the Library know, stating your reasons. In case of a legitimate complaint, the Library will make the material inaccessible and/or remove it from the website. Please Ask the Library: or a letter to: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam, The Netherlands. You will be contacted as soon as possible. UvA-DARE is a service provided by the library of the University of Amsterdam ( Download date: 15 Mar 2019

2 CHAPTERR I Generall Introduction Background d Borderlinee personality disorder (BPD) is probably one of the most stigmatizing mental disorders.. It is often undiagnosed, misdiagnosed, or treated inappropriately. Clinicians mayy limit the number of B P D patients in their practice or drop them as 'treatment resistant'.. Because of its classification as an Axis-n disorder, BPD is excluded from manyy managed care and healthcare plans. People with BPD often adopt maladaptive orr impulsive behaviours to cope with their pain. These behaviours account for some of thee nation's major public health problems, BPD has been found to be comorbid with manyy other conditions, such as substance abuse (Grilo et al., 1997; Crib et al., 1999), domesticc violence (Dutton etal., 1993; Dutton, 1995), eating disorders (Dennis, 1998), unprotectedd sex and increased risk for AIDS (Hull et al., 1993), stalking (Lewis et al., 2001),, and impulsive aggression (Goodman & New, 2000). BPD has an estimated suicidee rate of 10%. It is frequently masked by commonly known comorbid conditions thatt are easier to identify. Whatever symptom is identified first usually determines thee door the person opens into the health-cure system. What is treated may be a maladaptivee coping mechanism rather than the underlying syndrome. It is often the placee of entry that defines the primary diagnostic label (Coccaro & Kavoussi, 1997)- Thee frequent misdiagnosis of BPD and omission from studies may, next to the reasons connectedd with the negative connotation that goes with the disorder, be attributable to thee lack of an easily administered structured diagnostic interview capable of generating CHAPTERR I

3 reliablee psychiatric diagnoses in community and public health settings. Placement on Axis-iii in the DSM-IV, the confusing name of the disorder and its comorbidity with otherr illnesses such as substance abuse or PTSD appear to be contributing factors in thee under service and under recognition of BPD as a severe and disabling disorder. Becausee of its overlap with other disorders, evaluation of BPD research is difficult. Theree is an alarming shortage of trained therapists for these patients. In the United States,, the International Society for the Study of Personality Disorders lists its memberss by nationality. Some nations/countries list only one BPD researcher or clii nician, others just i to 5. Considering that the estimated BPD prevalence is 2% to 3% off the general population, this number of treatment professionals is much to low (Kessler,, 1994). Whyy is BPD the recipient of such professional disregard, and especially the BPD patient withh comorbid substance using problems? And, maybe even more important, can this bee changed? Because of the multi-problem character of BPD, it can be expected that symptom-specificc programs will be developed instead of integrated ones. This howeverr would introduce an undesirably high degree of differentiation that poses an enormouss organizational challenge for the mental health field. And, it would stress thee lack of trained therapists even more. Is it possible to give effective treatment too patients with impulse control disorders who tend to have multiple problems simultaneouslyy or, alternatively, tend to shift from one to another type of problem behaviour?? And, is it possible to recruit therapists who want to treat BPD patients in an,, evidence-based, effective way? Thesee questions were the main reasons that have led to the decision to study DBT in thee Netherlands, A research program was added because we wanted to replicate and extentt Unehan's original study with this group of patients. There are no other studies thatt have included borderline patients with and without substance abuse problems, recruitedd from addiction treatment services and from general psychiatric services. Maybee our results will show the feasibility of DBT for multi-problem BPD patients and underscoree the need of more integrated DBT programs and DBT trained therapists. Thee primary aim of this chapter is to provide insight in the Borderline Personality Disorderr and its severe symptomatology, and to give an overview of Dialectical Behaviorr Therapy in order to make understandable why a Randomised Controlled Triall was carried out in agroup of Dutch female borderline patients, with and without substancee abuse problems. The chapter ends with a description of the structure of thee thesis. BPD,, SUBSTANCE ABUSE, AND DBT - VAN DEN BOSCH

4 ii Borderline Personality Disorder Alreadyy in the 19 th century, patients who could not be designated to 'neurotic' or 'psychotic'' categories were placed in the 'borderland'. A hundred years later, in the beginningg of the 20 th century, psychoanalysis reinstated the use of a special name forr a group of patients that seemed not to be treatable and showed increasing therapy ii nterferi ng behaviou r during sessions. The term 'borderl i ne' originates th us from the conceptt that a psychopathological domain exists between neurosis and psychosis (Stern,, 1938).The psychopathology as described by Stern, was not only called 'borderline',, but also other diagnostic labels were used (e.g. 'bad hysteria', 'pseudoneuroticc schizophrenia'). Most analysts placed their borderline patients near the psychoticc end of the spectrum, at the border of schizophrenia. Knight (1953) was the onee to question this relationship with psychosis, because of the intact capacity for realityy testing. The concept was given clearer definitional boundaries by Kern berg (1967),, who developed the concept of the 'borderline personality organization', as a structurall diagnosis. For 35 years the concept of the'borderline patient'exclusively belongedd to the analytic literature, borderline being a specific early-childhood developmentall disorder. The first version of the DSM system did not mention the borderlinee personality disorder as a diagnosis (APA, 1952), nor did the DSM-II (APA, 1968).. Gunderson (1975) started the empirical research of BPD by describingthe operationalizedd criteria for borderline patients. Since 1980 three main, not fully overlappingg borderline concepts are used: the structural concept of Kern berg ((967), thee descriptive criteria of Gunderson (1975) and the criteria for the borderline e personalityy disorder by Spitzer (1979). Since the DSM-III (APA, 1980), the pathology (suicidality,impulsivity,, affect instability and unstable relations) is recognizable as a distinctt clinical syndrome, the Borderline Personality Disorder (BPD). The DSM-IV (APAA 1994) describes BPD as: 'A pervasive pattern of instability of interpersonal relationships,, self-image, and affects, and marked impulsivity beginning by early add ulthood and present in a variety of contexts, as indicated by five or more of the ninee described criteria'. It need to be mentioned that categorical descriptions of B PD likee the DSM, create diagnostic problems because of the overlap with other personality disorderss (Verheul et al., 1995), the heterogeneity within the category and the conceptuall fuzzi ness of the difference between Axis-i and Axis-11 (APA, 1995). The BPDD diagnosis, however, has proven to be one of the most reliable diagnostic categories,, although the necessity of a careful diagnostic process is stressed by manyy authors (e.g. Sanislow et al., 2002; Hudziak et al., 1996). Theree have been many hypotheses about the aetiology of the disorder, ranging fromm a firm relationship with the schizophrenic spectrum to borderline as a disorder belongingg to the affective or impulse control spectrum (Ingenhoven, 1990; Siever CHAPTERR 1

5 && Davis, 1991). As a consequence, different medications were tested, including antidepressants,, neuroleptics and mood stabilizers. At the same, different psychotherapeuticc approaches were developed and tested, ranging from 'no treatment ass the treatment of choice'(frances, 1986), through short-term outpatients treatments,, to long-term outpatient cognitive behavioural treatments (e.g. Beck & Freeman,, 1990; Linehan, 1991) and partial hospitalisation and psychodynamic psychotherapyy (e.g. Bateman & Fonagy). With the appearance of DSM-III, the diagnosis 'borderline'' expanded into all domains of psychiatry. Patients coming from all social levelss were being diagnosed as'bpd'and psychoanalytically oriented psychotherapy couldd no longer rationally be regarded as the treatment of choice for all those who now enteredd under this diagnostic label. Despite these developments, borderline patients aree still seen as 'therapeutically challenging'. According to Stone (1993), we usually comee to recognize who our borderline patients are because they refuse to leave the sessionn when the time is up, or they come in with a wrist bandaged up from a selfdamagingg gesture, or they call us at two in the morning in some quite preventable crisis.. In short, these patients are still misdiagnosed and subsequently do not receive adequatee treatment. This is (partial) the result of the fact that the incidence of this severee disorder is still underestimated, because it frequently stays hidden behind more strikingg Axis-i pathology (parasuicidality, depression, substance abuse, PTSD etcetera), whilee of course the lack of effective treatments for BPD contributes to the fact that patientss prefer not to be diagnosed as BPD. It is remarkable then that research of epidemiologicall aspects was developed no more then twenty years ago Epidemiology of BPD BPDD is a persistent and severe mental disorder. The prevalence is estimated to be about 1%1% of the general population, about 10% among individuals seen in outpatient mental healthh and addiction clinics, and about 20% among psychiatric and substance abuse inpatientss (APA 1994, Verheul et al 1995). Borderline personality disorder is characterizedd by intense negative emotions including depression, anger, self-hatred, andd hopelessness. In coping with these emotions, BPD individuals often engagee in impulsivee maladaptive behaviours, including suicidal behaviours and substance abuse. Thee majority of patients with BPD engage in suicide attempts and/or self-mutilation, andd 7-10% of them eventually die because of suicide (Perry 1993; Frances, et al., 1986). BPDD is the only DSM-IV diagnosis for which parasuicide' is a criterion and parasuicide is 11 Parasuicide (Linehan, 1993a; Kreitman, 1977) is a label for (1) nonfatal, intentional self-injurious behaviourr resulting in actual tissue damage, illness, or risk of death; or (2) any ingestion of drugs orr other substances not prescribed or in excess of prescription with clear intent to cause bodily harmm or death. It includes both actual suicide attempts and self-injuries with little or no intent to causee death. Parasuicide includes behaviours commonly labeled 'suicide gestures' and 18 8 BPD,, SUBSTANCE ABUSE, AND DST - VAN DEN BOSCH

6 thuss considered a'hallmark' of BPD. Rates of parasiticide among patients diagnosed withh BPD range from 69 to 80% (Clarkin etal., 1983; Cowdry, etal., 1985; Gunderson, 1984).. Rates of suicide among all individuals meeting criteria for BPD, without parasuicidall behaviour, are high and are doubled when those with a history of parasuicidearee included (Stone, etal., 1987). Researchh over the past two decades indicates that among those served by communityy mental health agencies, a sub-population utilizes a disproportionate amountt of inpatient psychiatric services: between 6 to 18% of all persons admitted to inpatientt psychiatric treatment account for 20 to 42% of admissions (Carpenter etal, 1985;; Geiler, 1986; Green, 1988; Hadley et al., 1990; Surber et al, 1987; Woogh, 1986). Peoplee with BPD are frequently among the high utilizers of inpatient psychiatric services.. It is estimated that between 10-40% of high utilizers have been diagnosed withh BPD (Geiler, 1986; Surber, et al, 1987; Widiger &. Weissman, 1991; Woogh, 1986). Itt can be concluded that BPD has a high incidence, goes with serious physical and mentall consequences and entails great, not well-grounded expenses on the communityy mental health system BPD and Comorbidity BPDD is the most commonly diagnosed personality disorder in both inpatient and outpatientt settings (Widiger & Trull, 1993) and it rarely occurs in isolation, BPD has beenn connected, etiological and symptomatological, to several other mental disorders, withh high comorbidity percentages with other Axis-i and Axis-n diagnoses, and with substancee abuse, trauma and dissociation being prominent among them (Zanarini et al.,, 1998,1990,1989; Gunderson et al, 1985). Manyy studies have shown significant comorbidity between BPD and substance use disorderss (SUD) or substance abuse (Trull et al., 2000; Links et al., 1995; Oldham et al., 1995;; Dulit et al., 1990; Zanarini et al, 1989; Zimmerman &. Coryell, 1989; Akiskal et al. 1985;; Loranger 8tTulis, 1985). The reported prevalence rates of SUD among patients withh BPD are so high, (39% - 84 % median 67%: Dulit et al., 1990; Links et al., 1995; Zanarinii et al, 1989,1990,1998), that some authors have suggested that SUD and BPD mustt be causally linked in some way (Verheul et al., 1997). Also,, a high incidence is reported of childhood physical and sexual abuse among femalee patients with BPD: 55% - 80% (Herman etal., 1989; Ogata etal., 1990; Paris ett al., 1994; Salzman et al., 1993; Westen et al., 1990; Roth et al., 1997). The same is 'manipulativee suicide attempts'. It is distinguished from suicide, where intentional, self-inflicted deathh occurs: suicide threats, where the individual says she is going to kill or harm herself but has yett to act on the statement; almost suicidal behaviours, where the individual puts herself at risk butt does not complete the act (e.g., dangling from a bridge or putting pills in her mouth but not swallowingg them); and suicide ideation. CHAPTERR I «9

7 truee for PTSD in female borderline patients: 33% - 56 % (Swartz et al., 1990; Zanarini etal.,1998).. Childhoodd trauma has been associated with both adult sud (Langeland et al., 2002;; Langeland & Hartgers, 1998; Brown et al., 1991) and BPD (Sabo, 1997). It, therefore,, comes as no surprise that high levels of dissociation among BPD patients aree reported (Carlson & Putnam, 1993).The relationship between childhood trauma andd adult dissociation seems to be somewhat more complicated in patients with SUD,, where dissociation in traumatized patients is often remarkably low. Until now, nothingg is known about the levels of dissociation in traumatized BPD patients with a comorbidsud.. Inn conclusion: all research of efficacy of treatment of BPD needs to pay attention to comorbidd disorders BPD and treatment Parasuicidalityy and self-injurious behaviour are seen as the most characteristic features off BPD. Many researchers and clinicians regard parasuicidality as a manifestation of dissociation,, associated with early-childhood traumatisation: a primary coping style to blockk out intolerable cognition and emotions, in order to master childhood physical andd sexual abuse (Langeland etal.,2002; Brunner et al.,2000; Ross-Goweret al., 1998; Zlotnicketal.,, 1996; Barstow, 1995; Brodsky etal., 1995). Self-injurious BPD patients evenn display more dissociative symptoms than patients who do not engage in selfinjuryy (Shearer, 1994). Finally, substance abuse may diminish an already vulnerable BPD patient'ss capacity for self-protective behaviour and further disinhibit control (Zanarini, 2000).. Using drugs becomes a viable although destructive coping mechanism. Some authorss have even proposed that alcohol and drug use might be some sort of chemical dissociationn (e.g. Langeland etal.,2002). Becausee of the high incidence and the important consequences, dissociation and self-mutilationn are usually considered a necessary focus of treatment in BPD programs. Borderlinee patients with SUD, however, tend to be treated differently from those withoutt SUD. The differential treatment occurs in clinical practice, but also in scientific studies.. It has often been observed and reported that borderline patients with SUD experiencee great difficulties when applying for treatment. This can be caused by the negativee connotation of the diagnosis 'BPD' (van den Bosch, 1996). Especially the BPD + SUDD patient seems to be stereotyped as difficult to treat, unsympathetic, unwilling, unreliable,unreliable, and with a poor prognosis, BPD patients belonging to this group usually are refusedd admission to the mental health service system until they stop using substances andd cannot enter substance abuse treatment system until suicidal and other selfdestructivee behaviours are under control (e.g., Verheul, 1997). Although substance 20 0 BPD,, SUBSTANCE ABUSE, AND DBT - VAN DEN BOSCH

8 abusee isgenerally considered a typical borderline manifestation rather than an independentt comorbid condition, there are no integrated treatment programs for BPDD patients using substances. It therefore comes as no surprise that the prognosis is generallyy regarded to be poor. In the daily practice of mental health and substance abusee services, clinicians seem to be prevented from undertaking integrated and collaborativee treatments for dual diagnosis patients, and the mental health field shows aa tendency toward differentiation between symptom- and disorder-specific modules. Onlyy two types of psychosocial treatments of BPD have shown promising, although not well-establishedd (cf. Crits-Christoph et al 1995), empirical evidence for their efficacy, i.e.. psychoanalytically oriented partial hospitalisation (Bateman & Fonagy, 1999,2001) andd outpatient Dialectical Behavior Therapy (e.g. Linehan, 1991,1993,1999)- No efficacy studiess compared BPD patients with SUD with BPD patients without SUD. Usually, BPD patient'ss comorbid with SUD are excluded from participation. When in 1995 the decisionn was made to start this study, Dialectical Behavior Therapy (D BT) was the only BPDD treatment with some empirical support. Therefore it was decided to study the possibilityy of the implementation of DBT in the Netherlands and to examine the longtermm results of DBT in a population of female borderline patients with and without substancee abuse problems. Itt can be concluded that till now there are no treatments, neither pharmacological norr psychosocial, for BPD with well-established efficacy (APA Practice Guideline, 2001). Dissociativee phenomena and coping strategies play an important role in BPD. Therefore,, it can be expected that the combination BPD-SUD creates special problems inn the examination of efficacy of psychotherapeutic treatments, and thus should be givenn specific attention. 22 Dialectical Behavior Therapy DBTT is a comprehensive psychosocial treatment developed specifically for severely y dysfunctionall and chronically suicidal individuals with borderline personality disorder. Thee philosophy, biosocial theory, treatment targets, structure, strategies, and protocolss of standard DBT are described in two treatment manuals (Linehan, 1993a, 1993b),, which are also available in Dutch translation (Linehan, 1996,2002). DBTT assumes that individuals with BPD lack important interpersonal, self-regulation (includingg emotional and behavioural regulation) and distress tolerance skills. Also, personall and environmental factors frequently block and/or inhibit the use of behaviourall skills that individuals do possess; these same factors often inadvertently CHAPTERR I

9 reinforcee dysfunctional behaviours. Furthermore, DBT assumes that people with BPD aree not at fault for having these motivational and skills deficits; these individuals are tryingg their best to cope with life. In spite of these assumptions, DBT also assumes that peoplee with BPD must nonetheless work harder to learn and apply the necessary skills neededd to improve the quality of their life and must fundamentally give up and replace dysfunctionall coping behaviours (e.g., cutting, suicide attempts, abusing drugs, etc.) by functionall behaviours. It logically follows that individuals with BPD need help in order too enhance their motivation and skills to develop a life worth living. Manyy of the BPD clients enter treatment with severely disordered and dysfunctional behaviour.. The goals of treatment for this first stage of DBT treatment are behavioural control,, stability, and connection with treatment and care provider. Consistent with otherr behavioural treatments, Linehan (1993a) has specified a pragmatic set of hierarchically-arrangedd behavioural targets for this stage: decrease suicidal and otherr life-threatening behaviours, decrease therapy-interfering behaviours (e.g., nott attending or coming late to therapy sessions, falling asleep during sessions, not completingg therapy homework assignments), decreasing quality-of-life interfering behaviourss (e.g., substance abuse, homelessness, unemployment, etc), and increasing behaviourall skills. Comprehensive DBT treatment for individuals in stage one includes fivefive important functions necessary to decrease dysfunctional behaviours, to increase functionality,, and to enhance quality of life. These functions include: 1. enhancing behaviourall capabilities; 2. improving motivation to change; 3. assuring new capabilities generalizee to the natural environment; 4. structuring the environment in the ways essentiall to support client and therapist capabilities; and 5. enhancing therapist capabilitiess and motivation to treat patients effectively. Thesee five functions are addressed within four different standard treatment modes,, including weekly individual psychotherapy (50-60 minutes weekly), group skillss training (150 minutes weekly), a consultation team meeting for providers of treatmentt to BPD clients receiving DBT (60 minutes weekly), and as-needed telephone consultationn (for in vivo skills coaching to avert crises, facilitate skills generalization, andd to repair between-session conflicts or misunderstandings between therapist and client).. Thee individual advances to the second stage of treatment once behavioural control is achievedd (e.g., when faced with situations that would historically trigger dysfunctional behaviour,, the individual is successful in applying skilful behaviour to solve or withstandd the problem rather instead of dysfunctional behaviour). The focus during thiss second stage is emotional experience and processing of trauma from the past. The thirdd stage emphasizes resolving ordinary problems in living (e.g., ordinary happiness andd unhappiness). And then there is a fourth stage (transcendence) for those who BPD,, SUBSTANCE ABUSE, AND DBT - VAN DEN BOSCH

10 desiree a more spiritual or meaningful existence. The focus of the DBT research has mainlyy been on the first stage: achieving behavioural control. DBTT is based on behaviour theory. Behavioural principles and learning theory are amongg the theories that form the backbone of D BT. Consistent with other behaviou ral approaches,, DBT assumes that all behaviour, including dysfunctional behaviour, occurs ass a result of prior learning or biology. People with BPD learned to react in certain maladaptivee ways to stimuli. Inn order to be able to change maladaptive behaviours, it is necessary to know which factorss are controlling the behaviour by means of a thorough behavioural assessment off the problem behaviour. Early on in treatment, the patient is taught that behavioural analysiss forms the backbone of each session and the way to fill in the diary cards is explainedd and agreed upon. This is done to be able from the first moment on to reveal byy analysis the problematic behaviour the patient mentions (monitoring) and to make itt ready for change. Itt is important to mention here that the application of behavioural analysis, and the startt of behavioural change can only begin after commitment of the patient is obtained accordingg to the therapy and after therapist and patient have reached agreement about goalss and targets of change (Linehan, 1993a.). DBTT uses a number of core methods that are also used in behaviour therapy. Next to thee already mentioned behavioural analysis we find solution analysis and solution strategies,, the skills training (acquisition and strengthening of newskills), insight strategies,, contingency management, exposure, cognitive modification, didactical interventions,, orienting strategies ('what is the goal of our cooperation'), and the acquisitionn and strengthening of commitment. Onee other important behavioural principle that is applied in DBT is that besides the acquisitionn and strengthening of new behaviour, generalization of that same behaviour mustt take place in every relevant context (Linehan, 1993a). Because it is important that patientss show effective behaviour outside the therapy, generalization of new, adaptive behaviourss needs to occur. Generalization is aimed at during role-play in the group session,, in homework assignments of the skills training and through the phone consultation.. DBTT differs from behaviour therapy pur sang in the fact that DBT integrates acceptance-basedd approaches with cognitive-behavioural change-based procedures. Validation,, mindfulness practices, reciprocity, and a focus on the patient-therapist relationshipp are integrated with basic behavioural procedures of skills training, exposure-basedd procedures, cognitive modification, contingency management; andd problem-solvi ng The concept of dialectics, with its em phasis on synthesis of CHAPTERR I

11 thesee polar opposite positions, provides a fresh lens in which to envision treatment possibilities,, DBT can be differentiated from other therapies by the systematic use off therapist-patient telephone consultation, and, the emphasis in DBT given to the consultationn team, where therapists' capabilities and motivation to treat patients effectivelyy are focus. In summary, DBT is a multi-model and rather complex and comprehensivee treatment strategy that is highly structured and fully manualized. AA critical overview of the empirical basis of DBT (Scheel, 2000) concludes that the findingss to date are encouraging and that careful considerations of multiple factors aree needed to reach the conclusion that DBT is effective treatment of BPD symptomatology.. Our results strongly enhance the empirical status of DBT (Verheul ett al., 2003; van den Bosch et al., 2002) Aims of the study and structure of the thesis Itt has been described that both mental health treatment centres and research programss examining efficacy of treatments of BPD exclude substance abusing BPD patientss from their treatment programs as well as from their research programs. Comorbidityy percentages of BPD and substance abuse are high, resulting in poor referrall conditions for many patients. In thejellinek Center for substance abuse treatmentt in Amsterdam, the treatment of substance abusing, suicidal BPD patients alsoo proved too be ineffective. Only one study (Linehan, 1991,1993) has shown that standard DBT comparedd to treatment-as-usual (TAU) is atreatment program that seems to be effectivee in reducing severe borderline symptomatology in borderline patients without substancee abuse. However, the meaning of the results is weakened by the fact that sampless are small, and the developer conducted all the published studies. The results, however,, show that DBT seems to enhance treatment retention, that DBT seems to reducee severe dysfunctional behaviours, and that DBT seems to reduce the number off hospitalisation days Inn 1995 thejellinek Center and the Amsterdam Institute for Addiction Research (AIAR)) decided to replicate Linehan's original study in a randomised controlled trial off DBT in a mixed population of borderline patients with and without comorbid substancee abuse. Several research goals were formulated. The main goal was to examinee the feasibility of DBT in the Netherlands and to test the efficacy of DBT by non-developerss (i.e. Marsha Linehan) in a mixed population of borderline patients withh and without substance abuse problems, in a larger sample and with more rigorous BPD,, SUBSTANCE ABUSE, AND DBT - VAN DEN BOSCH

12 methodology.. Severity of (para) suicidal behaviour, treatment retention and severity of substancee abuse problems were defined as outcome parameters of the study. Logically, thee development of an integrated, standard outpatient DBT program in Amsterdam wass a prerequisite. Thiss thesis includes four parts. Part i consists of the introduction. Part11 deals with thee role of SUD comorbidity in female borderline patients (Chapter 2 and 3). Partt111 focuses on the efficacy of DBT (Chapter 4,5 and 6). Part iv describes the implementationn of DBT, and the clinical implications and conclusions of the study (Chapterr 7 and 8) t Part 11. Characteristics of the research population: the influence of comorbidity Inn Chapter 2 the central question is whether the study results could be influenced by etiologicall and symptomatological differences between the substance abusing and non-substancee abusing BPD patients. There is hardly any research on the treatment of BPDD in which substance abuse is not an exclusion criterion. To our knowledge this is the firstt study to include a mixed sample of borderline patients with and without substance abuse.. It is at least remarkable that this issue has been rarely focused on empirically. Ass a first step, the differences and similarities in clinical characteristics and etiological factorss between female borderline patients with (n=33) and without SUD (n=3i) are investigated.. Clinical characteristics include borderline symptom severity, Axis-i comorbidity,, and treatment history. Etiological variables include family history of SUD, andd history of childhood trauma and adult victimization. Inn Chapter 3, as a second step, the question is answered whether the study results couldd be influenced by differences in coping mechanisms used by the female substance abusingg BPD patients (n=33) and the non-substance abusing female BPD patients (n=3i). Substancee abusers might have learned to cope with childhood sexual abuse (CSA) and childhoodd physical abuse (CPA) through a mechanism of'chemical dissociation'which iss developed instead of psychological dissociation or which may have replaced original copingg mechanisms of psychological dissociation (Langeland etal., 2002). The associationn of CSA/CPA and dissociative symptoms and PTSD among BPD patients withoutt SUD is consistent. It is hypothesized then, that in case of'chemical dissociation' differencess will be found in the associations CSA/CPA and dissociative symptoms and PTSDD between the BPD patients without SUD, and those with comorbid SUD. JJ.3.2 Part 111. Efficacy Thee female borderline patients of our study sample meet criteria for DSM-IV borderline personalityy disorder according to both the Personality Diagnostic Questionnaire CHAPTERR t

13 (pdq-4+)andthee Structural Clinical InterviewforDSM-iv Axis-n Personality Disorders (SCID-II).. Most of them engage in self-damaging and (para) suicidal behaviours. Preventionn of parasuicidal acts is of extreme importance in the treatment of borderline patients.. As a consequence, predictive validity of intermediate variables is of great importance.. In Linehans' study (1991,1993) the Reasons For Living Inventory (RFL;; Linehan et al., 1983) was used as an instrument with predictive validity for selfdamagingg and suicidal behaviour. Linehan et al. (1993),furthermore, hypothesized thatt the effect of cognitive behaviour therapies, in particular Dialectical Behavior Therapy,, is partly mediated by an increase of reasons for living. We, however, based onn cognitive behavioural therapeutic explanations of parasuicidal behaviour as coping behaviour,, wondered whether the RFL could be seen as an intermediate variable or just ass a coping scale. Although the possible character of the RFL as intermediate variable inn the efficacy study was not part of our research questions, we wanted to examine thee associations of subscales of the Reasons for Living Inventory with copingstrategies. Inn Chapter 4 the predictive validity of Survival and Coping Beliefs (SCB), one of the subscaless of the RFL, is examined. Thee replication of Linehan's original study, i.e. efficacy of DBT compared to TAU in thee treatment of female BPD patients', is investigated in Chapter 5. In a randomised controlledd trial, the efficacy of DBT in a group of 58 female BPD patients on the primary targett behaviours of DBT (suicidal, self-mutilating, and self-damaging impulsive behaviours;; treatment retention) is examined. In this chapter we also investigated whetherr DBT is equally efficacious among the female BPD patients with high and low levelss of risk behaviours. Inn chapter 6 the question whether the results found at 12 months hold at follow-up, afterr a six-months period, is answered. It is examined whether the difference between TAUU and DBT holds for BPD symptomatology. It is also investigated whether TAU and DBTT differ at 18 months follow-up, compared to the 12 months results, with regard to levell of substance abuse. j.3.33 Part 1 v. Clinical Implications, Implementation, Conclusion Chapter// examines whether standard DBT is applicable in the Netherlands and effectivee in the treatment of BPD symptomatology and substance abuse problems. Thee question what specific problems were encountered and what solutions were foundd for these problems during the implementation of DBT in Amsterdam, are answered.. It is examined whether standard DBT is equally efficacious in reducing borderlinee symptomatology among those with (n=3i) and those without comorbid substancee abuse (n=27), whether standard DBT is efficacious in terms of reducing the severityy of the substance use, and what the long-term effects of the treatment are BPD,, SUBSTANCE ABUSE, AND DBT - VAN DEN BOSCH

14 Also,, implications for the training of mental health professionals are discussed. Chapterr 8 gives an overview of the study results, discusses the limitations of this research,, recommends implications for future studies, and finally comes to conclusions.. CHAPTERR I *7 7

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