Improve Borderline Personality Disorder with Dialectical Behavior Therapy Mindfulness
By John M. de Castro, Ph.D.
“People with borderline personality disorder can be challenging to treat, because of the nature of the disorder. They are difficult to keep in therapy, frequently fail to respond to our therapeutic efforts and make considerable demands on the emotional resources of the therapist, particular when suicidal behaviors are prominent. Dialectical Behavior Therapy is an innovative method of treatment that has been developed specifically to treat this difficult group of patients in a way which is optimistic and which preserves the morale of the therapist.” – Psych Central
Borderline Personality Disorder (BPD) is a very serious mental illness that is estimated to affect 1.6% of the U.S. population. It involves unstable moods, behavior, and relationships, problems with regulating emotions and thoughts, impulsive and reckless behavior, and unstable relationships. BPD is associated with high rates of co-occurring depression, anxiety disorders, substance abuse, eating disorders, self-harm, suicidal behaviors, and completed suicides. Needless to say, it is widespread and debilitating.
One of the few treatments that appears to be effective for Borderline Personality Disorder (BPD) is Dialectical Behavior Therapy (DBT). It is targeted at changing the problem behaviors characteristic of BPD including self-injury. Behavior change is accomplished through focusing on changing the thoughts and emotions that precede problem behaviors, as well as by solving the problems faced by individuals that contribute to problematic thoughts, feelings and behaviors. In DBT five core skills are practiced; mindfulness, distress tolerance, emotion regulation, the middle path, and interpersonal effectiveness. Although the effectiveness of DBT for BPR is well established the most effective and cost effective means of delivering DBT has not been established.
In today’s Research News article “Effectiveness of step-down versus outpatient dialectical behaviour therapy for patients with severe levels of borderline personality disorder: a pragmatic randomized controlled trial.” (See summary below or view the full text of the study at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6040072/ ), Sinnaeve and colleagues examine the effectiveness of DBT provided either as a Step-down DBT program or delivered on an out-patient basis. The Step-down DBT program consisted of 3 months of therapy as an inpatient and then 6 months as an outpatient. Outpatient DBT was delivered for 12 months completely on an outpatient basis. They recruited adult (18–45 years of age) patients with severe Borderline Personality Disorder (BPD) and randomly assigned them to either the step-down or outpatient program of Dialectical Behavior Therapy (DBT). They were measured at baseline and at 3, 6, 9, and 12 months of treatment for psychiatric symptoms, borderline personality disorder, suicidal thoughts, quality of life, and costs of therapy delivery.
They found that both programs were effective and produced significant decreases in the severity of Borderline Personality Disorder (BPD). But, the step-down program was far more effective in retaining participants with 95% of the participants who started the program completing it as opposed to only 45% of the out-patient participants completing the program. In addition, the step-down program patients had significant reductions in suicidal intentions and improvements in quality of life while the out-patient participants did not. Hence the step-down delivery of DBT was found to be significantly more effective than the outpatient DBT,
On the other hand, the step-down program was far more expensive to deliver; €19,899 per patient versus €12,472. To further investigate this the costs per Quality Adjusted Life Year (QALY) for both programs were calculated. QALY measures how much benefit (increase in quality of life) is produced per unit of cost. This analysis suggested that the step-down program was not as cost effective as the outpatient program. So, it would appear that although a step-down program is more effective it may not be as cost effective as a more traditional outpatient program. Regardless, Dialectical Behavior Therapy (DBT) was an effective treatment for severe Borderline Personality Disorder (BPD) regardless of delivery method.
So, improve borderline personality disorder with dialectical behavior therapy produced mindfulness.
“DBT was the first psychotherapy shown to be effective in treating BPD in controlled clinical trials, the most rigorous type of clinical research.“ – Kristalyn Salters
CMCS – Center for Mindfulness and Contemplative Studies
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Sinnaeve, R., van den Bosch, L. M. C., Hakkaart-van Roijen, L., & Vansteelandt, K. (2018). Effectiveness of step-down versus outpatient dialectical behaviour therapy for patients with severe levels of borderline personality disorder: a pragmatic randomized controlled trial. Borderline Personality Disorder and Emotion Dysregulation, 5, 12. http://doi.org/10.1186/s40479-018-0089-5
Step-down dialectical behaviour therapy (DBT) is a treatment consisting of 3 months of residential DBT plus 6 months of outpatient DBT. The program was specifically developed for people suffering from severe borderline personality disorder (BPD). The present study examines the effectiveness and cost-effectiveness of step-down DBT compared to 12 months of regular, outpatient DBT.
Eighty-four participants reporting high levels of BPD-symptoms (mean age 26 years, 95% female) were randomly assigned to step-down versus standard DBT. Measurements were conducted at baseline and after 3, 6, 9 and 12 months. The Lifetime Parasuicide Count and BPD Severity Index (BPDSI) were used to assess suicidal behaviour, non-suicidal self-injury (NSSI) and borderline severity. Costs per Quality Adjusted Life Year (QALY) were calculated using data from the EQ-5D-3L and the Treatment Inventory Cost in Psychiatric Patients (TIC-P).
In step-down DBT, 95% of patients started the program, compared to 45% of patients in outpatient DBT. The probability of suicidal behaviour did not change significantly over 12 months. The probability of NSSI decreased significantly in step-down DBT, but not in outpatient DBT. BPDSI decreased significantly in both groups, with the improvement leveling off at the end of treatment. While step-down DBT was more effective in increasing quality of life, it also cost significantly more. The extra costs per gained QALY exceeded the €80,000 threshold that is considered acceptable for severely ill patients in the Netherlands.
A pragmatic randomized controlled trial in the Netherlands showed that 9 months of step-down DBT is an effective treatment for people suffering from severe levels of BPD. However, step-down DBT is not more effective than 12 months of outpatient DBT, nor is it more cost-effective. These findings should be considered tentative because of high noncompliance with the treatment assignment in outpatient DBT. Furthermore, the long-term effectiveness of step-down DBT, and moderators of treatment response, remain to be evaluated.