Refractory depression - mechanisms and efficacy of radically open dialectical behaviour therapy (RefraMED): findings of a randomised trial on benefits and harms.

BACKGROUND: Individuals with depression often do not respond to medication or psychotherapy. Radically open dialectical behaviour therapy (RO DBT) is a new treatment targeting overcontrolled personality, common in refractory depression. AIMS: To compare RO DBT plus treatment as usual (TAU) for refractory depression with TAU alone (trial registration: ISRCTN 85784627). METHOD: RO DBT comprised 29 therapy sessions and 27 skills classes over 6 months. Our completed randomised trial evaluated RO DBT for refractory depression over 18 months in three British secondary care centres. Of 250 adult participants, we randomised 162 (65%) to RO DBT. The primary outcome was the Hamilton Rating Scale for Depression (HRSD), assessed masked and analysed by treatment allocated. RESULTS: After 7 months, immediately following therapy, RO DBT had significantly reduced depressive symptoms by 5.40 points on the HRSD relative to TAU (95% CI 0.94-9.85). After 12 months (primary end-point), the difference of 2.15 points on the HRSD in favour of RO DBT was not significant (95% CI -2.28 to 6.59); nor was that of 1.69 points on the HRSD at 18 months (95% CI -2.84 to 6.22). Throughout RO DBT participants reported significantly better psychological flexibility and emotional coping than controls. However, they reported eight possible serious adverse reactions compared with none in the control group. CONCLUSIONS: The RO DBT group reported significantly lower HRSD scores than the control group after 7 months, but not thereafter. The imbalance in serious adverse reactions was probably because of the controls' limited opportunities to report these.

Radically open DBT: Targeting emotional loneliness in Anorexia Nervosa.

This article conceptualizes Anorexia Nervosa (AN) as a prototypical overcontrolled disorder, characterized by low receptivity and openness, low flexible control, pervasive inhibited emotional expressiveness, low emotional awareness, and low social connectedness and intimacy with others. As a result, individuals with AN often report high levels of emotional loneliness. A new evidence-based treatment, Radically Open Dialectical Behavior Therapy (RO-DBT), and its underlying neuroregulatory theory, offer a novel way of understanding how self-starvation and social signaling deficits are used as maladaptive regulation strategies to reduce negative affect. RO-DBT proposes that rather than trying to be 'emotionally regulated' or achieving equanimity, long-term psychological well-being is achieved by increasing social connectedness. RO-DBT skills, including body posture, gestures, and facial expressions, activate brain regions that increase social safety responses that function to automatically enhance the open-minded and flexible social-signaling, which are crucial for establishing long-term intimate bonds with others and becoming part of a "tribe."

Adapting dialectical behavior therapy for outpatient adult anorexia nervosa--a pilot study.

OBJECTIVE: Anorexia Nervosa (AN) is associated with excessive self-control. This iterative case series describes the augmentation of Dialectical Behavior Therapy (DBT) for outpatient adult AN with skills addressing emotional and behavioral overcontrol. An overly controlled style is theorized to develop from the transaction between an individual with heightened threat sensitivity and reduced reward sensitivity, interacting with an environment reinforcing overcontrol and punishing imperfection. METHOD: Case Series 1 utilized standard DBT, resulting in retention of 5/6 patients and a body mass index (BMI) effect size increase of d = -0.5 from pre- to post-treatment. Case series 2, using standard DBT augmented with skills addressing overcontrol, resulted in retention of 8/9 patients with an effect size increase in BMI at post-treatment that was maintained at 6- and 12-months follow-up (d = -1.12, d = -0.87, and d = -1.12). DISCUSSION: Findings suggest that skills training targeting rigidity and increasing openness and social connectedness warrant further study of this model and treatment for AN.

Interpersonal assessment of borderline personality disorder: preliminary findings.

We examined the reliability and validity of scores on an interpersonal measure of borderline personality disorder (BPD). Ratings on the Interpersonal Measure of Borderline Personality Disorder (IM-B) were based on nonverbal behaviors and interpersonal interactions occurring during clinical interviews with 276 adults. Scores on the IM-B exhibited good reliability. IM-B scores also displayed expected patterns of associations with scores on other measures of BPD, as well as with scores on measures of affective dysfunction, interpersonal pathology, and behavioral impairment associated with BPD, including indexes of maladaptive emotion regulation, interpersonal sensitivity, and self-harm. The pattern of associations for IM-B scores was quite similar to what would be expected for a dimensional measure of BPD symptoms. Scores on the IM-B were also associated with symptoms of disorders generally comorbid with BPD. Finally, IM-B scores contributed incrementally to the prediction of interpersonal dysfunction and suicidal ideation and behavior. Discussion focuses on implications for the assessment of BPD.

Radically Open-Dialectical Behavior Therapy for Disorders of Over-Control: Signaling Matters.

Radically Open-Dialectical Behavior Therapy (RO-DBT) is a transdiagnostic treatment designed to address a spectrum of difficult-to-treat disorders sharing similar phenotypic and genotypic features associated with maladaptive over-control-such as anorexia nervosa, chronic depression, and obsessive compulsive personality disorder. Over-control has been linked to social isolation, aloof and distant relationships, cognitive rigidity, high detailedfocused processing, risk aversion, strong needs for structure, inhibited emotional expression, and hyper-perfectionism. While resting on the dialectical underpinnings of standard DBT, the therapeutic strategies, core skills, and theoretical perspectives in RO-DBT often substantially differ. For example, RO-DBT contends that emotional loneliness secondary to low openness and social-signaling deficits represents the core problem of over-control, not emotion dysregulation. RO-DBT also significantly differs from other treatment approaches, most notably by linking the communicative functions of emotional expression to the formation of close social bonds and via skills targeting social-signaling and changing neurophysiological arousal. The aim of this paper is to provide a brief overview of the core theoretical principles and unique treatment strategies underlying RO-DBT.

Radically open-dialectical behavior therapy for adult anorexia nervosa: feasibility and outcomes from an inpatient program.

BACKGROUND: Anorexia Nervosa (AN) is a highly life-threatening disorder that is extremely difficult to treat. There is evidence that family-based therapies are effective for adolescent AN, but no treatment has been proven to be clearly effective for adult AN. The methodological challenges associated with studying the disorder have resulted in recommendations that new treatments undergo preliminary testing prior to being evaluated in a randomized clinical trial. The aim of this study was to provide preliminary evidence on the effectiveness of a treatment program based on a novel adaptation of Dialectical Behavior Therapy (DBT) for adult Anorexia Nervosa (Radically Open-DBT; RO-DBT) that conceptualizes AN as a disorder of overcontrol. METHODS: Forty-seven individuals diagnosed with Anorexia Nervosa-restrictive type (AN-R; mean admission body mass index = 14.43) received the adapted DBT inpatient program (mean length of treatment = 21.7 weeks). RESULTS: Seventy-two percent completed the treatment program demonstrating substantial increases in body mass index (BMI; mean change in BMI = 3.57) corresponding to a large effect size (d = 1.91). Thirty-five percent of treatment completers were in full remission, and an additional 55% were in partial remission resulting in an overall response rate of 90%. These same individuals demonstrated significant and large improvements in eating-disorder related psychopathology symptoms (d = 1.17), eating disorder-related quality of life (d = 1.03), and reductions in psychological distress (d = 1.34). CONCLUSIONS: RO-DBT was associated with significant improvements in weight gain, reductions in eating disorder symptoms, decreases in eating-disorder related psychopathology and increases in eating disorder-related quality of life in a severely underweight sample. These findings provide preliminary support for RO-DBT in treating AN-R suggesting the importance of further evaluation examining long-term outcomes using randomized controlled trial methodology.

Processes of change in a randomized clinical trial of radically open dialectical behavior therapy (RO DBT) for adults with treatment-refractory depression.

OBJECTIVE: Radically open dialectical behavior therapy (RO DBT) is an empirically supported psychotherapy for treatment-refractory depression (TRD) that targets psychological inflexibility and interpersonal functioning within the context of maladaptive overcontrol. However, it is unknown whether change in these mechanistic processes is associated with decreased symptoms. This study tested whether change in psychological inflexibility and interpersonal functioning is associated with change in depressive symptoms in RO DBT. METHOD: Adults with TRD from The Refractory Depression: Mechanisms and Efficacy of RO DBT (RefraMED) randomized controlled trial of RO DBT, n = 250; M (SD) age = 47.2 (11.5); 65% female; 90% White, were assigned to RO DBT or treatment as usual. Psychological inflexibility and interpersonal functioning were assessed at baseline, 3 (midtreatment), 7 (posttreatment), 12, and 18 months. Mediation analyses and latent growth curve modeling (LGCM) assessed whether change in psychological inflexibility and interpersonal functioning was associated with change in depressive symptoms. RESULTS: The effect of RO DBT in decreasing depressive symptoms was mediated by changes in psychological inflexibility and interpersonal functioning at 3 (95% CI [-2.35, -0.15]; [-1.29, -0.04], respectively), 7 (95% CI [-2.80, -0.41]; [-3.39, -0.02]), and only psychological inflexibility at 18 (95% CI [-3.22, -0.62]) months. LGCM indicated only in RO DBT was a decrease in psychological inflexibility through 18 months associated with a decrease in depressive symptoms (B = 0.13, p < .001). CONCLUSIONS: This supports RO DBT theory about targeting processes related to maladaptive overcontrol. Interpersonal functioning, and in particular, psychological flexibility, may be mechanisms that decrease depressive symptoms in RO DBT for TRD. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The prevalence and correlates of sexual risk behaviors and sexually transmitted infections in outpatients with borderline personality disorder.

This study examined the prevalence and correlates of sexual risk behaviors and sexually transmitted infections (STIs) in two samples of outpatients with borderline personality disorder (BPD), including suicidal BPD women (n = 99) and opiate-dependent BPD men and women (n = 125). High rates of sexual risk behaviors and STIs were found, particularly in the opiate-dependent BPD sample. Compared with suicidal BPD outpatients, opiate-dependent BPD outpatients reported higher rates of past-year sexual activity, commercial sex work, and lifetime hepatitis, as well as a greater number of lifetime sex partners. Substance use and demographic characteristics (age, sex, and marital status) were associated with higher rates of sexual risk behaviors and/or STIs, whereas cognitive-behavioral factors and indicators of psychiatric impairment were not. These findings point to a clear need for interventions aimed at decreasing sexual risk behaviors among individuals with BPD.

Psychological therapy for mood instability within bipolar spectrum disorder: a randomised, controlled feasibility trial of a dialectical behaviour therapy-informed approach (the ThrIVe-B programme).

BACKGROUND: A subgroup of those with bipolar spectrum disorders experience ongoing mood fluctuations outside of full episodes. We conducted a randomised, controlled feasibility study of a Dialectical Behavioural Therapy-informed approach for bipolar mood fluctuations (Therapy for Inter-episode mood Variability in Bipolar [ThrIVe-B]). Our study aimed to examine the feasibility and acceptability of a future definitive trial evaluating the clinical and cost effectiveness of the ThrIVe-B programme. Participants were required to meet diagnostic criteria for a bipolar spectrum disorder and report frequent mood swings outside of acute episodes. They were randomised to treatment as usual (control arm) or the ThrIVe-B intervention plus treatment as usual (intervention arm). Follow-up points were at 3, 6, 9 and 15 months after baseline, with 9 months as the primary end point. To evaluate feasibility and acceptability we examined recruitment and retention rates, completion rates for study measures, adverse events and feedback from participants on their experience of study participation and therapy. RESULTS: Of the target 48 participants, 43 were recruited (22 in the intervention arm; 21 in the control arm), with a recruitment rate of 3.9 participants per month. At 9 months 74% of participants engaged in research follow-up assessment, exceeding the pre-specified criterion of 60%. There were no serious concerns about the safety of the research procedures or the intervention. On one of the four candidate primary outcome measures, the 95% CI for the between-group mean difference score excluded the null effect and included the minimal clinically important difference, favouring the intervention arm, whilst on no measure was there evidence of deterioration in the intervention arm relative to the control arm. Attendance of the intervention (50% attending at least half of the mandatory sessions) was below the pre-specified continuation criterion of 60%, and qualitative feedback from participants indicated areas that may have hampered or facilitated engagement. CONCLUSIONS: It is broadly feasible to conduct a trial of this design within the population of people with frequent bipolar mood swings. Changes should be made to the therapy to increase uptake, such as simplifying content and considering individual rather than group delivery. Trial registration ISRCTN: ISRCTN54234300. Registered 14th July 2017, http://www.isrctn.com/ISRCTN54234300.

Methodological considerations treatment trials for persons personality disorder.

BACKGROUND: The National Institute of Mental Health convened an international group of experts to examine the conduct of treatment trials for persons with borderline personality disorder (BPD). The rapid growth of treatment research had led to the recognition that investigators face unique methodological issues with these challenging patients. METHODS: Conference members reviewed critical aspects of psychotherapy and pharmacotherapy trial design for patients with BPD. RESULTS: This article summarizes discussions held on March 17-18, 2005. CONCLUSION: This paper addresses the most pressing issues in sample selection and trial design pertaining to BPD; issues that have bedeviled both investigators submitting applications and reviewers trying to assess the merit of these grants. By disseminating this work, conference members hope to make this process more consistent and productive for all concerned.

The dialectical behavior therapy ways of coping checklist: development and psychometric properties.

Skills training is a crucial mode of treatment in dialectical behavioral therapy (DBT; Linehan, 1993b), yet a psychometrically sound measure of DBT skills use does not exist. We adapted the Revised Ways of Coping Checklist (RWCCL; Vitaliano, Russo, Carr, Maiuro, & Becker, 1985) to create the DBT Ways of Coping Checklist (DBT-WCCL). Using factor analysis procedures, two subscales emerged: one assessing coping via DBT skills, the DBT Skills Subscale (DSS), and one assessing coping via dysfunctional means, the Dysfunctional Coping Subscale (DCS). Principal component, internal consistency, test-retest reliability, and content validity analyses suggested that the scale has good to excellent psychometric properties. In addition, the DSS successfully discriminated patients who received skills training during 4 months of treatment from patients who did not. Moderators of skills use are also discussed. The DBT-WCCL appears to be a promising new measure of DBT skills use.

Course of suicide ideation and predictors of change in depressed older adults.

BACKGROUND: Rates of suicide among older adults in the United States are higher than that of other age groups. Therefore, it is critically important to deepen understanding of the processes that drive suicide risk among at-risk older patients. To this end, we examined the longitudinal course of suicide ideation in a sample of treatment-seeking depressed adults 60 years of age or older. METHODS: Secondary analyses were conducted with a longitudinal dataset including 343 older adults seeking treatment for depression in the context of a naturalistic treatment setting. Participants completed assessments of depressive symptoms and thoughts of suicide every three months for one year. Multi-level mixed models were used to examine the trajectory of suicide ideation over five waves. RESULTS: Depressive symptoms contributed significantly to change in thoughts of suicide early in treatment for depression. Age-related differences were also observed, such that increasing age was associated with significantly greater reports of suicide ideation. LIMITATIONS: Use of a single measure to ascertain severity of depressive symptoms and thoughts of suicide. CONCLUSIONS: Clinicians should expect to see the most pronounced decrease in thoughts of suicide during the first two months of depression treatment for older adults. Further, clinicians should be especially vigilant to monitor suicide ideation for adults, with increasing vigilance for those at more advanced ages.

Refractory depression - cost-effectiveness of radically open dialectical behaviour therapy: findings of economic evaluation of RefraMED trial.

BACKGROUND: Refractory depression is a major contributor to the economic burden of depression. Radically open dialectical behaviour therapy (RO DBT) is an unevaluated new treatment targeting overcontrolled personality, common in refractory depression, but it is not yet known whether the additional expense of RO DBT is good value for money.AimsTo estimate the cost-effectiveness of RO DBT plus treatment as usual (TAU) compared with TAU alone in people with refractory depression (trial registration: ISRCTN85784627). METHOD: We undertook a cost-effectiveness analysis alongside a randomised trial evaluating RO DBT plus TAU versus TAU alone for refractory depression in three UK secondary care centres. Our economic evaluation, 12 months after randomisation, adopted the perspective of the UK National Health Service (NHS) and personal social services. It evaluated cost-effectiveness by comparing the net cost of RO DBT with the net gain in quality-adjusted life-years (QALYs), estimated using the EQ-5D-3L measure of health-related quality of life. RESULTS: The additional cost of RO DBT plus TAU compared with TAU alone was £7048 and was associated with a difference of 0.032 QALYs, yielding an incremental cost-effectiveness ratio (ICER) of £220 250 per QALY. This ICER was well above the National Institute for Health and Care Excellence (NICE) upper threshold of £30 000 per QALY. A cost-effectiveness acceptability curve indicated that RO DBT had a zero probability of being cost-effective compared with TAU at the NICE £30 000 threshold. CONCLUSIONS: In its current resource-intensive form, RO DBT is not a cost-effective use of resources in the UK NHS.Declaration of interestR.H. is co-owner and director of Radically Open Ltd, the RO DBT training and dissemination company. D.K. reports grants outside the submitted work from the National Institute for Health Research (NIHR). T.L. receives royalties from New Harbinger Publishing for sales of RO DBT treatment manuals, speaking fees from Radically Open Ltd, and a grant outside the submitted work from the Medical Research Council. He was co-director of Radically Open Ltd between November 2014 and May 2015 and is married to Erica Smith-Lynch, the principal shareholder and one of two directors of Radically Open Ltd. H.O'M. reports personal fees outside the submitted work from the Charlie Waller Institute and Improving Access to Psychological Therapy. S.R. provides RO DBT supervision through her company S C Rushbrook Ltd. I.R. reports grants outside the submitted work from NIHR and Health & Care Research Wales. M. Stanton reports personal fees outside the submitted work from British Isles DBT Training, Stanton Psychological Services Ltd and Taylor & Francis. M. Swales reports personal fees outside the submitted work from British Isles DBT Training, Guilford Press, Oxford University Press and Taylor & Francis. B.W. was co-director of Radically Open Ltd between November 2014 and February 2015.

A multimodal assessment of the relationship between emotion dysregulation and borderline personality disorder among inner-city substance users in residential treatment.

The concept of emotion dysregulation has been integrated into theory and treatment for borderline personality disorder (BPD), despite limited empirical support. Expanding upon existing research on the relationship between emotion dysregulation and BPD, the present study utilized a multimodal approach to the assessment of emotion dysregulation (including two behavioral measures of the willingness to tolerate emotional distress, and a self-report measure of emotion dysregulation broadly defined) to examine the relationship between emotion dysregulation and BPD among inner-city substance users in residential treatment (n=76, with 25 meeting criteria for BPD). Results provide laboratory-based evidence for heightened emotion dysregulation in BPD, extending extant research on BPD to underserved clinical populations. Specifically, the presence of a BPD diagnosis among a sample of inner-city inpatient substance users was associated with both higher scores on the self-report measure of emotion dysregulation and less willingness to tolerate emotional distress on the behavioral measures of emotion dysregulation. Moreover, both self-report and behavioral measures of emotion dysregulation accounted for unique variance in BPD status, suggesting the importance of utilizing comprehensive assessments of emotion dysregulation within studies of BPD. Findings suggest the need to further explore the role of emotion dysregulation in the development and maintenance of BPD among inner-city substance users in residential treatment.

Borderline personality disorder and emotional responding: a review of the research literature.

Although problems with emotional functioning are considered central to borderline personality disorder (BPD), it is only recently that studies have begun utilizing laboratory biobehavioral measures (including neuroimaging and psychophysiological measures) to examine emotional responding in BPD. The application of basic science methodologies used in a systematic program of research to investigate clinically relevant phenomena, often called translational research, holds much promise in advancing the assessment and treatment of BPD. In this paper, we begin with an overview of the research on self-reported emotional responding in BPD. Next, we outline the advantages that translational research has over traditional self-report methodology in furthering an understanding of emotional responding in BPD, and review the extant laboratory studies of emotional responding in BPD. Finally, problems commonly encountered when conducting translational research on emotion in BPD are outlined, and solutions to these problems are offered.

Prefrontal mechanisms for executive control over emotional distraction are altered in major depression.

A dysfunction in the interaction between executive function and mood regulation has been proposed as the pathophysiology of depression. However, few studies have investigated the alteration in brain systems related to executive control over emotional distraction in depression. To address this issue, 19 patients with major depressive disorder (MDD) and 20 healthy controls were scanned using functional magnetic resonance imaging. Participants performed an emotional oddball task in which infrequently presented circle targets required detection while sad and neutral pictures were irrelevant novel distractors. Hemodynamic responses were compared for targets, sad distractors, and for targets that followed sad or neutral distractors (Target-after-Sad and Target-after-Neutral). Patients with MDD revealed attenuated activation overall to targets in executive brain regions. Behaviorally, MDD patients were slower in response to Target-after-Sad than Target-after-Neutra stimuli. Patients also revealed a reversed activation pattern from controls in response to this contrast in the left anterior cingulate, insula, right inferior frontal gyrus (IFG), and bilateral middle frontal gyrus. Those patients who engaged the right IFG more during Target-after-Neutral stimuli responded faster to targets, confirming a role of this region in coping with emotional distraction. The results provide direct evidence of an alteration in the neural systems that interplay cognition with mood in MDD.

Impulsivity and emotion dysregulation in Borderline Personality Disorder.

This study examined the association of borderline personality disorder (BPD) and negative emotional states with impulsivity in the laboratory. Undergraduate participants who were high in BPD features (high-BPD; n = 39) and controls who were low in BPD features (low-BPD; n = 56) completed measures of negative emotional state before a laboratory measure of impulsivity--a passive avoidance learning task. Controlling for psychopathology, high-BPD participants committed a greater number of impulsive responses than did low-BPD participants. Negative emotional state moderated the effect of BPD on impulsive responses. High-BPD participants who were in a negative emotional state committed fewer impulsive responses than high-BPD participants who were low in negative emotional state. Fear, nervousness, and shame negatively correlated with impulsivity among high-BPD participants but not among low-BPD participants. In addition, high-BPD participants reported greater emotion dysregulation in a variety of domains, compared with low-BPD participants.

Differences in emotional experience and emotion regulation as a function of age and psychiatric condition.

In this study, self-reported experiences of negative affectivity and emotional regulation in a sample of older and younger adults with and without psychiatric co-morbidity were evaluated. Study participants were divided into four separate groups (younger nonpsychiatric = YN; younger psychiatric = YP; older non-psychiatric = ON; and older psychiatric = OP). Findings indicated that, as hypothesized, individuals in the OP and YP groups reported more negative affect intensity and reactivity and more maladaptive emotion regulation than individuals in the ON and YN groups. Contrary to hypotheses, when collapsed across psychiatric conditions, older adults did not report significantly less negative affect intensity and reactivity than younger adults. A significant age by psychiatric group interaction effect on negative affect intensity occurred such that individuals in YN and ON groups reported similar levels of negative affect intensity and individuals in the YP group reported more negative affect intensity than individuals in the OP group. The finding that older adults with Axis I and Axis II diagnoses differ in their symptom reports from younger adults with similar diagnoses suggests there may be important assessment and intervention issues related to the interaction of aging and psychopathology. Clinical implications and directions for future studies are discussed.

Personality traits and perceived social support among depressed older adults.

The contribution of personality traits and social support to mental health is well established, but to our knowledge there have been no longitudinal investigations of the relation between personality and social support in depressed older adults. In the current study, we examined a repeated measures multi-level mixed model of change in perceived social support to determine whether personality traits and depressive symptoms were associated with changes in perceived social support over the 3 year study interval in a sample of depressed older adults. Results suggest that Conscientiousness and Extraversion were personality traits that were significantly predictive of changes in perceived social support over this time interval. Based on these results it appears that, among depressed older adults, those with conscientious or extraverted personality traits are more likely to resist impulses to withdraw from relationships. In addition, these traits may lead to more satisfying interactions and greater perceived social support over time. The implications of these results are discussed.

Decision-making and risk aversion among depressive adults.

Depression is associated with behavioral avoidance of potentially rewarding environmental contexts. The present study examined the performance of depressive individuals and controls on a neuropsychological measure of decision-making that favors risk avoidance. Depressive (n=41) and control (n=44) participants were administered the Iowa Gambling Task, which measures the ability of participants to maximize earnings by choosing low-risk, low-reward responses over high-risk, high-reward responses. Results provided partial support for the hypothesis that depressive participants would learn to avoid risky responses faster than control participants. Depressive participants demonstrated better performance than controls, scoring higher than controls overall and showing a trend toward earning more money overall. However, the lack of an interaction between depressive status and time does not support the specific hypothesis of more rapid learning. Findings suggested enhanced feedback-based decision-making and risk aversion among depressive individuals.