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1 Downloaded from UvA-DARE, the institutional repository of the University of Amsterdam (UvA) File ID Filename Version uvapub:31218 CHAPTER 6 Sustained efficacy of Dialectical Behavior Therapy for Borderline Personality Disorder unknown SOURCE (OR PART OF THE FOLLOWING SOURCE): Type PhD thesis Title Borderline personality disorder, substance abuse, and dialectical behavior therapy Author(s) L.M.C. van den Bosch Faculty AMC-UvA Year 2003 FULL BIBLIOGRAPHIC DETAILS: Copyright 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 licence (like Creative Commons). UvA-DARE is a service provided by the library of the University of Amsterdam ( (pagedate: )

2 CHAPTERR 6 Louisaa M.C van den Bosch Maartenn Koeter Theoo Stijnen Roell Verheul Wimvandenn Brink Sustainedd efficacy of Dialectical Behavior Therapyy for Borderline Personality Disorder BritishBritish Journal ofpsychiatry, submitted

3 Summary y Background:Background: Dialectical Behavior Therapy (DBT) is widely considered to be one of mostt promisingtreatments for borderline personality disorder (BPD). Recently, we reportedd significant positive effects of 12 months DBT on parasinoidal behaviour and impulsivityy in a mixed group of female BPD patients with and without substance abuse problems.. However, there is very few data on its long-term efficacy. Aims:Aims: To study the long-term efficacy of DBT in a mixed group of borderline patients withh and without substance abuse problems. Method:Method: Fifty-eight women with BPD were randomly assigned to either 52 weeks of DBTT or treatment as usual (TAU). Follow-up assessment took place at 78 weeks, i.e. 6 monthss after discontinuation of DBT. Participants were clinical referrals from addiction treatmentt and psychiatric services. Outcome measures included parasuicidal behaviour,, impulsivity and substance abuse. Data were analysed using a General Linear Mixedd Model (CLMM) approach. Results:Results: Six months after treatment discontinuation, the benefits of DBT over TAU in termss of lower levels of parasuicidal and impulsive behaviours sustained. In addition, at 788 weeks the DBT group showed significantly larger reductions in alcohol use than the TAUU group. No differences between the treatment conditions were found for drug abuse.. Conclusions:Conclusions: DBT has a sustained effect on some of the core symptoms of BPD and alcoholl problems in a mixed population of female borderline patients with and without substancee abuse problems BPD,, SUBSTANCE ABUSE, AND DBT - VAN DEN BOSCH

4 Introduction n Borderlinee Personality Disorder (BPD) is a persistent and severe mental disorder (Americann Psychiatric Association, 1994; Verheul et al., 1995). It is, therefore, extremely importantt to develop and test psychosocial interventions that might have long-term effectss beyond the actual treatment period and change the course of BPD. In a recent 12 monthss randomised controlled trial, we replicated the positive short-term effects of Dialecticall Behavior Therapy (DBT) originally reported by the developer of DBT. (Verheuu I et al., 2003; Li nehan et at., 1991) With the exception of some data from a smal I, naturalisticc follow-up study (n=9), currently no data are available on the long-term efficacyy of DBT in the treatment of BPD (Linehan etal., 1993). Thiss study examines whether the treatment results, observed at the end of treatment, sustainn over 6 months follow-up. In addition to the outcome measures from the 12- monthh trial (parasuicidal behaviour and impulsivity; Verheul et al., 2003), we also examinedd the efficacy of DBT in this mixed population of female BPD patients in terms off decreased substance abuse. Method d Design,Design, Sample recruitment, Treatments, Outcome assessments Thee design of the study, the sample characteristics, in- and exclusion criteria, screening,, assignment of subjects to treatment, and a description of the treatment conditionss have been described in detail in an earlier publication (Verheul et al 2003). Heree it suffices to mention that this study is a randomised controlled trial, comparing DBT(n=27)) andtau (n=3i) in a mixed population of borderline patients with (n=3i) and withoutt (n=27) substance abuse problems recruited from mental health institutions (n=39)) and addiction treatment services (n=ig). The diagnosis of BPD was based on the Structuredd Clinical Interview for DSM-ivAxis-ii(sciD-n:Spitzer etal., 1990), and the presencee of substance abuse problems was based on the ratings on the European versionn of the Addiction Severity Index (EuropASi; Kokkevi and Hartgers, 1998). Treatmentt conditions we compared after a 12 months treatment period (week 52) in termss of treatment retention, the course of suicidal, self-mutilating, and self-damaging impulsivee behaviours, impulsivity, and substance abuse. In the current study, both treatmentt groups are compared six months after discontinuation of DBT (week 78) with parasuicidall behaviour, self-mutilating behaviour, impulsive behaviour, alcohol abuse, usee of soft drugs and hard drugs use as the main outcome parameters. It should be notedd that patients in thetau condition were allowed to continue their treatment, CHAPTERR

5 whereass the D BT patients had to leave the program for at least two months and were nott allowed to re-enter a DBT program, in order to avoid the possible biases effects of a naturalisticc follow-up. They were also not allowed to attend DBT support groups during thee full follow-up period. 16 of the 27 former DBT patients (59%) received ambulatory treatmentt during follow-up, compared to 17 of the 31 control patients (55%). Impulsivee acts, suicidal behaviours and substance abuse were measured using the impulsivityy and parasuicide sections of the Borderline Personality Disorder Severity IndexIndex (BPDSI). The BPDSI is a semi-structured interview (Arntz et al., 2003), assessing thee frequency of borderline symptoms in the previous 3-month period. The BPDSI consistss of nine sections, one for each of the DSM-IV criteria for BPD. The impulsivity sectionn includes11 items reflectingthe manifestations of self-damaging impulsivity (e.g.,, gambling, binge eating, substance abuse [alcohol, soft drugs and hard drugs], recklesss driving). The parasuicide section includes 3 items reflecting distinct suicidal behaviourss (i.e. suicide threats, preparations to suicide attempts, and actual suicide attempts).. Self-mutilatingg behaviours were measured usingthe Lifetime Parasuicide Count (LPC) (Comtoiss & Linehan, 1999) at baseline and the adapted (3-month) version at 22,52 and 788 weeks after randomisation. The LPC obtains information about the frequency and subsequentt medical treatment of self-mutilating behaviours (e.g., cutting, burning, pricking).. StatisticalStatistical analysis Off only 29 patients (50%) the complete data were available. Of 42 patients (72%) the dataa of week 52 and week 78 both were gathered. The incompleteness of the data lead too the decision to use a general linear mixed model approach for all analyses (SAS proc mixedd version 8.2).This method takes missingoutcome values due to dropout and loss too follow-up into account and gives unbiased effect estimates (assuming missing at randomm [MAR]). Although this article focuses on the 26-week following discontinuationn of treatment, the 6 measurements during treatment were also used for thee estimation of the parameters of interest. Since all outcome measures had highly skewedd distributions, a shifted log transformation in (X+i) was used for all outcome variables.. Thee actual statistical model used in the analysis for the dependent variable ln(x+i) is( fs,t + fi 2 t 0 + fs 3 t, + fi 4 t 2 +{2^ + fi 6 t 4 ^t 5 + fê 8 t 6 + tëg^ + <s lo B,T + is B 2 T +fê l2 C, with T dichotomouss variable defining treatment category (1 = experimental and o = control); withh tj (i 1..7) dichotomous variables indicating the measurement times (ti = 1 for measurementt i and o for all other measurements); B, = z-52 for z<52, o otherwise. B 2 = BPD,, SUBSTANCE ABUSE, AND DBT - VAN DEN BOSCH

6 z-522 for z>52, o otherwise; here z = number of weeks since t 0 and C = baseline X score. Inn this model ft lo is the difference in change in ln(x+i) per week between experimentall and control group during the experimental period (i.e. the first 52 weeks) andd f2 is the difference in change in ln(x+i) per week between the experimental and controll group duringthe follow-up period (i.e. between week 52 and week 76). For the interpretationn of the coefficients, shown in the first column of table 1, one has to keep in mindd that the intervention aims at the decrease of the dependent variable (i.e. the extentt of self damaging, suicidal, impulsive behaviour and substance abuse). Treatment iss effective if fi lo < o (i.e. difference between experimental and control group increases byy fi 10 each week between start and end of treatment in favour of experimental group).,,, can be used to test whether there is a sustained effect of DBT in the 6 months followingg discontinuation of the experimental intervention: {?,, =0 (or not significantly differentt from o), indicating that the difference between experimental and control groupp does not change in the 26 weeks after the end of the intervention; fê <o, indicatingg that the effect of DBT increases, i.e. the difference between the DBT and TAU becomess larger in favour of DBT; f?,,>o, indicating that the effect of DBT diminishes, i.e. thee difference between DBT and TAU becomes smaller. Differences between the experimentall and control group at a given measurement time i can be assessed by tè,+ (2 I0 B,, between week o and week 52 and (2,+ fi B 2 between week 52 and week 78. Results s TableTable 1 shows that 12 months DBT had a significant effect on the extend of impulsive behaviour,, self-mutilating behaviour and alcohol consumption. Between start andd end (weekk o thru 52), all these behaviours decreased more in the DBT group compared to thee control group (p values ii lo <.05). Moreover, these treatment effects were sustainedd in the first 6 months following treatment discontinuation (p values fi >.05). Noo initial and sustained effects are found for parasuicidal behaviour, soft drugs and hardd drugs. It should be noted here that, although the fi M values are not significantly differentt from o, most (^estimates are positive, indicating a possible tendency towards diminishingg effects between week 52 and week 78. CHAPTERR

7 Outcome e :.-u(') ) BPDS-2:BPDS-2: impulsive behaviour Treatmentt (fi,) 2 Time3 3 Timee by treatment 1 {810)* - Timee by treatment II (6 ) BPDSl'S:BPDSl'S: parauiicidal behaviour Treatmentt (fi,) Time3 3 Timee by treatment 1 {filo) Timee by treatment 11 {8 ) s LPCLPC self mutilating behaviour Treatmentt (6,) 2 Time3 3 Timee by treatment 1 (S,0) 4 Timee by treatment II (fim) Bposr.Bposr. alcohol Treatmentt {fi,) 2 Time3 3 Timee by treatment 1 (fi,0) 4 Timee by treatment 11 (6M) 5 o o ' BPDsrsoftdrugs BPDsrsoftdrugs Treatmentt (fi,) 2 Time3 3 Timee by treatment 1 (8,0) 4 Timee by treatment II (8M) ' BPDSI:BPDSI: hard drugs Treatmentt (fi,) 2 Time3 3 Timee by treatment 1 (8lo) 4 Timee by treatment II (8 ) " " 7 7 ')') SAsProc Mixedversion 8.2, dependent variable ln(x+i) with X is outcome measure in question;for model see statisticalstatistical analysis section article; structure covariance matrix: unstructured/or LPC, Alcohol, Drugs-1 and Drugs-It;Drugs-It; compound symmetry for BPDSI-2 andtoeplitzfor BPDSI-S; t?s in table refer to model described in statisticalstatistical analysis section. 22 )) difference between DBTand TA U at week 52, difference at start of treatment (tj can befound by S lo S2*S lo whichwhich is.12582for BPDSI-2,.00816for BPDSI-S, 2 974f or LPC > 23604for alcohol, for drugs-! and. 172 for drugs-it; drugs-it; 3)) the time main effect, with time as a categorical variable, comprises 7 parameters (&, thru SJ; since they are not relevantrelevant for this article, only the overall test of the time effect is presented in this table; 44 )) change in difference between DBTand TA uper week between start and end of treatment (week o and week 52); 5)5) change in difference per week between DBTand TAU between end of treatment andfoltow-up (weekst and weekji). weekji). TableTable 1 Initial (52 weeks) and sustained (78 weeks) effect of DBT compared to TAU. BPD,, SUBSTANCE ABUSE, AND DBT - VAN DEN BOSCH

8 Inn order to get an idea about the clinical relevance of the initial and sustained effects of DBT,, table 2 provides the model based mean scores back transformed to the original scalee for all outcome measures at the start of treatment (week o), the end of treatment (weekk 52), and at 26-weeks follow-up (week 78).The means in data columns 1 to 4 are estimatess based on a general linear mixed model approach, taking into account all availablee data. Although all initial effects (impulsive behaviour, self-mutilating behaviour,, alcohol abuse) do not change statistically significantly over the follow-up periodd (table 1), tabid shows that these psychopathology scores in the 26-weeks follow-upp period increase in the DBT group and decrease in thetau group, resulting inn smal Ier differences between DBT and TAU. CLMM -1 M 1 DBT T TAU U CLMM-HI I OBT T TAU U BPDSI-I:BPDSI-I: impulsive startt treatment (wk o) endd treatment (wit 51) Follow-upp (wk 78) behaviour O.99 9 O.88 8 O O.7O O O.74 4 O.98 8 O.95 5 O.81 1 BPDSi-s-BPDSi-s- parasuicidal startt treatment (wk 0) endd treatment (wk 52) Follow-upp (wk78) behaviour O O.3O O O.16 6 O.I2 2 O LPCLPC self-mutilating behaviour startt treatment (wk 0) Endd treatment (wk 52) Follow-upp (wk78) o O.SI I O.76 6 i * * BPDsr.BPDsr. alcohol startt treatment (wk 0) Endd treatment (wk 52) Follow-upp (wk 78) I.IO O I.98 8 O.97 7 I.l I.OI I BPDSI:BPDSI: soft drugs startt treatment (wk 0) Endd treatment (wk 52) Follow-up(wk78) ) O.47 7 O.19 9 O BPDsr.BPDsr. hard drugs startt treatment (wk 0) Endd treatment (wk 52) Follow-upp (wk 78) O.I o O.69 9 O.3O O O TableTable 2 Model based medians at the start of treatment (week o), the end of treatment (week 52) andd at 26 weeks follow-up (week 78) 1. 1)1) To get results in the original scale X we used the following transformation: [exp(ln(x+1)) -1] with ln(x +1) = mean ofof shifted log transformed variable X.Asa consequence the means in this table are model based medians (which is a betterbetter measure of central tendency in case of a skewed distribution). CHAPTERR 6

9 Discussion n SummarySummary ofthefindings Thee results of the follow-up study indicate that six months after treatment discontinuation,, the benefits of DBT over TAU in terms of lower levels of impulsive andd self-mutilating behaviours are sustained. At 18 months no relapse is observed for thee DBT group to the former levels of problem behaviour. In addition, the DBT group showss significantly larger reductions in alcohol use than the TAU group, both at 52 andd 78 weeks. It should be noted, however, that non-significant tendencies were observedd suggesting that the superiority of DBT over TAU might become smaller andd possibly might disappear on the long term without effective treatment. This is consistentt with the view that personality disorders are chronic disorders with a high probabilityy of relapse after discontinuation of symptomatic treatment. Chronic lowintensityy care might eventually be a more appropriate strategy than repeated crisis managementt or intensive long-term treatment. SignificanceSignificance ofthefindings Thee conclusion of the 12 months study, that DBT is superior to TAU can now be extendedd to at least 6 months follow-up without treatment, but overly optimistic expectationss about the longer-term effects of a single one-year treatment episode withh DBT should be avoided. ClinicalClinical implications DBTT is specifically developed to keep the BPD patient alive and reduce the lifethreateningg behaviour in order to make long-lasting treatment possible. When the studyy was started it was expected that DBT would prove to be superior over TAU in thee reduction of severe, life-threatening impulsive behaviours. Because we limited thee treatment program to one year only, we did not expect a reduction of depression, hopelessnesss or other core features of the pathology in patients with BPD. The serious andd persistent character of the disorder would make such an effect unlikely. Based on earlierr research about the effect of Cognitive Behavioural Treatment we expected the effectt on life threatening behaviour to sustain at follow-up. Our findings corroborated thiss expectation. They, however, also demonstrated that the patients from the DBT condition,, showed no improvement during the 6-month follow-up period when no DBTT was applied. The data indicate that a longer follow-up period might even have shownn an extinction ofthe effect of DBT, which is of important clinical relevance. Ourr data show that once the high-risk behaviours are sufficiently reduced and stabilizationn has set in, for the effect of DBTto be retained, long-term treatment seems BPD,, SUBSTANCE ABUSE, AND DBT - VAN DEN BOSCH

10 too be needed. The next stages of the D BT program, following stage i, might be effective here,, as was hypothesized by Linehan (1993b). It can also be argued that standard DBT treatmentt should be followed by booster sessions to obtain a sustained effect (Lam et al.,, 2003; Clark et al., 1999). Thee results of the Bateman and Fonagy study (1999) preclude the conclusion that DBTT should be treatment of choice for BPD. Their 18-month psychoanalytically oriented partiall hospitalization treatment has shown to be at least as effective or maybe even moree effective than DBT in the treatment of borderline patients. Although substanceabusingg patients were excluded, the subjects of the Bateman and Fonagy randomized controlledd study were comparable to ours. The results indicate that after 18 months treatment,, patients showed significant improvements in borderline as well as depressivee symptoms. Follow-up data 18 months following treatment discontinuation showedd that patients who completed the Bateman and Fonagy program not only maintainedd their substantial gains but also showed a statistically significant continued improvementt on most measures (Bateman & Fonagy, 2001). Theree are, however, some notable differences between the Bateman and Fonagy programm and the DBT program that need to be mentioned. First, the program is more intensee and extended than DBT: approximately 6 J hours of standard therapy sessions, inn a day treatment setting, spread over 5 days (partial hospitalisation not included), comparedd to approximately 3 J hours DBT for patients, spread over two days, in an outpatientt setting. Also, the programs differ substantially in treatment duration: 18 monthss partial hospitalisation versus 12 months in outpatient DBT. More important, however,, is the question whether the Bateman and Fonagy program can be as easily disseminatedd as DBT(e.g.Alper,200i), i.e. accepted and understood by clinicians of diversee backgrounds other than the developers of the 18 months partial hospitalisation program.. The fact that it is not protocollized can be a serious problem in this respect. Limitations Limitations Somee limitations need to be mentioned. First, the application of the CLMM model wass necessary because this seemed to be the only valid approach for an ITT analysis. AA complete cases analysis including only those patients who were present at all the treatmentt and assessment times might have resulted in seriously biased estimates. Second,, the general low level of the BPDSI scores (parasuicide, impulsivity, alcohol and drugs)) and the LPC total score - in combination with the highly skewed distributions - indicatee that a substantial part of the study population only has a moderate level of problematicc behaviour, while a smaller fraction can be characterized as high-severity BPDD patients. Unfortunately, the chosen statistical procedure does not allow the study off the modifying effect of borderline symptom severity on the treatment related coursee of the symptoms. CHAPTERR 6

11 FurtherFurther directions Thee conclusion of this article then must be that future research on BPD, in which standardd DBT stage i treatment is given, and the treatment period is extended to long termm DBT, is needed. Clinicall implications Thee effect of DBT on life threatening behaviour is sustained at 6-month follow-up. Thee data indicate that when treatment of BPD patients is limited to a single one-year treatmentt episode, a longer follow-up period will show an extinction of the effect of DBT.. As soon as the high-risk behaviours are sufficiently reduced subsequent stages of thee DBT program, following stage i, must be applied, or standard DBT treatment should bee followed by booster sessions. Basedd upon multiple, independent clinical trials, it is now well established that DBT is ann efficacious treatment of high-risk behaviours among patients with B PD. The results off the Bateman and Fonagy study, however, preclude the conclusion that DBTshould bee treatment of choice. Limitations s Thee results may be influenced by the highly skewed distribution of the data. Only a substantiall part of the study population has a moderate level of problematic behaviour, whilee a smaller fraction can be characterized as high-severity BPD patients. Thee application oftheclmm model did not allow the study of the modifying effect of thee differences in borderline symptom severity among the patients on the treatment relatedd course of the symptoms, but it seemed to be the only valid approach for an ITT analysis.. Comparingg DBT with treatment-as-usual allows no conclusions about the efficacy of DBTT relative to other manualized treatment programs BPD,, SUBSTANCE ABUSE, AND DBT- VAN DEN BOSCH

12 References References All per G, Peterson SJ. Dialectical Behavior Therapy for patients with borderline personality disorder. jj Psychosoc Nurs Ment Health Serv 2001; 39(10): nn Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (fourth edition). Americann Psychiatric Press Washington, DC: Arntzz A, Hoorn M van den, Cornelis J. etal. Reliability and validity of the Borderline Personality Disorder Severityy Index./ Person Disord 2003;17: Batemann A,Fonagy P. Treatment of borderline personality disorder with psychoanalytically oriented partial hospitalisation:: an 18 month follow-up. Am) Psychiatry 2001; IS8(I): Batemann A, Fonagy P. Effectiveness of partial hospitalisation in the treatment of borderline personality disorder:: a randomised controlled trial. Am) Psychiatry. 1999; 156 :i563-is6g. Clarkk DM, Salkovskis PM, Hackmann A, Wells A, LudgateJ, Celder M, Brief cognitive therapy for panic disorder:: a randomised controlled trial./ Consult Clin Psychol 1999; 67: Clarkinn JF, Foelsch PA, Levy KN, Hull JW, DelaneyJC, Kernberg OF. The development of a psychodynamic treatmentt for patients with borderline personality disorder: a preliminary study of behavioural change. // Personal Disoriooi; 15 (6) Comtoiss KA, Linehan MM. Lifetime Parasiticide Count: Description and Psychometrics. Paper presented at the Americann Association of Suicidology Annual Conference Houston, TX. Kernbergg OF. Borderline Personality Disorder. New York, Elsevier Science, Lamm DH, Watkins ER, Hayward P, BrightJ, Wright K, Kerr N, Parr-Davis G, Sham P. Arandomisedcontrolled studyy of cognitive therapy for relapse prevention for bipolar affective disorder: outcome of thefirstyear. ArchArch Cen Psychiatry 2003;60: Linehann MM, Armstrong HE, Suarez A, et al. Cognitive-behavioural treatment of chronically parasuicidal borderlinee patients. Arch CenPsychiatry 1991;48: Linehann MM, Heard HL, Armstrong HE. Naturalistic follow-up ofa behavioural treatment for chronically parasuicidall borderline patients. Arch Cen Psychiatry. 1993;50: Linehann MM. Cognitive behavioural treatment ofborderline personality disorder. New York, NY: Guilford Presss 1993b. Spitzerr RL, Williams JBW, Gibbon M &. First M. Structured Clinical interviewfor DSM-III-R (SCID). Washington, DC:: American Psychiatric Press Verheull R, van den Brink W, Hartgers C. Prevalence of personality disorders among alcoholics and drug addicts:: an overview. EurAddHes 1995; 1: Verheull R, Bosch LMC van den, Koeter MWJ, Ridder MAJ de, StijnenT& Brink W van den. A 12-month randomisedd clinical trial of Dialectical Behavior Therapy for women with borderline personality disorder inn the Netherlands.Br/ Psychiatry 2003; «82: CHAPTERR 6 5 5

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