Originalbeiträge (Originals). Wirksamkeit und Grenzen einer DBT-basierten tagesklinischen Behandlung für Patient:innen mit Borderline-Persönlichkeitsstörung.

Effectiveness and limitations of a DBT-informed day-patient treatment for patients with borderline personality disorder Introduction: Borderline personality disorder, a highly prevalent personality disorder is associated with remarkable impairment and is considered one of the most challenging mental illnesses to treat. Dialectical Behavioral Therapy has been recommended by the American Psychiatric Association as a specific treatment for patients with borderline personality disorder. So far, little is known about its effectiveness in a day-patient setting. METHODS: This retrospective longitudinal study investigates changes in symptom burden during an average of 11 weeks of DBT-informed treatment at discharge, and three months after discharge. The symptomatology of n = 178 patients with borderline personality disorder treated from 2009 to 2017 was investigated with established borderline-specific (BSL) and -unspecific questionnaires (BSI-18, BDI) at admission, discharge, and 3-months follow-up by calculating mixed models, effect sizes, and response rates. RESULTS: 80 % of the patients completed the treatment regularly. In borderline-specific impairments, there were moderate and highly significant improvements with good effects and a response rate of 48 %. Approximately 20 % showed a symptom level equivalent to that of the general population. The strongest effect sizes of approximately .8 were obtained for general psychopathology, with a response rate of 66 %. Results remained stable at follow-up. DISCUSSION: Similar effects to inpatient treatment with good acceptance and efficacy could be achieved. Effect sizes differed for borderline-specific and unspecific symptoms, suggesting that DBT has different effects on different symptom areas. When comparing responders and non-responders, outpatient psychotherapy appeared to have a positive impact on the therapeutic effect. Furthermore, the results suggest that changes in borderline personality disorder extend over a longer period of time, which may indicate the limitations of curative treatment.

[Exposure therapy for panic disorder and agoraphobia in the context of existing antidepressive medication]. / Expositionstherapie bei Panikstörung und Agoraphobie im Kontext bestehender antidepressiver Medikation.

BACKGROUND: Cognitive behavioral therapy (CBT) and pharmacotherapy with antidepressants are both a highly effective treatment for agoraphobia and/or panic disorder; however, a combination of CBT and antidepressants is under debate due to potentially unfavorable interference effects. The associations of existing antidepressant medication with panic and agoraphobia symptom burden and their change in the context of a structured 5­week day hospital and exposure-focused treatment in a naturalistic setting were investigated. METHODS: Out of a total of n = 488 patients medication use during treatment was retrospectively determined for n = 380: n = 100 (26.3%) were taking antidepressants of different drug classes. Calculations were performed using multiple linear regression analysis, t­tests, response analyses, and χ2-tests. RESULTS: Patients with existing antidepressant medication more often met the criteria for comorbid depressive disorder (p < 0.001). The measure of symptom change and treatment response rates did not differ between patients with and without antidepressants with respect to anxiety symptoms. DISCUSSION: In the context studied, patients with and without existing antidepressant medication benefited equally from CBT with respect to anxiety symptoms.

[Effectivity of Inpatient and Day-clinic Psychosomatic-Psychotherapeutic Treatment]. / Effektivität stationärer und teilstationärer psychosomatisch-psychotherapeutischer Behandlung.

AIM: (Partial) inpatient psychotherapy is well implemented in Germany. To better understand efficacy factors and effects, efficacy studies are necessary. This naturalistic study investigates the effectiveness of inpatient and day clinic psychotherapy as well as patient-and disorder-related factors influencing individual symptom improvements. METHODS: Patients at a psychosomatic-psychotherapeutic university hospital treated from 2015 to 2019 who completed the BSI-18 either at admission and discharge (n=1366) or at admission and three-month catamnesis (n=497) were included in the analysis. RESULTS: Improvements in global symptom severity showed moderate effect sizes. Descriptively, these were larger for day clinic patients than for those receiving treatment as inpatients-especially in the follow-up comparison (immediately after discharge: dinpatient=0.401, dday clinic=0.482; three months after discharge: dinpatient=0.403, dday clinical=0.807). Day hospitalized patients differed significantly from inpatients-slightly in age, employment status, ability to work and initial symptom burden, moderately in the number of mental comorbidities and strongly in their main diagnoses. Socio-demographic factors showed no positive influence on symptom improvement, initial symptom severity a moderate positive influence and the number of mental comorbidities a complex influence. DISCUSSION: In general, this study confirms the effectiveness of (partial) inpatient psychosomatic therapy. The relevance of day clinic offers is emphasised in the context of cost efficiency and good integration into everyday life, but under consideration of individual treatment indications.

[Differential Reflection of the Relationship between Therapeutic Alliance and Outcome in a Day Treatment Hospital Setting]. / Differentielle Betrachtung des Zusammenhangs von therapeutischer Beziehung und Therapieerfolg in einem tagesklinischen Versorgungssetting.

OBJECTIVE: The therapeutic alliance is considered to be a significant and empirically well-documented determinant of therapeutical success. The aim of the present study was to replicate this effect using a large daily clinical sample and to consider different aspects of the therapeutic relationship in an extreme group of particularly low relationship satisfaction separately. METHOD: A longitudinal examination of a sample of n=809 patients (M=34,32; SD=10,7; 72,6% female) in a day care hospital setting was carried out. Using multiple regression analysis, the link between therapeutic alliance (Helping Alliance Questionnaire; HAQ-S) in the third week and therapeutic outcome (Brief Symptom Inventory-18; BSI-18) was investigated. Analyses have been conducted for the overall sample as well as for the extreme group representing the lowest decile regarding relationship satisfaction and the remaining 90%. A distinction was also made between the 2 subscales of the HAQ, satisfaction with the relationship and satisfaction with the outcome. RESULTS: The therapeutic alliance after 3 weeks was a significant predictor for therapeutic outcome. Within the extreme group with initially low relationship satisfaction, relationship satisfaction proved to be a significant and strong predictor for therapeutic outcome, but was not useable for the prediction of individual cases due to wide confidence interval (ß=0,622; 95% CI [0,051; 1,095]). In contrast, the relationship satisfaction in the remaining 90 percent explained no additional variance of therapeutic outcome beyond the explanation by satisfaction with the outcome (ß=0,244; 95% CI [0,176; 0,391]). DISCUSSION: The results emphasize the importance of therapeutic alliance also in a day care hospital setting. Relationship satisfaction plays a central, other factors exceeding role in the prediction of therapeutic outcome only in the extreme group of particularly dissatisfied patients. CONCLUSION: Ensuring at least a sufficiently good therapeutic relationship is of great importance and therefore requires early identification and, if necessary, intervention.

The alliance-outcome association in borderline and obsessive-compulsive personality disorder.

Personality disorders are considered a possible factor affecting the relationship between therapeutic alliance and therapy outcome. The present study investigated the alliance-outcome effect in patient groups with borderline personality disorder (BPD) and obsessive-compulsive personality disorder (OCPD). Data derived from a sample of n = 66 patients, treated in a day care hospital setting with a dialectical-behavioral and schema therapeutic treatment concept. Patients rated their symptom severity at admission, early alliance after 4-6 therapy sessions and symptom severity as well as alliance at discharge. Results showed no significant differences between BPD and OCPD patients regarding symptom severity and alliance. Multiple regression analyses indicated that the alliance was a significant predictor of symptom reduction, however only in the OCPD group. Our results showed an exceptionally strong alliance-outcome relationship in OCPD patients, suggesting that focusing on building a strong alliance and measuring it early in therapy may be especially beneficial for this patient group. For patients with BPD, a more regular screening of the therapeutic alliance might be helpful.

Subtypes of borderline personality disorder in a day-clinic setting-Clinical and therapeutic differences.

This preliminary study aims at extending existing empirical evidence on subtypes of borderline personality disorders (BPDs) by identifying subtypes among patients with BPD, comparing their characteristics to the trait domains of the dimensional model of the International Classification of Diseases, 11th Revision (ICD-11; World Health Organization [WHO], 2022), and examining differences in sociodemographic, clinical, and therapeutic outcome variables. Data of N = 109 patients were subjected to cluster analysis based on the International Personality Disorder Examination variables for BPD and analyzed regarding differences in clinical and therapeutic variables. Clustering suggested a three-cluster solution, namely, internalizing (n = 35), externalizing (n = 28), and mixed subtype (n = 46). Subtypes showed differences in clinical variables and therapeutic outcomes with the internalizing showing more affective disorders and the mixed subtype showing the lowest therapeutic change in borderline-specific symptoms. Together, the present results correspond to the model of the ICD-11 (WHO, 2022). Clinical and treatment implications are being discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Cortisol response under low intensity exercise during cognitive-behavioral therapy is associated with therapeutic outcome in panic disorder-an exploratory study.

OBJECTIVES: Patients with Panic Disorder (PD) show an abnormal stress-induced functioning of the Hypothalamic-Pituitary-adrenal (HPA)-axis. Different protocols for stress induction are of rather low relevance for the psychotherapeutic treatment. In practice, interoceptive exposure is often realized as Low Intensity Exercise (LIE), as compared to an incremental cycle exercise test to exhaustion. Currently, it is not known, whether LIE displays an effective interoceptive stressor 1.) leading to a significant anxiety induction; 2.) a comparable HPA- and Sympathetic-Adreno-Medullar (SAM)-axis response in both patients and healthy controls; 3.) stress responses under LIE are associated with treatment outcomes. PATIENTS AND METHODS: N = 20 patients with PD and n = 20 healthy controls were exposed to ten minutes of LIE on an exercise bike. LIE was applied as part of the interoceptive exposure, during an intensive Cognitive-Behavioral Therapy (CBT) in a day clinic. Heart rate was monitored and salivary cortisol samples collected. Before and after the LIE, state anxiety/ arousal were assessed. In order to evaluate psychopathology, the Panic and Agoraphobia Scale, Mobility Inventory, Agoraphobic Cognitions Questionnaire and Body Sensations Questionnaire were applied, before (T1) and after five weeks (T2) of an intensive CBT. RESULTS: LIE led to a significant and similar heart rate increase in both groups. Cortisol decreased over time in both groups, especially in male patients. A higher psychopathology before, and after CBT, was associated with a significantly lower cortisol response under LIE. CONCLUSIONS: In the present study, LIE led to a divergent stress response: while there was a significant heart rate increase, cortisol decreased over time, particularly in male patients. A lower reactivity of the HPA-axis seems to be associated with a lower treatment outcome, which may affect extinction based learning. The findings suggest, that interoceptive stimuli should be designed carefully in order to be potent stressors.