Treating Individuals With Intellectual Disabilities and Challenging Behaviors With Adapted Dialectical Behavior Therapy.

Approximately one third of adults with intellectual and developmental disabilities have emotion dysregulation and challenging behaviors (CBs). Although research has not yet confirmed that existing treatments adequately reduce CBs in this population, dialectical behavior therapy (DBT) holds promise, as it has been shown to effectively reduce CBs in other emotionally dysregulated populations. This longitudinal single-group pilot study examined whether individuals with impaired intellectual functioning would show reductions in CBs while receiving standard DBT individual therapy used in conjunction with the Skills System (DBT-SS), a DBT emotion regulation skills curriculum adapted for individuals with cognitive impairment. Forty adults with developmental disabilities (most of whom also had intellectual disabilities) and CBs, including histories of aggression, self-injury, sexual offending, or other CBs, participated in this study. Changes in their behaviors were monitored over 4 years while in DBT-SS. Large reductions in CBs were observed during the 4 years. These findings suggest that modified DBT holds promise for effectively treating individuals with intellectual and developmental disabilities.

The Coping Cat program for children with anxiety and autism spectrum disorder: a pilot randomized controlled trial.

The purpose of this pilot study was to evaluate whether a modified version of the Coping Cat program could be effective in reducing anxiety in children with autism spectrum disorder (ASD). Twenty-two children (ages 8-14; IQ ≥ 70) with ASD and clinically significant anxiety were randomly assigned to 16 sessions of the Coping Cat program (cognitive-behavioral therapy; CBT) or a 16-week waitlist. Children in the CBT condition evidenced significantly larger reductions in anxiety than those in the waitlist. Treatment gains were largely maintained at two-month follow-up. Results provide preliminary evidence that a modified version of the Coping Cat program may be a feasible and effective program for reducing clinically significant levels of anxiety in children with high-functioning ASD.

A comparison of borderline personality disorder with and without eating disorders.

This study examines the degree to which an eating disorder (ED) is associated with the recurrence and severity of suicide attempts, non-suicidal self-injury, rates of co-occurring Axis I and II disorders, and psychosocial functioning among Borderline Personality Disorder (BPD) outpatients. A group of 135 treatment-seeking women with BPD were assessed using structured clinical interviews. BPD was assessed using the International Personality Disorders Examination, confirmed by the Structured Clinical Interview for DSM-IV (SCID)-II, and Axis I disorders were assessed with the SCID I. A total of 17.8% of the sample met criteria for a current ED, with 6.7% meeting criteria for Anorexia Nervosa (AN), 5.9% for Bulimia Nervosa (BN), and 5.2% for Binge-Eating Disorder (BED). In this BPD sample, in the last year, current BN was associated with a significantly greater risk of recurrent suicide attempts while current AN was associated with increased risk of recurrent non-suicidal self-injury. BPD with current AN or BED was associated with a greater number of non-ED current Axis I disorders. Further replication of these results is needed. Women with BPD must be assessed for AN and BN as these diagnoses may confer greater risk for suicidal and self-injurious behavior and may have to be prioritized in treatment.

Which training method works best? A randomized controlled trial comparing three methods of training clinicians in dialectical behavior therapy skills.

This study evaluated the efficacy of three methods of training community mental health providers (N = 150) in Dialectical Behavior Therapy skills, including a written treatment manual; an interactive, multimedia online training (OLT); and a two-day instructor-led training workshop (ILT). A hybrid design was utilized that incorporated aspects of efficacy and effectiveness trials. Assessments were completed at baseline, post-training, and 30- and 90-days following training. The results indicate that learner satisfaction with the training was highest in OLT and ILT, and both resulted in significantly higher satisfaction ratings than the manual. OLT outperformed ILT and the manual in increasing knowledge of the treatment, whereas ILT and the manual did not differ. All three training methods resulted in comparable increases in clinicians' ability to apply course content in clinical simulations. Overall, the results provide strong support for the efficacy of technology-based OLT methods in disseminating knowledge of empirically supported treatments to community mental health providers, suggesting that OLT may be a high-quality, easily accessible, and affordable addition to traditional training methods.

Shame as a prospective predictor of self-inflicted injury in borderline personality disorder: a multi-modal analysis.

The primary aim of this study was to examine the prospective association of shame with self-inflicted injury (SII), including suicide attempts and nonsuicidal self-injury, among women with borderline personality disorder (BPD) who were enrolled in a clinical trial (N = 77). A multi-method approach was used to assess self-reported shame, nonverbal shame behaviors, and assessor ratings of shame during an interview regarding antecedents for a recent episode of SII. Higher levels of nonverbal shame behaviors predicted a higher likelihood of subsequent SII, and shorter time to SII, after controlling for past SII as well as other emotions associated with SII. Self-reported state shame and assessor ratings of shame were associated with prospective SII, but not after controlling for other emotions. These findings underscore the important role of shame in SII, particularly shame in the presence of contextual prompts for events that surround episodes of SII.

Olanzapine plus dialectical behavior therapy for women with high irritability who meet criteria for borderline personality disorder: a double-blind, placebo-controlled pilot study.

OBJECTIVE: This double-blind study examined whether olanzapine augments the efficacy of dialectical behavior therapy (DBT) in reducing anger and hostility in borderline personality disorder patients. METHOD: Twenty-four women with borderline personality disorder (DSM-IV criteria) and high levels of irritability and anger received 6 months of DBT. Subjects were randomly assigned to receive either low-dose olanzapine or placebo and were assessed with standardized measures in a double-blind manner. The study was conducted from September 2000 to December 2002. RESULTS: Intent-to-treat analyses indicated that both treatment conditions resulted in significant improvement in irritability, aggression, depression, and self-inflicted injury (p < .01 for each). Irritability and aggression scores tended (p < .10) to decrease more quickly for the olanzapine group than for the placebo group. Self-inflicted injury tended (p < .10) to decrease more for the placebo group than for the olanzapine group. CONCLUSIONS: Olanzapine may promote more rapid reduction of irritability and aggression than placebo for highly irritable women with borderline personality disorder. Effect sizes were moderate to large, with the small sample size likely limiting the ability to detect significant results. Overall, there were large and consistent reductions in irritability, aggression, depression, and self-injury for both groups of subjects receiving DBT.

Sexually transmitted disease rates and high-risk sexual behaviors in borderline personality disorder versus borderline personality disorder with substance use disorder.

We examined the rates of sexually transmitted diseases (STDs) in women with borderline personality disorder (BPD) (using PDE and SCID-II) and substance abuse or dependence (SCID-I) (BPD-SUD) (N=82) compared with those with BPD-only (N=102), exploring mediators of this relationship. Participants were interviewed about STD history (gonorrhea, genital herpes, syphilis, trichomonas, human papillomavirus, and HIV), condom use, number of sexual partners, poverty, and prostitution. BPD-SUD appeared to be particularly at high risk for STDs, reporting significantly more STDs than BPD (F[1,172]=11.74, p=0.001, d=.27), particularly for gonorrhea, trichomonas, and human papillomavirus. The relationship between BPD-SUD and STDs is mediated by poverty, prostitution in the last year, recent unprotected sex with two or more partners, and >20 lifetime partners (z=-2.16 which is p=0.03), with prostitution alone making a significant contribution to this relationship (z=-2.49, p=0.01).

Suicide Attempt Self-Injury Interview (SASII): development, reliability, and validity of a scale to assess suicide attempts and intentional self-injury.

The authors describe the development of the Suicide Attempt Self-Injury Interview (SASII), an instrument designed to assess the factors involved in nonfatal suicide attempts and intentional self-injury. Using 4 cohorts of participants, authors generated SASII items and evaluated them with factor and content analyses and internal consistency statistics. The final measure was assessed for reliability and validity with collateral measures. The SASII assesses variables related to method, lethality and impulsivity of the act, likelihood of rescue, suicide intent or ambivalence and other motivations, consequences, and habitual self-injury. The SASII was found to have very good interrater reliability and adequate validity.

Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder.

CONTEXT: Dialectical behavior therapy (DBT) is a treatment for suicidal behavior and borderline personality disorder with well-documented efficacy. OBJECTIVE: To evaluate the hypothesis that unique aspects of DBT are more efficacious compared with treatment offered by non-behavioral psychotherapy experts. DESIGN: One-year randomized controlled trial, plus 1 year of posttreatment follow-up. SETTING: University outpatient clinic and community practice. PARTICIPANTS: One hundred one clinically referred women with recent suicidal and self-injurious behaviors meeting DSM-IV criteria, matched to condition on age, suicide attempt history, negative prognostic indication, and number of lifetime intentional self-injuries and psychiatric hospitalizations. INTERVENTION: One year of DBT or 1 year of community treatment by experts (developed to maximize internal validity by controlling for therapist sex, availability, expertise, allegiance, training and experience, consultation availability, and institutional prestige). MAIN OUTCOME MEASURES: Trimester assessments of suicidal behaviors, emergency services use, and general psychological functioning. Measures were selected based on previous outcome studies of DBT. Outcome variables were evaluated by blinded assessors. RESULTS: Dialectical behavior therapy was associated with better outcomes in the intent-to-treat analysis than community treatment by experts in most target areas during the 2-year treatment and follow-up period. Subjects receiving DBT were half as likely to make a suicide attempt (hazard ratio, 2.66; P = .005), required less hospitalization for suicide ideation (F(1,92) = 7.3; P = .004), and had lower medical risk (F(1,50) = 3.2; P = .04) across all suicide attempts and self-injurious acts combined. Subjects receiving DBT were less likely to drop out of treatment (hazard ratio, 3.2; P < .001) and had fewer psychiatric hospitalizations (F(1,92) = 6.0; P = .007) and psychiatric emergency department visits (F(1,92) = 2.9; P = .04). CONCLUSIONS: Our findings replicate those of previous studies of DBT and suggest that the effectiveness of DBT cannot reasonably be attributed to general factors associated with expert psychotherapy. Dialectical behavior therapy appears to be uniquely effective in reducing suicide attempts.

Solving the puzzle of deliberate self-harm: the experiential avoidance model.

Despite increasing attention to the phenomenon of deliberate self-harm (DSH), the literature currently lacks a unifying, evidence-based, theoretical framework within which to understand the factors that control this behavior. The purpose of the present paper is to outline such a framework-the Experiential Avoidance Model (EAM) of DSH. The EAM poses that DSH is primarily maintained by negative reinforcement in the form of escape from, or avoidance of, unwanted emotional experiences. Literature on factors that may lead to experiential avoidance is reviewed, along with the mounting empirical evidence that DSH functions to help the individual escape from unwanted emotional experiences. The EAM integrates a variety of research on emotions, experiential avoidance, and DSH within a clinically useful framework that sparks novel research directions.

Reasons for suicide attempts and nonsuicidal self-injury in women with borderline personality disorder.

Self-reported reasons for suicide attempts and nonsuicidal self-injury were examined using the Parasuicide History Interview within a sample of chronically suicidal women meeting criteria for borderline personality disorder (N = 75). Overall, reasons given for suicide attempts differed from reasons for nonsuicidal self-injury. Nonsuicidal acts were more often reported as intended to express anger, punish oneself, generate normal feelings, and distract oneself, whereas suicide attempts were more often reported as intended to make others better off. Almost all participants reported that both types of parasuicide were intended to relieve negative emotions. It is likely that suicidal and nonsuicidal parasuicide have multiple intents and functions.