The Effectiveness of Dialectical Behavior Therapy Compared to Schema Therapy for Borderline Personality Disorder: A Randomized Clinical Trial.

INTRODUCTION: In the treatment of borderline personality disorder (BPD), there is empirical support for both dialectical behavior therapy (DBT) and schema therapy (ST); these treatments have never been compared directly. This study examines whether either of them is more effective than the other in treating patients with BPD. METHODS: In this randomized, parallel-group, rater-blind clinical trial, outpatients aged between 18 and 65 years with a primary diagnosis of BPD were recruited in a tertiary outpatient treatment center (Lübeck, Germany). Participants were randomized to DBT or ST with one individual and one group session per week over 1.5 years. The primary outcome was the BPD symptom severity assessed with the mean score of the Borderline Personality Disorder Severity Index at 1-year naturalistic follow-up. RESULTS: Between November 26, 2014, and December 14, 2018, we enrolled 164 patients (mean age = 33.7 [SD = 10.61] years). Of these, 81 (49.4%) were treated with ST and 83 (50.6%) with DBT, overall, 130 (79.3%) were female. Intention-to-treat analysis with generalized linear mixed models did not show a significant difference at 1-year naturalistic follow-up between DBT and ST for the BPDSI total score (mean difference 3.32 [95% CI: -0.58-7.22], p = 0.094, d = -24 [-0.69; 0.20]) with lower scores for DBT. Pre-to-follow-up effect sizes were large in both groups (DBT: d = 2.45 [1.88-3.02], ST: d = 1.78 [1.26-2.29]). CONCLUSION: Patients in both treatment groups showed substantial improvements indicating that even severely affected patients with BPD and various comorbid disorders can be treated successfully with DBT and ST. An additional non-inferiority trial is needed to show if both treatments are equally effective. The trial was retrospectively registered on the German Clinical Trials Register, DRKS00011534 without protocol changes.

The Effectiveness of Metacognitive Therapy Compared to Behavioral Activation for Severely Depressed Outpatients: A Single-Center Randomized Trial.

INTRODUCTION: Major depressive disorder (MDD) is a highly prevalent and disabling disorder. This study examines two psychotherapy methods for MDD, behavioral activation (BA), and metacognitive therapy (MCT), when applied as outpatient treatments to severely affected patients. METHODS: The study was conducted in a tertiary outpatient treatment center. Patients with a primary diagnosis of MDD (N = 122) were included in the intention-to-treat sample (55.7% female, mean age 41.9 years). Participants received one individual and one group session weekly for 6 months (M). Assessments took place at baseline, pretreatment, mid-treatment (3 M), post-treatment (6 M), and follow-up (12 M). The primary outcome was depressive symptomatology assessed by the Hamilton Rating Scale for Depression at 12 M follow-up. Secondary outcomes included general symptom severity, psychosocial functioning, and quality of life. RESULTS: Linear mixed models indicated a change in depressive symptoms (F(2, 83.495) = 12.253, p < 0.001) but no between-group effect (F(1, 97.352) = 0.183, p = 0.670). Within-group effect sizes were medium for MCT (post-treatment: d = 0.610; follow-up: d = 0.692) and small to medium for BA (post-treatment: d = 0.636, follow-up: d = 0.326). In secondary outcomes, there were improvements (p ≤ 0.040) with medium to large within-group effect sizes (d ≥ 0.501) but no between-group effects (p ≥ 0.304). Response and remission rates did not differ between conditions at follow-up (response MCT: 12.9%, BA: 13.3%, remission MCT: 9.7%, BA: 10.0%). The deterioration rate was lower in MCT than in BA (χ21 = 5.466, p = 0.019, NTT = 7.4). DISCUSSION: Both MCT and BA showed symptom reductions. Remission and response rates were lower than in previous studies, highlighting the need for further improvements in adapting/implementing treatments for severely affected patients with MDD.

The societal cost of treatment-seeking patients with borderline personality disorder in Germany.

According to previous research, borderline personality disorder (BPD) is associated with high cost-of-illness. However, there is still a shortage of cost-of-illness-studies assessing costs from a broad societal perspective, including direct and indirect costs. Further, there are considerable differences in the results among the existing studies. In the present study, 167 German men and women seeking specialized outpatient treatment for BPD were included. We assessed societal cost-of-illness bottom-up through structured face-to-face interviews and encompassed a wide range of cost components. All costs were calculated for the 2015 price level. Cost-of-illness amounted to € 31,130 per patient and year preceding disorder-specific outpatient treatment. € 17,044 (54.8%) were direct costs that were mostly related to hospital treatment. Indirect costs amounted to € 14,086 (45.2%). Within indirect costs, costs related to work disability were the most crucial cost driver. The present study underlines the tremendous economic burden of BPD. According to the present study, both the direct and indirect costs are of significant importance for the societal costs associated with BPD. Besides the need for more disorder-specific treatment facilities for men and women with BPD, we assume that education and employment are topics that should be specifically targeted and individually supported at an early stage of treatment.Trial Registration: German Clinical Trial Registration, DRKS00011534, Date of Registration: 11/01/2017, retrospectively registered.

Neural basis of shame and guilt experience in women with borderline personality disorder.

Borderline personality disorder (BPD) is characterized by instability of affect, emotion dysregulation, and interpersonal dysfunction. Especially shame and guilt, so-called self-conscious emotions, are of central clinical relevance to BPD. However, only few experimental studies have focused on shame or guilt in BPD and none investigated their neurobiological underpinnings. In the present functional magnetic resonance imaging study, we took a scenario-based approach to experimentally induce feelings of shame, guilt, and disgust with neutral scenarios as control condition. We included 19 women with BPD (age 26.4 ± 5.8 years; DSM-IV diagnosed; medicated) and 22 healthy female control subjects (age 26.4 ± 4.6 years; matched for age and verbal IQ). Compared to controls, women with BPD reported more intense feelings when being confronted with affective scenarios, especially higher levels of shame, guilt, and fear. We found increased amygdala reactivity in BPD compared to controls for shame and guilt, but not for disgust scenarios (p = 0.05 FWE corrected at the cluster level; p < 0.0001 cluster defining threshold). Exploratory analyses showed that this was caused by a diminished habituation in women with BPD relative to control participants. This effect was specific to guilt and shame scenarios as both groups showed amygdala habituation to disgust scenarios. Our work suggests that heightened shame and guilt experience in BPD is not related to increased amygdala activity per se, but rather to decreased habituation to self-conscious emotions. This provides an explanation for the inconsistencies in previous imaging work on amygdala involvement in BPD as well as the typically slow progress in the psychotherapy of dysfunctional self-conscious emotions in this patient group.

Feasibility and outcome of metacognitive therapy for major depressive disorder: a pilot study.

BACKGROUND: Several studies have shown the effectiveness of Metacognitive Therapy (MCT) in treating different mental disorders. Most of these studies were performed in English speaking countries using the original English version of the manual. Our study aimed to examine the feasibility of the translated MCT manual in a sample of German patients with major depressive disorder. METHODS: Twenty outpatients (6 male, 14 female, mean age 42.1y) with major depressive disorder were included. The main outcome was drop-out rate and satisfaction with the treatment; secondary outcomes were changes in metacognitive beliefs assessed with the metacognitive questionnaire 30 (MCQ-30), and symptom reduction measured with the Beck Depression Inventory-2 sum score (BDI-2). RESULTS: No drop-outs during the treatment and the follow-up phase were observed. Patients and therapists were highly satisfied with MCT treatment. The MCQ-30 significantly declined over the treatment course, paralleled by a significant reduction of the BDI-2 sum scores (from 29 ± 8.6 at T0 to 8.4 ± 9.6 at the end of treatment). The average treatment duration was 10 ± 4 sessions. CONCLUSIONS: Applying the German version of the manual for Metacognitive Therapy proved to be feasible in the treatment of depressed patients in an outpatient setting. The treatment was well tolerated by German patients. Outcome in terms of reduction of depressive symptoms was good. Remarkable is the comparably short treatment duration which should be investigated further in future studies. TRIAL REGISTRATION: German Clinical Trials Register (DRKS): DRKS00023644, 17.11.2020 (retrospectively registered).

Do interpersonal fears mediate the association between childhood maltreatment and interpersonal skills deficits? A matched cross-sectional analysis.

Objective: Childhood maltreatment, interpersonal fear and a specific kind of interpersonal skills deficit (preoperational thinking) have all been associated with persistent depressive disorder (PDD). We hypothesize that interpersonal fears mediate the association between childhood maltreatment and preoperational thinking.Method: A total of 108 matched participants have been examined cross-sectionally (31 healthy controls, 30 patients with episodic depression and 47 patients with PDD) with the following instruments: the Childhood Trauma Questionnaire (CTQ-SF), a measure of interpersonal fear (CBASP Interpersonal Questionnaire) and the Lübeck Questionnaire of Preoperational Thinking.Results: Patients with PDD reported significantly more childhood maltreatment than patients with episodic depression (d = 0.65) and healthy controls (d = 1.29). They also had more interpersonal fears (d = 0.71 and d = 2.11 respectively) and higher levels of preoperational thinking (d = 0.90 and d = 2.78 respectively). The association between childhood maltreatment and preoperational thinking was mediated through interpersonal fears.Conclusions: Our findings might have important implications for psychotherapy of PDD because they demonstrate how specific problems in social interactions can be associated with interpersonal fears that arise secondary to childhood maltreatment.

Psychometric evaluation of a screening question for persistent depressive disorder.

BACKGROUND: About one in five patients with depression experiences a chronic course. Despite the great burden associated with this disease, there is no current screening instrument for Persistent Depressive Disorder (PDD). In the present study, we examine a short screening test, the persistent depression screener (PDS), that we developed for DSM-5 PDD. The PDS is comprised of one question that is administered following an initial self-assessment for depression. METHODS: Ninety patients from an inpatient clinic/day clinic specialized in treating depression completed the PDS. They were also assessed using a structured clinical interview covering the DSM-5 criteria for PDD. Retest reliability was examined after two weeks (n = 69, 77%). RESULTS: In this sample, the prevalence of PDD was 64%. Sensitivity of the PDS was 85% with a positive predictive value of 80%. Specificity was 63%. Positive and negative likelihood ratios were 2.3 and .24, respectively. Agreement between the PDS results and the outcome of the clinical interview was moderate (Cohen's Kappa κ = .48 ([95%-CI .28, .68], p < .001, SE = 0.10)). Prevalence-adjusted bias-adjusted Kappa was PABAK = .53. Retest reliability of the PDS was moderate (Cohen's Kappa κ = .52 ([95%-CI .3, .74], p < .001, SE = 0.11)). CONCLUSIONS: The present study shows that the PDS - when applied following a self-rating depression scale - might be a valid and reliable way to detect PDD. However, the results of the PDS must be confirmed by a diagnostic interview.

Moderating effect of comorbid anxiety disorders on treatment outcome in a randomized controlled psychotherapy trial in early-onset persistently depressed outpatients.

BACKGROUND: Persistent depressive disorder (PDD) is associated with high rates of comorbid psychiatric disorders, mostly anxiety disorders (ADs). Comorbid AD was found to be associated with poorer treatment outcome in PDD patients. The effect of comorbid AD on disorder-specific treatment for PDD (Cognitive Behavioral Analysis System of Psychotherapy [CBASP]) has not been studied yet. METHODS: We analyzed whether the presence of a comorbid AD was moderating the effectiveness of disorder-specific (CBASP) versus nonspecific psychotherapy (supportive therapy [SP]) on depressive symptoms (24-item Hamilton Rating Scale for Depression [HRSD-24]) in a sample of unmedicated early-onset PDD outpatients (N = 268). Secondary outcomes were response and remission of depressive symptoms and the extent of interpersonal problems (Inventory of Interpersonal Problems [IIP-64]). RESULTS: The superiority of CBASP over SP was significantly stronger in PDD patients with comorbid AD compared to patients without AD (in HRSD-24 and IIP-64). There was no significant moderation for remission or response of depressive symptoms. DISCUSSION: Our hypothesis of a moderating effect of comorbid AD was confirmed. The main limitation might be the exclusion criteria of our sample limiting the generalizability. The major strength is the systematic analysis of the effect of AD in treating early-onset PDD with high quality of psychotherapy in both arms of this trial. CONCLUSION: Patients suffering from PDD comorbid with AD might experience greater benefit when they are treated with specific as opposed to unspecific therapy. Analyzing subgroups of patients with PDD seems worthwhile to improve treatment effectiveness even within disorder-specific treatment programms.

PRO*BPD: effectiveness of outpatient treatment programs for borderline personality disorder: a comparison of Schema therapy and dialectical behavior therapy: study protocol for a randomized trial.

BACKGROUND: Borderline Personality Disorder (BPD) is a severe mental illness that is associated with low quality of life, low psychosocial functioning, and high societal costs. Treatments for BPD have improved in the last decades. Dialectical behavior therapy (DBT) and Schema therapy (ST) have demonstrated efficacy in reducing BPD symptoms and costs. However, research has not compared these two treatment approaches. In addition, there is a lack of 'real world studies' that replicate positive findings in regular mental healthcare settings. Thus, the PROgrams for Borderline Personality Disorder (PRO*BPD) study will compare the (cost-) effectiveness of DBT and ST in structured outpatient treatment programs in the routine clinical setting of an outpatient clinic. METHODS/DESIGN: We aim to recruit 160 BPD patients, who will be randomly assigned to either DBT or ST. In both conditions, patients receive one group therapy and one individual therapy session/week for a maximum of 18 months. Both treatment programs have similar frameworks, which guarantee clinical equipoise. The primary outcome is a reduction of BPD-symptoms. Also, the costs related to BPD are assessed and an economic evaluation is performed from a societal perspective. Secondary outcomes examine other measures of BPD-typical and general psychopathology, comorbidity, quality of life, psychosocial functioning and participation. Data are collected prior to the beginning therapy and every six months until the end of therapy, as well as at six months, one year and two years of follow-up after the end of therapy. Finally, we conduct a qualitative study to understand patients' experiences with the two methods. DISCUSSION: The PRO*BPD study is the first randomized trial to compare the (cost-) effectiveness of DBT and ST. By examining the clinical effectiveness of a broad spectrum of outcome parameters, conducting an economic evaluation and assessing patients' experiences, this study will significantly advance our knowledge on psychotherapy for BPD and will provide insight into the treatment approaches that should be offered to different BPD patients from clinical, economic and stakeholder's perspectives. TRIAL REGISTRATION: German Clinical Trial Register, DRKS00011534 , Date of registration: 11/01/2017, retrospectively registered.

Hypothalamic-Pituitary-Adrenocortical Dysfunction in Elderly, Male Marathon Runners: Feedback Sensitivity, Stress Response, and Effects on Verbal Memory.

Animal studies suggest that repeated episodes of elevated glucocorticoids lead to a dysregulation of the hypothalamic-pituitary-adrenal (HPA) system at a suprapituitary level, and to impaired mnemonic function. We compared cognitive tests, as well as feedback integrity and stress responsivity of the HPA system, between 11 elderly, male marathon runners - a model of repeated HPA system activation - and 10 sedentary controls. The marathon runners had significantly increased baseline, stress, and post-stress ACTH - but not cortisol - concentrations. Also, suppression of ACTH by 3 mg dexamethasone was impaired in the athletes compared to the control subjects, while the ACTH and cortisol response to additional CRH did not differ between the 2 groups. Finally, long-term verbal memory was impaired in the athletes compared to the controls. Regarding the HPA system, these findings are in accordance with an acquired suprapituitary feedback disturbance in marathon runners; however, the similar glucocorticoid concentrations in the 2 groups may be due to reduced adrenal sensitivity to ACTH. Together with impaired verbal memory, these data support the assumption that repeated episodes of HPA system activity may exert negative effects at the level of the hippocampus.

[Treatment of Eating Disorders by Emotion Regulation]. / Therapie der Essstörung durch Emotionsregulation.

Patients with an eating disorder have difficulties perceiving emotions. They have skills deficits in the acceptance, modification and opposite action to emotion driven behavior. They use disturbed eating behavior (restrained eating, binge eating and purging), but also situational avoidance, dissociation and substance use as an instrument for emotional avoidance. This constitutes an innovative starting point for therapy.

Development and psychometric evaluation of the Interactive Test of Interpersonal Behavior (ITIB): a pilot study examining interpersonal deficits in chronic depression.

Chronic depression is assumed to be caused and maintained by interpersonal deficits. We describe the development and psychometric evaluation of the Interactive Test of Interpersonal Behavior (ITIB) that we developed for self-assessment of these deficits. Participants with chronic depression (CD, N = 15), episodic depression (ED, N = 15) and healthy controls (HC, N = 15) participated in this pilot study. They completed the ITIB and a number of pen and paper questionnaires including the Lübeck Questionnaire of Preoperational Thinking (LQPT) and the inventory of interpersonal problems (IIP). The ITIB was highly acceptable for use in these participants. Internal consistency for the ITIB was adequate for group comparisons (Cronbach's alpha = 0.649). Item-total correlations indicated adequate discriminatory power of five of the six items. The ITIB correlated moderately with the LQPT (r = 0.524) and the IIP (r = -0.568). The ITIB score differed significantly between the diagnostic groups (ANOVA F(2,42) = 6.22, p = 0.004). It was the only measure that - albeit at a trend level - was associated with diagnostic group (CD vs. ED) on multinomial logistic regression analysis (B = 0.049 ± 0.029; OR 1.051; p = 0.088). We found preliminary evidence that the ITIB is an acceptable and psychometrically adequate measure of interpersonal behavior that distinguishes between patients with CD and patients with ED. If replicated with an improved version of the test, our results could support the hypothesis that having interpersonal problems is a core deficit in patients with CD.

Integration of e-Health Tools Into Face-to-Face Psychotherapy for Borderline Personality Disorder: A Chance to Close the Gap Between Demand and Supply?

Borderline personality disorder (BPD) is a severe, highly prevalent mental disorder. Effective psychological treatments for BPD are available. However, most patients do not receive evidence-based treatments partly because of high treatment delivery costs and lack of specialized therapists. By integrating specialized e-health tools into BPD-specific treatments, treatment intensity can be increased, frequency of face-to-face sessions and burden for psychotherapists can be reduced, and implementation of new skills and experiences in the everyday life of these patients can be promoted. This bears great potential to increase the availability of evidenced-based psychotherapy for BPD patients and close the gap between demand and supply. In this article we present such an innovative e-health tool, priovi, which has been developed for schema therapy. The concept and application of priovi are described and illustrated with a case example.

Design of an international multicentre RCT on group schema therapy for borderline personality disorder.

BACKGROUND: Borderline personality disorder (BPD) is a severe and highly prevalent mental disorder. Schema therapy (ST) has been found effective in the treatment of BPD and is commonly delivered through an individual format. A group format (group schema therapy, GST) has also been developed. GST has been found to speed up and amplify the treatment effects found for individual ST. Delivery in a group format may lead to improved cost-effectiveness. An important question is how GST compares to treatment as usual (TAU) and what format for delivery of schema therapy (format A; intensive group therapy only, or format B; a combination of group and individual therapy) produces the best outcomes. METHODS/DESIGN: An international, multicentre randomized controlled trial (RCT) will be conducted with a minimum of fourteen participating centres. Each centre will recruit multiple cohorts of at least sixteen patients. GST formats as well as the orders in which they are delivered to successive cohorts will be balanced. Within countries that contribute an uneven number of sites, the orders of GST formats will be balanced within a difference of one. The RCT is designed to include a minimum of 448 patients with BPD. The primary clinical outcome measure will be BPD severity. Secondary clinical outcome measures will include measures of BPD and general psychiatric symptoms, schemas and schema modes, social functioning and quality of life. Furthermore, an economic evaluation that consists of cost-effectiveness and cost-utility analyses will be performed using a societal perspective. Lastly, additional investigations will be carried out that include an assessment of the integrity of GST, a qualitative study on patients' and therapists' experiences with GST, and studies on variables that might influence the effectiveness of GST. DISCUSSION: This trial will compare GST to TAU for patients with BPD as well as two different formats for the delivery of GST. By combining an evaluation of clinical effectiveness, an economic evaluation and additional investigations, it will contribute to an evidence-based understanding of which treatment should be offered to patients with BPD from clinical, economic, and stakeholders' perspectives. TRIAL REGISTRATION: Netherlands Trial Register NTR2392. Registered 25 June 2010.

[Metacognitive Therapy in the Treatment of Depression.] / Die Metakognitive Therapie in der Behandlung der unipolaren Depression.

Metacognitive Therapy (MCT) developed by A. Wells is one of the new developments of Behavior Therapy. It assumes that not the content of cognition is important for the treatment of psychological disorders. Instead of this from a metacognitive perspective persistent and unflexible patterns of thinking and focusing attention and therewith associated dysfunctional coping behaviors play a crucial role for their development and maintenance. These patterns are called Cog-nitive Attentional Syndrome (CAS). In depres-sion the CAS consists of excessive rumination and worry, focusing attention on potential danger (threat monitoring) and maladaptive coping strategies, e. g. avoidance of social contact or substance abuse. The reason for the use of these strategies is the existence of positive metacognitions which highlight its benefit for the patient (e. g. "Rumination helps me to find a solution for my problems!"). Over time however negative metacognitive beliefs develop about the uncontrollability and danger of these processes (e. g., "Rumination is uncontrollable!"). They account for the continued use of these strategies and of further coping behaviors that backfire. The aim of MCT is to improve the metacognitive awareness of the patients and to regain flexible control over processes of thinking and focusing attention. The CAS is reduced, the underlying metacognitive beliefs are changed and alternative plans of cognitive processing are generated. The existing data suggest that regarding treatment outcome MCT is possibly superior to Cognitive Behavior Therapy.

Prevalence of the metabolic syndrome in patients with borderline personality disorder: results from a cross-sectional study.

Metabolic syndrome (MetS) is an important risk factor for the development of type-2 diabetes and coronary artery disease. We aimed to compare the MetS prevalence in patients with borderline personality disorder (BPD) with comparison subjects followed in primary care from a similar region. One hundred and thirty-five BPD patients according to DSM-IV diagnostic criteria were compared to 1009 subjects from primary care. We used the American Heart Association/National Heart, Lung and Blood Institute criteria to determine the rate of MetS. The age-standardized prevalence of MetS was more than double in patients with BPD compared to comparison subjects (23.3 vs. 10.6 %, p < 0.05). Regarding individual MetS criteria, hyperglycemia was significantly more prevalent in both genders (p < 0.05). Abdominal obesity (p < 0.05) and hypertriglyceridemia (p < 0.05) were significantly higher only in women with BPD. Within BPD patients, an increased rate of MetS was associated with higher BMI (p = 0.004), age (p = 0.03), treatment with second-generation antipsychotics (quetiapine, olanzapine and clozapine; p = 0.032), dysthymia (p = 0.031), panic disorder (p = 0.032), benzodiazepine dependency (p = 0.015) and binge eating disorder p = 0.02). Our results demonstrate an increased MetS rate, dysregulated glucose and lipid metabolism in patients with BPD. Cardiometabolic monitoring and careful screening for physical health conditions among people with BPD is warranted.