Investigating the stress-related fluctuations of level of personality functioning: A critical review and agenda for future research.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the International Classification of Diseases (ICD-11) proposed a dimensional approach to the assessment of personality disorders (PDs). Both models dictate that the clinician first determines PD severity before assessing maladaptive traits, invoking the level of personality functioning (LPF) construct. We consider LPF a promising dimensional construct for translational research because of its clinical importance and conceptual overlap with the Research Domain Criteria (RDoC) Social Processes. We aim to identify biomarkers that co-vary with fluctuations in LPF in adulthood, ultimately to predict persistent decrease in LPF, associated with suicidality and morbidity. However, a theoretical framework to investigate stress-related oscillations in LPF is currently missing. In this article, we aim to fill this hiatus with a critical review about stress and LPF. First, we discuss acute stress and LPF. We briefly present the basics of the neurophysiological stress response and review the literature on momentary and daily fluctuations in LPF, both at a subjective and physiological level. Second, we review the effects of chronic stress on brain function and social behaviour and recapitulate the main findings from prospective cohort studies. This review underlies our suggestions for multimethod assessment of stress-related oscillations in LPF and our theoretical framework for future longitudinal studies, in particular studies using the experience sampling method (ESM).

Reviewing the availability, efficacy and clinical utility of Telepsychology in dialectical behavior therapy (Tele-DBT).

BACKGROUND: Telepsychology is increasingly being implemented in mental health care. We conducted a scoping review on the best available research evidence regarding availability, efficacy and clinical utility of telepsychology in DBT. The review was performed using PRISMA-ScR guidelines. Our aim was to help DBT-therapists make empirically supported decisions about the use of telepsychology during and after the current pandemic and to anticipate the changing digital needs of patients and clinicians. METHODS: A search was conducted in PubMed, Embase, PsycARTICLES and Web of Science. Search terms for telepsychology were included and combined with search terms that relate to DBT. RESULTS: Our search and selection procedures resulted in 41 articles containing information on phone consultation, smartphone applications, internet delivered skills training, videoconferencing, virtual reality and computer- or video-assisted interventions in DBT. CONCLUSIONS: The majority of research about telepsychology in DBT has focused on the treatment mode of between-session contact. However, more trials using sophisticated empirical methodologies are needed. Quantitative data on the efficacy and utility of online and blended alternatives to standard (i.e. face-to-face) individual therapy, skills training and therapist consultation team were scarce. The studies that we found were designed to evaluate feasibility and usability. A permanent shift to videoconferencing or online training is therefore not warranted as long as face-to-face is an option. In all, there is an urgent need to compare standard DBT to online or blended DBT. Smartphone apps and virtual reality (VR) are experienced as an acceptable facilitator in access and implantation of DBT skills. In addition, we have to move forward on telepsychology applications by consulting our patients, younger peers and experts in adjacent fields if we want DBT to remain effective and relevant in the digital age.

Effectiveness of step-down versus outpatient dialectical behaviour therapy for patients with severe levels of borderline personality disorder: a pragmatic randomized controlled trial.

BACKGROUND: Step-down dialectical behaviour therapy (DBT) is a treatment consisting of 3 months of residential DBT plus 6 months of outpatient DBT. The program was specifically developed for people suffering from severe borderline personality disorder (BPD). The present study examines the effectiveness and cost-effectiveness of step-down DBT compared to 12 months of regular, outpatient DBT. METHODS: Eighty-four participants reporting high levels of BPD-symptoms (mean age 26 years, 95% female) were randomly assigned to step-down versus standard DBT. Measurements were conducted at baseline and after 3, 6, 9 and 12 months. The Lifetime Parasuicide Count and BPD Severity Index (BPDSI) were used to assess suicidal behaviour, non-suicidal self-injury (NSSI) and borderline severity. Costs per Quality Adjusted Life Year (QALY) were calculated using data from the EQ-5D-3L and the Treatment Inventory Cost in Psychiatric Patients (TIC-P). RESULTS: In step-down DBT, 95% of patients started the program, compared to 45% of patients in outpatient DBT. The probability of suicidal behaviour did not change significantly over 12 months. The probability of NSSI decreased significantly in step-down DBT, but not in outpatient DBT. BPDSI decreased significantly in both groups, with the improvement leveling off at the end of treatment. While step-down DBT was more effective in increasing quality of life, it also cost significantly more. The extra costs per gained QALY exceeded the €80,000 threshold that is considered acceptable for severely ill patients in the Netherlands. CONCLUSIONS: A pragmatic randomized controlled trial in the Netherlands showed that 9 months of step-down DBT is an effective treatment for people suffering from severe levels of BPD. However, step-down DBT is not more effective than 12 months of outpatient DBT, nor is it more cost-effective. These findings should be considered tentative because of high noncompliance with the treatment assignment in outpatient DBT. Furthermore, the long-term effectiveness of step-down DBT, and moderators of treatment response, remain to be evaluated. TRIAL REGISTRATION: www.clinicaltrials.govNCT01904227. Registered 22 July 2013 (retrospectively registered).

Sustained efficacy of dialectical behaviour therapy for borderline personality disorder.

Dialectical Behaviour Therapy (DBT) is considered one of the most promising treatments for borderline personality disorder (BPD). Recently, we reported significantly positive effects of 12 months DBT on parasuicidal behaviour and impulsivity in a mixed group of female BPD patients with and without substance abuse. Fifty-eight women with BPD were randomly assigned to either 52 weeks of DBT or treatment as usual (TAU). Follow-up assessment took place at 78 weeks, i.e., 6 months after discontinuation of DBT. Participants were clinical referrals from addiction treatment and psychiatric services. Outcome measures included parasuicidal behaviour, impulsivity and substance abuse. Six months after treatment discontinuation, the benefits of DBT over TAU in terms of lower levels of parasuicidal and impulsive behaviours, and in alcohol use, sustained. No differences between the treatment conditions were found for drug abuse. In conclusion, DBT seems to have a sustained effect on some of the core symptoms of BPD and on alcohol problems in a mixed population of female borderline patients with and without substance abuse problems.

Change in interpersonal functioning during psychological interventions for borderline personality disorder­a systematic review of measures and efficacy.

OBJECTIVE: To provide a systematic review of measures of interpersonal functioning used in treatments for people diagnosed with borderline personality disorder (BPD) and to report the effectiveness of treatments on these measures of interpersonal functioning. METHOD: Literature was reviewed using the online databases and reference lists of previous systematic reviews. Selected studies were randomized controlled trials (RCTs) that examined psychotherapeutic interventions for people with BPD and contained quantitative outcomes on various aspects of interpersonal functioning and reported their results in peer-reviewed journals. Reliability and validity of the results were evaluated. RESULTS: Nineteen RCTs met our inclusion criteria. We found 16 different (sub)scales that measured some aspect of interpersonal functioning. Only four instruments were used by more than one research team. There is some evidence that psychotherapeutic interventions have beneficial effects on some aspects of interpersonal functioning in people diagnosed with BPD, both after individual and group therapy. Generalizability of these findings is limited. CONCLUSION: There is preliminary evidence that psychotherapeutic interventions have beneficial effects on various aspects of interpersonal reactivity that characterize people diagnosed with BPD. However, none of these effects have a robust evidence base. There are serious concerns about the lack of agreed-upon concepts and instruments.

Dialectical Behavior Therapy of borderline patients with and without substance use problems. Implementation and long-term effects.

OBJECTIVE: The aim of this article is to examine whether standard Dialectical Behavior Therapy (DBT) (1) can be successfully implemented in a mixed population of borderline patients with or without comorbid substance abuse (SA), (2) is equally efficacious in reducing borderline symptomatology among those with and those without comorbid SA, and (3) is efficacious in reducing the severity of the substance use problems. METHOD: The implementation of DBT is examined qualitatively. The impact of comorbid SA on its efficacy, as well as on its efficacy in terms of reducing SA, is investigated in a randomized clinical trial comparing DBT with treatment-as-usual (TAU) in 58 female borderline patients with (n = 31) and without (n = 27) SA. RESULTS: Standard DBT can be applied in a group of borderline patients with and without comorbid SA. Major implementation problems did not occur. DBT resulted in greater reductions of severe borderline symptoms than TAU, and this effect was not modified by the presence of comorbid SA. Standard DBT, as it was delivered in our study, however, had no effect on SA problems. CONCLUSIONS: Standard DBT can be effectively applied with borderline patients with comorbid SA problems, as well as those without. Standard DBT, however, is not more efficacious than TAU in reducing substance use problems. We propose that, rather than developing separate treatment programs for dual diagnosis patients, DBT should be "multitargeted." This means that therapists ought to be trained in addressing a range of severe manifestations of personality pathology in the impulse control spectrum, including suicidal and self-damaging behaviors, binge eating, and SA.

Efficacy and cost-effectiveness of an experimental short-term inpatient Dialectical Behavior Therapy (DBT) program: study protocol for a randomized controlled trial.

BACKGROUND: Borderline Personality Disorder (BPD) is a serious psychiatric condition associated with substantial mortality, burden and public health costs. DBT is the treatment model with the largest number of published research articles showing effectiveness. However, some patients are not sufficiently engaged in outpatient treatment while presenting severe parasuicidal behavior, making hospitalization necessary. The Center for Personality Disorders Jelgersma developed an intensive 12-week inpatient DBT program that (i) rapidly reduces core borderline symptoms like suicidal behavior, (ii) minimizes the negative effects of an inpatient setting, and (iii) enhances compliance with outpatient treatment. We evaluate the (cost-) effectiveness of this experimental program. METHODS/DESIGN: Seventy patients, aged 18 to 45 years with a primary diagnosis of BPD, showing a chronic pattern of parasuicidal gestures and/or reporting high degrees of severity of other borderline symptoms, are randomly allocated to the control and intervention groups. Subjects in the control group receive standard outpatient DBT, provided in one of three regular mental health settings in GGZ Rivierduinen. Subjects in the intervention group receive 12 weeks of intensified inpatient DBT plus six months of standard DBT, provided in the Center for Personality Disorders Jelgersma. The primary outcome is the number of suicide attempts/self-harming acts. Secondary outcomes are severity of other borderline complaints, quality of life, general psychopathological symptoms and health care utilization and productivity costs. Data are gathered using a prospective, two (group: intervention and control) by five (time of measurement) repeated measures factorial design.Participants will complete three-monthly outcome assessments in the course of therapy: at baseline, and 12, 24, 36 and 52 weeks after the start of the treatment. The period of recruitment started in March 2012 and the study will end in December 2014. DISCUSSION: Highly suicidal outpatient patients can pose a dilemma for mental health care professionals. Although hospitalization seems inevitable under some circumstances, it has proven to be harmful in its own right. This paper outlines the background and methods of a randomized trial evaluating the possible surplus value of a short-term inpatient DBT program.

Trauma, dissociation, and posttraumatic stress disorder in female borderline patients with and without substance abuse problems.

OBJECTIVE: To examine the associations of childhood traumatic experiences and childhood neglect with dissociative experiences and posttraumatic stress disorder (PTSD) in a population of female borderline personality disorder (BPD) patients with and without substance abuse. METHOD: The sample included 64 female patients with BPD. Childhood traumatic experiences and childhood neglect were measured using the Structured Trauma Interview, dissociative experiences with the Dissociative Experiences Scale, and PTSD with the Structured Clinical Interview for DSM-IV. RESULTS: In general, dissociation scores were higher among those with a history of childhood trauma and neglect, in particular among those who reported both sexual and physical abuse before age 16, more than one perpetrator and severe maternal dysfunction. The prevalence of PTSD was clearly associated with the severity of childhood sexual abuse (CSA) in terms of the occurrence of penetration during CSA, intrafamilial CSA, a duration of CSA longer than 1 year and more than one perpetrator. Comorbid substance abuse problems modified the observed associations such that the associations mentioned above were also present or even more pronounced among those without substance abuse, whereas no associations were found in those with substance abuse. CONCLUSIONS: The results suggest a moderately strong association between childhood trauma and neglect with dissociation and PTSD. However, trauma-dissociation and trauma-PTSD links were only observed among BPD patients without addictive problems. The findings are largely consistent with the literature. Potential explanations for the lack of a trauma-dissociation and trauma-PTSD link in the addicted subgroup are discussed.