Borderline personality disorder is a common disorder within the realm of psychiatric illnesses classified under DSM-IV. The usual therapy consisted of behavioral therapy combined with drug treatment or some psychotherapy. Dialectical behavior therapy (DBT) was discovered by Marsha Linehan for parasuicidal women. Research has suggested that a short term therapy of three months of DBT was sufficient to produce a favorable outcome of remission lasting for years. The focus here is on self- harming behavior, impulsivity and relationship instability which form 3 criteria of the illness as classified in the DSM-IV. The objective is to examine the quality of life of the patients of BPD who have had a short term therapy of 3 months of DBT in relation to self- harming behavior, impulsivity and relationship instability. These patients would be having other treatment to continue on the DBT. Previous research has investigated remissions and followed-up for 21 months from the end of DBT when they were discharged. This study intends to further the period of follow-up to 33 months.
Dialectical behavior therapy was a treatment developed by Marsha Linehan for parasuicidal women with BPD or borderline personality disorder (Robins and Chapman, 2004). A cognitive -behavioral therapy, it can be provided as an outpatient treatment or inpatient or crisis center treatment (Brodsky and Stanley, 2002). Structured and time-limited, dialectical behavior therapy is delivered on an individual basis. Researchers have found that attrition rate, parasuicidal episodes and inpatient days were much reduced with this therapy (Swales et al, 2000). Patients are led through change-oriented and acceptance-oriented treatment to overcome their difficulty in tolerating stress, accepting themselves and others, self-harming behaviors, impulsiveness and relationship instability (Robins and Chapman, 2004). Borderline personality disorder patients are prone to suicide and the rate of completed suicide is similar to that in major depression and schizophrenia: 1-3 or between 3% and 9% (Brodsky and Stanley, 2002). Producing serious problems not only for themselves, families, friends and physicians also feel the impact of having to care for them (Robins, 2002). The incidence of BPD is 10% in outpatient psychiatric patients and 20% of inpatients (Robins, 2002). The effect of inpatient dialectical behavior therapy which is short-term has been found to persist after the patients returned to normal life (Kleindienst, 2008). The benefits of therapy have been elicited in women prisoners in the UK (Nee and Farman, 2005). This paper intends to explore the improvement in the quality of life of patients of borderline personality disorder following the dialectical behavior therapy focusing on three behaviors : self-harming behaviors, impulsiveness and relationship instability which form three of the 9 diagnostic criteria of the DSM-IV.
Thesis
It can be hypothesized that DBT improves the quality of life in patients with BPD as evidenced by a decrease in self-harming behaviors, decrease in impulsiveness and better relationship stability.
Definitions
“Borderline personality disorder (BPD) is a serious mental illness characterized by pervasive instability in moods, interpersonal relationships, self-image, and behavior” (Borderline personality disorder, NIMH).
Dialectical behavior therapy is a cognitive behavioral therapy delivered individually to borderline personality disorder patients, through change-oriented and acceptance-oriented treatments to improve their quality of life.
Quality of life in borderline personality disorder for the purpose of this study is being defined as the lesser number of incidences of self-harming behaviors, acts of impulsiveness and relation instability.
Self-harming behaviors include suicidal tendencies and non suicidal; the latter include gestures, threats and self-mutilating behaviors. Recurrence of these form one criteria of diagnosis of the disorder by the DSM-IV (APA, 1994, p 654).
Impulsiveness in the context of the study refers at least two acts which are “potentially self-damaging” (APA, 1994, p 654) and which forms another criterion for diagnosis by DSM-IV.
Relation instability refers to the pattern of unstable and intense interpersonal relationships alternating between idealization and devaluation (APA, 1994, p 654).
Dialectical behavior therapy
Weekly meetings with individual therapists, one or more weekly group sessions for skills training and meetings of therapists for supervision and consultation are included in dialectical behavior therapy (Oldham et al, 2001). Palmer (2002) also speaks of out-of-hours telephone contact. Building a strong therapeutic alliance between the therapist and patient is essential especially in the intervention for a behavior associated with childhood abuse and neglect. The suicidal and self-injurious behaviors are considered first in priority when implementing the therapy. Then behaviors interfering with therapy like lateness, missed sessions and failure to maintain the diary card are dealt with. Finally behaviors interfering with quality of life like interpersonal difficulties are considered (Oldham et al, 2001). Patients tend to blame themselves for all the stress that occurred in their lives. Therapists convey the message that previous events were not to be blamed upon themselves but that they are now responsible for their actions. Effective therapy requires flexibility. Supportive strategies should not be misunderstood as mere friendship. The patient’s experience is first affirmed. This is followed by strengthening of his adaptive defenses and then methods of support are provided (Oldham et al, 2001).
Studies which provided the idea for thesis
Robins and Chapman (2004) studied the outcomes of dialectical behavior therapy on borderline personality disorder patients in “outpatient, inpatient, and crisis intervention settings, borderline patients with substance use disorders, suicidal adolescents, patients with eating disorders, inmates in correctional settings, depressed elders, and adults with attention-deficit/hyperactivity disorder” in a meta-analysis. The main predictors of the outcome of DBT were identified as “characteristics of the patient; (b) characteristics of the therapist; and (c) characteristics of the combination of patient and therapist, including their relationship” (Robins and Chapman, 2004). Many randomized control trials confirmed that women benefited from DBT (Linehan et al, 1991; Linehan, Tutek, Heard, & Armstrong, 1994 and Linehan, Heard, & Armstrong, 1993 all cited in Robins and Chapman, 2004). The lesser frequency and severity of parasuicides, the less frequent number of hospitalizations and better treatment outcome reported, all point to the improvement in the quality of life of the patient with DBT as compared to the usual treatment. Less trait anger and an improvement in social functioning was also seen. Another study by Koon et al (2001 cited in Robins and Chapman, 2004) where women with BPD were treated with DBT for 6 months showed improvements in suicidal attempts, feelings of hopelessness, depression and anger. However anxiety showed no improvement in both the DBT group and the usual treatment group. Verheul et al (2003 cited in Robins and Chapman, 2004) studied 58 BPD women who also had a history of substance abuse and DBT for 12 months. The improvement was more obvious in the women with greater incidence of problem behaviors like substance abuse, drinking, gambling and careless driving than those with lesser incidence, again signifying the improvement in quality of life. More DBT patients continued their treatment compared to the usual treatment group. An uncontrolled trial at a community center showed more than 75% reduction in the number of hospitalization days, a 56% reduction in crisis bed use and 80% reduction for emergency services use. Total treatment costs also diminished. Similar results were obtained in the Elwood, Comtois Holdcraft, and Simpson study (2002 cited in Robins and Chapman, 2004). In a nonrandomized controlled trial in adolescents with DBT and usual treatment groups over 12 weeks, it was found that suicide attempts were equal in number in both groups. The DBT patients who started out with more symptoms had lesser dropouts and inpatient care.
Brodsky and Stanley (2002) elaborated how DBT changed the life of a girl who had been sexually abused by her stepfather and had a borderline personality disorder. This girl mainly exhibited suicidal tendencies and self-harm. The authors provided details of how the therapy was implemented and the validity of a therapeutic alliance. They also mentioned a study which showed the efficacy of outpatient DBT. Suicidal and nonsuicidal self-injury diminished in number, treatment attrition rate was reduced by 84% and the number of days in hospital was also reduced (Brodsky and Stanley, 2002). They reported not much difference between the DBT and treatment as usual considering the factors of “depression, hopelessness, suicidal tendency or reasons for living”. Barley et al (1993 cited in Brodsky and Stanley, 2002) indicated that suicidal behavior and self-mutilation reduced in number. Monthly rates of self-injurious behavior were lesser after DBT was instituted in an inpatient unit. The group which did not get the DBT showed no difference in the monthly rates. It was concluded that DBT was useful for treating suicidal behavior and self-mutilation.
Robins (2002) had a randomized controlled study on DBT with 20 women veterans with BPD who were randomly assigned into two groups, one which had DBT and the other treatment as usual for 6 months. Suicide ideation, hopelessness, depression and anger were reduced immensely (Robins, 2002). Parasuicides, anger, dissociation and more hospitalizations were found. Depressive symptoms show differences but anxiety showed no difference in the two groups.
DBT was used for the first time in 3 selected UK prisons; two had year-long programs while the other had short-term treatment programs (Nee and Farman, 2005). The outcomes were promising. DBT had been found efficacious in diminishing the “criminogenic risk and improving the manageability and quality of life” for the problematic female prisoners. More research is necessary to prove that DBT is useful in prison settings (Nee and Farman, 2005).
The North Wales pilot project in the UK health care system echoed the results mentioned above (Swales et al, 2000). Long term effects of 31 inpatients who had DBT were studied by Kleindienst et al (2008). A high intraindividual concordance was seen. Patients went into remission 2 years after short-term treatment. The chance of DBT outcomes persisting when patients returned to normal lives is high (Kleindienst, 2008).
Summary
The studies selected indicate that DBT stands out as a good method of therapy when compared to the usual treatment. The main predictors of the outcome of DBT were identified as “characteristics of the patient; (b) characteristics of the therapist; and (c) characteristics of the combination of patient and therapist, including their relationship” (Robins and Chapman, 2004). The lesser frequency and severity of parasuicides, the less frequent number of hospitalizations and better treatment outcome after DBT all point to the improvement in the quality of life of the patient with DBT as compared to the usual treatment. Less trait anger and an improvement in social functioning were also seen (Robins and Chapman, 2004). Women with BPD who were treated with DBT for 6 months showed improvements in suicidal attempts, feelings of hopelessness, depression and anger (Robins and Chapman, 2004). The improvement was more obvious in the women with BPD and substance abuse. Those with greater incidence of problem behaviors like substance abuse, drinking, gambling and careless driving showed greater improvement than those with lesser incidence, again signifying the marked improvement in quality of life. A significant reduction was seen in the number of hospitalization days, crisis bed use and emergency services use in another study (Robins and Chapman, 2004; Brodsky and Stanley, 2002). The findings were similar whether it was a short term DBT (Robins and Chapman, 2004; Robins, 2002) or long-term effects of short term DBT (Kleindienst, 2008) or inpatient DBT (Kleindienst, 2008) or outpatient DBT (Robins and Chapman, 2004). DBT has been found to be a good method of therapy for prison settings too (Nee and Farman, 2005). The selection of thesis is justified. Self-harming behaviours, impulsiveness and relations instability constitute three criteria of the DSM-IV for borderline personality disorder. This study will be investigating how these behaviors are transformed after DBT and thereby improving the quality of life of the patient.
Methods
The study is aimed at clarifying the mental health status of patients of borderline personality disorder who are being treated with dialectical behavior therapy for a short period of 3 months, prospectively during a long term of 3 years. The participants will be recruited from the neighboring psychiatric hospital. At least 20 patients can be expected to be having borderline personality disorder and on dialectical behavior therapy. They may be in various stages of therapy and would include men, women and adolescents. Inpatients are being selected and their treatment is stopped after 3 months. The observation period will be 33 months after discharge from the hospital under natural circumstances as indicated in Kleindienst’s study of 2008. Usual treatment will follow the 3 months DBT. Prospective ratings will be done at 4, 12, 24 and 36th months (T1, T2, T3 and T4). Improvements are expected to occur over the full follow-up period. The increase of patients in remission is expected to be steady. Psychopathology will be broad and effect sizes are expected to be 0.70-1.71 as evident from Appendix B. (Kleindienst, 2008). Analysis will show a high intraindividual concordance: the short term treatment will have produced remissions by 2 years and this study will be examining if the remissions stand good even after 3 years or whether a relapse has set in. A comparison group of patients, with similar age, gender, ethnicity and severity of illness, who are having treatment as usual will also be selected (TAU). The number of criteria by virtue of DSM-IV, number of previous hospitalizations, number of other psychiatric illnesses and all the outcome measures will be noted. Completers and dropouts had similar trends in Kleindienst’s study (p value<=O.10).
Ethics
An approval from the Ethics Committee in the University will be secured first followed by a written permission from the institution housing the patients. The details of the study, its duration, its implications in society and the issue of borderline personality disorder will be imparted to the participants. Written informed consent will be obtained from the prospective participants.
Diagnosis of BPD and data collection
This will be done by trained and experienced physicians. Diagnosis will be confirmed using the revised version of the diagnostic interview for BPD and SCID-II. The instrument SCID-I will be used for ruling out co-occurrence of Axis I disorders. The primary end-point will be the global severity index of the symptom checklist (SCL-90-R). Secondary outcomes will be assessed using various tools for different outcomes: the Hamilton Anxiety Scale (HAMA) or the State Trait Anxiety Inventory for anxiety, the Beck Depression Inventory or the Hamilton Depression Scale (HAMD) for depression, the State-Trait Anger Inventory for anger, the Dissociation Experiences Scale for dissociation (DES) , the Global Assessment of Functioning Scale (GAF) and the Inventory of Interpersonal Problems. Suicidal ideation and non suicidal self-injurious behavior is assessed by the Suicidal Attempt and Self Injury Interview (SASII). The days of hospitalization will be obtained from the data in the hospital. The data collection will be of the data obtained through the various instruments.
McNemar tests were used for comparisons of the percentages of the patients before the intervention and after it. Hospitalization days and the events of self-injurious behavior were evaluated using Friedman statistic. To test for changes over time, Cochrane’s Q test was used. Mann Whitney U tests were used for group comparisons. Test for equality was done using Fisher exact test. A 2 tailed p value of <=0.05 was statistically significant.
Data analysis
Analyses will be based on the intent-to-treat (ITT) analyses and analyses of protocol. The last observation will be applied to missing values and then the ITT analyses will be calculated. The sphericity of the variance –covariance matrix will be tested with Mauchly’s test with the purpose of analyses of variance. If the assumption does not comply with the p value</= 0.10, the Greenhouse-Geisser technique will be used. To assess clinical improvement, Jacobson’s criteria will be applied. They are clinical response and reliability of change beyond chance variance. “Clinical response is defined as a shift from the dysfunctional to the functional range” (Kleindienst, 2008). “Reliable change indices for each patient were defined as with SCLpost and SCLpre corresponding the SCL-90-R (GSI) scores to be compared, rSCL = 0.92 = test-retest reliability of the SCL-90-R (GSI) according to Franke (1999), spre = 0.48356 = standard-deviation of the SCL-90-R (GSI) for the study sample at T0” as seen from Appendix C (Kleindienst, 2008). The analysing of variance will show a significant improvement for 7 out of 8 secondary measures for the evaluation of secondary outcomes(See Appendix A). The psychopathology (GSI of the SCL-90-R) in the duration of the study is depicted in the Appendix B where a comparison between the two groups of patients is obvious.
Results
Results similar to Kleindienst’s study will be expected. The mean age of patients was 29.6 years. The patients satisfied 6.6 criteria of DSM-IV. 65% of them had anxiety, 61% depression and 39% had eating disorder. Previous hospitalizations were at a mean of 5.2. Lifetime suicide attempts were at a mean of 3.4.
Discussion
This study is expected to indicate the usefulness of dialectical behavior therapy for borderline personality disorder patients on the lines of earlier research. The improvement of quality of life is assessed by investigating the change in number of self-harming acts, impulsivity and relations instability. Lesser number of self-harming acts, lesser incidences of impulsive behaviors like injudicious overspending or sexual indiscretion and acquiring the ability to maintain good interpersonal relationships would constitute the quality of life that has become better. This study also hopes to find that remissions last for more than 3 years and patients do not have relapses long after the short-term DBT is stopped.
Limitations
All patients who qualify for the study may not be willing to participate in the study. There may be another limitation due to most patients being started on dialectical behaviour therapy and sufficient participants for the TAU group not being obtained initially. Thirdly follow-up of the TAU group will not be possible for 3 years as the patients of TAU are started on dialectical behavior therapy after 3 months of wait. Fourthly the patients who start in the study may drop-out of treatment before the 3 months are over. Kleindienst had 31 patients for dialectical behavior therapy from an initial strength of 40 of which 9 had dropped out. The TAU group had 20 patients but they could not be followed-up after 3 months. Of the 31 patients, 8 did not finish the assessment points. A similar picture will be expected in this study too.
Implications for future research
Only 3 criteria from DSM-IV for borderline personality disorder have been considered in this study. Future research may include more of the nine criteria for the illness. DBT is a difficult procedure to implement and needs more research to find ways to make the implementation easier to handle. The therapy may be more organized and more specific in future.
References
American Psychiatric Association (1994) Diagsnotic and Statistical Manual of Mental Disorders (4th edn) (DSM–IV). Washington, DC: APA.
Brodsky, B.S. and Stanley, B. (2002). Dialectical behavior therapy for borderline personality disorder, Psychiatric Annals, Vol. 32, No. 6, p. 347-360
Kleindienst, N., Limerger, M., Schmahl, C., Steil, R. Ebner-Priemer, U.W. & Bohus, M. (2008). Do Improvements After Inpatient Dialectial Behavioral Therapy Persist in the Long Term?: A Naturalistic Follow-Up in Patients With Borderline Personality Disorder. The Journal of Nervous and Mental Disease, Vol. 196, No.11.
Nee, C. and Farman, S. (2005). Female prisoners with borderline personality disorder: some promising treatment developments. Criminal Behavior and Mental Health, Vol. 15, p 2-16
Oldham, John (2009). Borderline Personality Disorder Journal of Psychiatric Practice Volume 15(3).
Robins, C.J. & Chapman, A.L. (2004). Dialectical behavior therapy: current , recent developments and future directions, Journal of Personality Disorders, Vol. 18, No. 1, p. 73-89
Robins, C.J. (2002). Dialectical behavior therapy for borderline personality disorder, Psychiatric Annals Vol. 32, No. 10. p 608-616
Swales, M., Heard, H.L. & Williams, M.G., (2000). Linehan’s Dialectical behavior Therapy (DBT) for borderline personality disorder: overview and adaptation. Journal of Mental Health, Vol. 9, No. 1, p7-23
Appendix A
Table 1 : Analyses of Variance of Metric Outcome Measures (Completer Analyses)
Appendix B
Appendix C
