Naturalistic Outcomes of Evidence-Based Therapies for Borderline Personality Disorder at a Medical University Clinic.

Dialectical behavior therapy (DBT) and dynamic deconstructive psychotherapy (DDP) are listed in the National Registry of Evidence-Based Programs and Practices based on their performances in randomized controlled trials. However, little is known about their effectiveness in real-world settings. In the present study, the authors observed the naturalistic outcomes of 68 clients with borderline personality disorder (BPD) who were treated at a medical university clinic by experienced therapists using either comprehensive DBT (n = 25) or DDP (n = 27), with 16 clients treated with unstructured psychotherapy serving as a control. We found both DBT and DDP achieved significant reductions in symptoms of BPD, depression, and disability by 12 months of treatment, and showed effect sizes consistent with controlled trials. However, attrition from DBT was high and DDP obtained better outcomes than DBT (d = .53). Larger effectiveness studies are needed to replicate these findings, delineate common and unique treatment processes, and determine therapist and patient characteristics predicting positive outcomes.

Dynamic Deconstructive Psychotherapy for Suicidal Adolescents: Effectiveness of Routine Care in an Outpatient Clinic.

Suicidal behavior and demand for services have been increasing in adolescents. Many of the current treatments are focused on symptom mitigation, crisis management, and safety planning; however, few are aimed at remediating underlying vulnerabilities that may be contributing to suicide risk. Dynamic Deconstructive Psychotherapy (DDP) has been found to be effective for suicidal adults but has never been studied for adolescents. The present study examined real-world outcomes of 65 suicidal adolescents, aged 13-17 years, receiving weekly DDP in an outpatient clinic. The primary outcome was change in suicide ideation from baseline to 6 months of treatment as assessed by the Suicide Ideation Subscale of the Columbia Suicide Severity Rating Scale. In intent-to-treat analyses, suicide ideation significantly decreased over the 6 months with a large treatment effect (d = 1.19). Secondary measures, such as suicide attempts, self-harm, depression, anxiety, disability, self-compassion, and inpatient utilization, also improved significantly. Among the 42 adolescents (65%) who completed at least 6 months of treatment, suicide attempts decreased by 84%. DDP may be effective in reducing suicide ideation and other risk factors in suicidal adolescents and may be cost-effective given reduced inpatient utilization. These initial promising findings warrant further research and development.

Magical thinking in narratives of adolescent cutters.

Adolescents sometimes cut themselves to relieve distress; however, the mechanism is unknown. Previous studies have linked self-injury to deficits in processing emotions symbolically through language. To investigate expressive language of adolescent cutters, the authors analyzed 100 narratives posted on the Internet. Most narratives (n = 66) displayed idiosyncratic use of language indicating poor differentiation between the real and the symbolic, such as blood substituting for negative emotions, which can then be released from the self; or emotional pain magically transforming into physical pain, which can then be managed. This kind of magical thinking correlated with cutting to relieve distress, to see blood, and to feel pain, but negatively correlated with complex representation of people, understanding social causality, and self-esteem. The results suggest that magical thinking represents a pre-symbolic mental state that processes and organizes distressing emotions through body schema. Magical thinking thus provides a plausible mechanism for why cutting works.

Three cases of dissociative identity disorder and co-occurring borderline personality disorder treated with dynamic deconstructive psychotherapy.

Dissociative Identity Disorder (DID) is an under-researched entity and there are no clinical trials employing manual-based therapies and validated outcome measures. There is evidence that borderline personality disorder (BPD) commonly co-occurs with DID and can worsen its course. The authors report three cases of DID with co-occurring BPD that we successfully treated with a manual-based treatment, Dynamic Deconstructive Psychotherapy (DDP). Each of the three clients achieved a 34% to 79% reduction in their Dissociative Experiences Scale scores within 12 months of initiating therapy. Dynamic Deconstructive Psychotherapy was developed for treatment refractory BPD and differs in some respects from expert consensus treatment of DID. It may be a promising modality for DID complicated by co-occurring BPD.

A Novel Recovery-Based Suicide Prevention Program in Upstate New York.

Suicide prevention efforts have focused primarily on screening, education, and brief interventions rather than on treatment of underlying vulnerabilities. The Psychiatry High Risk Program (PHRP) is a specialized outpatient program for suicidal youths and young adults that facilitates transitions in care and provides comprehensive treatment aimed at healing and recovery. The authors evaluated the program's impact on inpatient utilization and suicide risk for patients (N=32) who were referred to the PHRP after psychiatric hospitalization for suicidality. Results indicate that program participants had large reductions in depression and suicidal ideation over 180 days postdischarge; they also had significantly fewer rehospitalizations than did a matched historical cohort, with an average savings of >6 hospital days per patient. These preliminary results suggest that a recovery-based suicide prevention program can be feasible and sustainable and may be cost-effective in a value-based system of care.

The dawn of a new competency-based training era.

The imminent introduction of the new Trauma & Orthopaedic (T&O) curriculum, and the implementation of the Improving Surgical Training initiative, reflect yet another paradigm shift in the recent history of trauma and orthopaedic training. The move to outcome-based training without time constraints is a radical departure from the traditional time-based structure and represents an exciting new training frontier. This paper summarizes the history of T&O training reform, explains the rationale for change, and reflects on lessons learnt from the past. Cite this article: Bone Jt Open 2021;2-3:181-190.

Dynamic deconstructive psychotherapy versus optimized community care for borderline personality disorder co-occurring with alcohol use disorders: a 30-month follow-up.

Patients having co-occurring borderline personality disorder and alcohol use disorders represent a common, but particularly severe and refractory subgroup. An individual, time-limited treatment, dynamic deconstructive psychotherapy (DDP), has been shown to be effective for this subgroup, but long-term outcomes are not known. Participants were recruited from a sample of 30 patients enrolled in a 12-month randomized controlled trial of DDP versus optimized community care (OCC). Outcomes were assessed after an additional 18 months of naturalistic follow-up. DDP participants received an equivalent amount of individual treatment and less group therapy than those receiving OCC, but demonstrated large, sustained treatment effects over a broad range of outcomes and achieved significantly greater improvement in core BPD symptoms, depression, parasuicide, and recreational drug use over the 30-month study. These results suggest that DDP is a cost-effective treatment that can lead to broad and sustained improvement for the dually diagnosed subgroup.

Relationships between techniques and outcomes for borderline personality disorder.

Although a number of psychotherapeutic modalities for borderline personality disorder (BPD) have empirical support, it is unclear what aspects of treatment are responsible for improvement. The present study analyzes the relationships between different techniques and outcomes in a randomized controlled trial of dynamic deconstructive psychotherapy (DDP) for comorbid BPD and alcohol-use disorders. Video recordings of psychotherapy sessions at 3-month intervals were rated to measure therapeutic alliance and the relative frequencies of specific treatment interventions. Outcomes included measures of borderline symptoms, depression, dissociation, social support, alcohol misuse, parasuicide, and institutional care. Discrete sets of techniques were associated with reliable changes in specific outcomes, indicating that treatments for BPD should be tailored to the specific constellation of symptoms presenting in a given individual. The study findings suggest that treatments with a specified set of techniques, such as DDP, dialectical behavior therapy, mentalization-based treatment, schema therapy, supportive therapies, and transference-focused psychotherapy, may be helpful for different individuals, depending on their particular set of symptoms.

Current provision of simulation in the UK and Republic of Ireland trauma and orthopaedic specialist training: a national survey.

AIMS: The primary aim of the survey was to map the current provision of simulation training within UK and Republic of Ireland (RoI) trauma and orthopaedic (T&O) specialist training programmes to inform future design of a simulation based-curriculum. The secondary aims were to characterize; the types of simulation offered to trainees by stage of training, the sources of funding for simulation, the barriers to providing simulation in training, and to measure current research activity assessing the educational impact of simulation. METHODS: The development of the survey was a collaborative effort between the authors and the British Orthopaedic Association Simulation Group. The survey items were embedded in the Performance and Opportunity Dashboard, which annually audits quality in training across several domains on behalf of the Speciality Advisory Committee (SAC). The survey was sent via email to the 30 training programme directors in March 2019. Data were retrieved and analyzed at the Warwick Clinical Trials Unit, UK. RESULTS: Overall, 28 of 30 programme directors completed the survey (93%). 82% of programmes had access to high-fidelity simulation facilities such as cadaveric laboratories. More than half (54%) had access to a non-technical skills simulation training. Less than half (43%) received centralized funding for simulation, a third relied on local funding such as the departmental budget, and there was a heavy reliance on industry sponsorship to partly or wholly fund simulation training (64%). Provision was higher in the mid-stages (ST3-5) compared to late-stages (ST6-8) of training, and was formally timetabled in 68% of prostgrammes. There was no assessment of the impact of simulation training using objective behavioural measures or real-world clinical outcomes. CONCLUSION: There is currently widespread, but variable, provision of simulation in T&O training in the UK and RoI, which is likely to expand further with the new curriculum. It is important that research activity into the impact of simulation training continues, to develop an evidence base to support investment in facilities and provision.

Is a psychodynamic perspective relevant to the clinical management of obsessive-compulsive disorder?

Obsessive-compulsive disorder (OCD) can be a severe and disabling condition with considerable variability in clinical presentation, course, and treatment response. Based upon demonstrated efficacy in clinical trials, selective serotonin reuptake inhibitors (SSRIs) and cognitive behavioral therapy (CBT) have become the treatments of choice for patients with OCD. By contrast, psychodynamic formulations and treatments are often considered irrelevant or contraindicated. In the present paper, the authors present five clinical cases of OCD where psychodynamic understanding and/or treatment was essential for optimizing outcome. The authors suggest that a careful psychosocial history and dynamic formulation can enrich understanding in patients with OCD and may sometimes point to alternative or supplementary treatments. Psychodynamic interventions may be considered for two subgroups of patients: those with late-onset OCD that coincides with interpersonal stressors, and those having borderline personality disorder, for whom specialized forms of treatment, such as dynamic deconstructive psychotherapy, may be indicated.

Preliminary relationships between adherence and outcome in dynamic deconstructive psychotherapy.

This study examined adherence to specific psychotherapeutic techniques as a predictor of outcome in dynamic deconstructive psychotherapy (DDP), a new psychodynamic therapy for treatment-resistant clients with borderline personality disorder (BPD). Ten clients dually diagnosed with BPD and alcohol use disorders underwent 12 months of DDP. Outcome indexes included measures of borderline symptoms, depression, dissociation, social support, alcohol misuse, parasuicide, and institutional care. Independent raters coded videorecorded sessions on adherence to DDP techniques, using a scale developed for this study, as well as therapeutic alliance and standard cognitive-behavioral and psychodynamic techniques. The adherence instrument demonstrated excellent interrater and test-retest reliability. Adherence to DDP techniques was positively related to improvement in BPD symptoms (ρ = .64) and most secondary outcomes. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

A manual-based psychodynamic therapy for treatment-resistant borderline personality disorder.

The authors introduce a manual-based treatment, labeled dynamic deconstructive psychotherapy, developed for those patients with borderline personality disorder who are most difficult to engage in therapy, such as those having co-occurring substance use disorders. This treatment model is based on the hypothesis that borderline pathology and related behaviors reflect impairment in specific neurocognitive functions, including association, attribution, and alterity that form the basis for a coherent and differentiated self. Dynamic deconstructive psychotherapy aims to activate and remediate neurocognitive self-capacities by facilitating elaboration of affect-laden interpersonal experiences and integration of attributions, as well as providing novel experiences in the patient-therapist relationship that promote self-other differentiation. Treatment involves weekly individual sessions for a predetermined period of time and follows sequential stages. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

A controlled trial of psychodynamic psychotherapy for co-occurring borderline personality disorder and alcohol use disorder.

A randomized controlled trial was conducted to determine whether a manual-based psychodynamic treatment, labeled dynamic deconstructive psychotherapy (DDP), would be feasible and effective for individuals with co-occurring borderline personality disorder (BPD) and alcohol use disorder. Thirty participants were assessed every 3 months during a year of treatment with either DDP or treatment as usual (TAU) in the community. DDP participants showed statistically significant improvement in parasuicide behavior, alcohol misuse, institutional care, depression, dissociation, and core symptoms of BPD, and treatment retention was 67% to 73%. Although TAU participants received higher average treatment intensity, they showed only limited change during the same period. The results support the feasibility, tolerability, and efficacy of DDP for the co-occurring subgroup and highlight the need for further research. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

Borderline attributions.

Borderline personality disorder is characterized as an identity disturbance or pathology of the self-structure. The author employs concepts from deconstruction philosophy and object relations theory to explore how persons with borderline personality disorder attempt to generate meaning, eliminate ambiguity, and maintain idealizations by assigning polarized attributions of value, agency, and motivation to their experiences. The author proposes that these binary attributions interact to form multiple, discrete self-structures or states of being. Each state is characterized by stereotyped expectations for self and other and patterns of relatedness that are self-perpetuating. The author delineates four common states, labeled as helpless victim, guilty perpetrator, angry victim, and demigod perpetrator, and suggests treatment strategies to deconstruct each state and to facilitate the development of an integrated and differentiated self.

Factitious disorder on an inpatient psychiatry ward.

The authors present 6 cases of factitious disorder seen on a general adult inpatient psychiatry unit of a university hospital. They review the clinical features of this disorder and suggest that factitious disorder is much more prevalent among psychiatric inpatients than is commonly recognized. Strategies to assist in the diagnosis and management this disorder are detailed.

The deconstructive experience.

Logocentrism was conceptualized by Jacques Derrida as connoting the assertion within Western philosophical traditions of certain assumed truths and the exclusion of alternative perspectives. In this paper, the author proposes that the concept of logocentrism may be usefully applied within the clinical situation to enrich understanding of splitting between idealized and devalued perceptions of self and others. He presents a case of a woman with borderline personality disorder to illustrate a logocentric self-structure, as well as how common psychotherapeutic models inadvertently risk reinforcing such structures through the hierarchical nature of the patient-therapist relationship. The process of deconstructing logocentric self-structures is facilitated by the patient experiencing the therapist paradoxically as an extension of the self that sometimes behaves contrary to expectations. Such a deconstructive experience challenges reified perceptions of self and others, serves to broaden the experience of self, and enhances qualities of self-reflection and empathy.