Transcript Document

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. Harned
Alexander L. Chapman
Elizabeth T. Dexter-Mazza
et al.
Journal of Consulting and Clinical Psychology2008, Vol. 76, No. 6, 1068–1075
Background
2
• 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)
3
• 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
4
• 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).
5
• 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.
6
Objective
7
• To examine the efficacy of DBT versus
CTBE in treating co-occurring Axis I
disorders among suicidal BPD patients.
• Based on previous study (Linehan et al., 2006):
Compared with those of general nonbehavioral
expert therapy, DBT has unique effects in
reducing suicide attempts, inpatient
hospitalizations and treatment dropout.
8
Methods
Participants
• 101 women (age 18–45) who met criteria for
BPD
• reported at least two suicide attempts and/or
NSSI (nonsuicidal self-injury) acts in the past 5
years
• at least one act in the 8-week prestudy period.
10
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
11
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 1year follow-up period
• Assessments were conducted blindly by
independent clinical assessors.
12
13
Treatment Conditions
14
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.
15
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
16
Assessment Measures
17
• 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 24month point.
• The SCID–I assessed Axis I diagnoses at
pretreatment
18
• The Longitudinal Interval Follow-Up (LIFE)
Evaluation was used to gather retrospective
ratings of Axis I disorders for each week of the
study (i.e.,104 weeks).
• psychological status ratings (PSRs) was
assigned weekly for each disorder identified at
pretreatment via the SCID–I.
19
• 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).
20
• DSM–IV–TR was used as the remission criteria
for substance dependence disorders (SDD)
– (a) early partial remission (PSR=2 for at least 4
weeks)
– (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
meeting full criteria for a disorder after having
achieved full remission.
21
Statistical Methods
22
• 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
23
Results
Baseline Sample Characteristics
The two groups did not differ significantly on any demographic characteristics or
25
in rates of lifetime or current Axis I diagnoses at pretreatment
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
26
Group comparisons of rates of full
remission
For specific Axis I disorders, DBT patients were significantly more likely
to achieve full remission from SDD than were CTBE patients
27
DBT patients spent significantly more time in partial remission and less
time in no remission from SDD than did CTBE patients
28
Survival analyses of the time to the first full remission did not indicate significant
differences between treatments for any Axis I disorder
29
DBT patients and CTBE patients did not significantly differ in
rates of relapse for any Axis I disorder
30
DBT patients with SDD reported a significantly greater proportion of drug and
alcohol-abstinent days across time than did CTBE patients with SDD
31
DBT and CTBE patients with SDD did not significantly differ in the
number of BPD criteria met or in use of psychotropic medication
32
Discussion
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
34
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?
35
Answer: maybe not
• DBT targets substance use directly (via selfmonitoring, 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
36
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.
37
Notably high remission rates
• 74% of DBT patients and 67% of CTBE patients
achieved full remission from at least one Axis I
disorder, and patients in both treatments fully
remitted from approximately 50% of their cooccurring 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).
38
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.
39
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.
40
Comments
41
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
42
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
43
Summary
• In intervention study, indicators of efficacy should
be designed carefully.
• Under the condition that China is quite lack of
mental 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?
44
45