Kathlen Priebe

Dialectical Behaviour Therapy for Post-traumatic Stress Disorder after Childhood Sexual Abuse in Patients with and without Borderline Personality Disorder: A Randomised Controlled Trial

Background: Post-traumatic stress disorder (PTSD) with co-occurring severe psychopathology such as borderline personality disorder (BPD) is a frequent sequel of childhood sexual abuse (CSA). CSA-related PTSD has been effectively treated through cognitive-behavioural treatments, but it remains unclear whether success can be achieved in patients with co-occurring BPD. The aim of the present study was to determine the efficacy of a newly developed modular treatment programme (DBT-PTSD) that combines principles of dialectical behaviour therapy (DBT) and trauma-focused interventions. Methods: Female patients (n = 74) with CSA-related PTSD were randomised to either a 12-week residential DBT-PTSD programme or a treatment-as-usual wait list. About half of the participants met the criteria for co-occurring BPD. Individuals with ongoing self-harm were not excluded. The primary outcomes were reduction of PTSD symptoms as assessed by the Clinician-Administered PTSD Scale (CAPS) and by the Posttraumatic Stress Diagnostic Scale (PDS). Hierarchical linear models were used to compare improvements across treatment groups. Assessments were carried out by blinded raters at admission, at end of treatment, and at 6 and 12 weeks post-treatment. Results: Under DBT-PTSD the mean change was significantly greater than in the control group on both the CAPS (33.16 vs. 2.08) and the PDS (0.70 vs. 0.14). Between-group effect sizes were large and highly significant. Neither a diagnosis of BPD nor the severity or the number of BPD symptoms was significantly related to treatment outcome. Safety analyses indicated no increase in dysfunctional behaviours during the trial. Conclusion: DBT-PTSD is an efficacious treatment of CSA-related PTSD, even in the presence of severe co-occurring psychopathology such as BPD.

Dialectical Behavior Therapy for Posttraumatic Stress Disorder Related to Childhood Sexual Abuse: A Pilot Study of an Intensive Residential Treatment Program

Dialectical behavior therapy for posttraumatic stress disorder (DBT-PTSD) is tailored for adults with PTSD from childhood sexual abuse (CSA). It uses principles from DBT and trauma-focused cognitive-behavioral approaches. To evaluate acceptance and safety, the authors treated 29 women with chronic CSA-related PTSD plus at least one other comorbid diagnosis. The Posttraumatic Diagnostic Scale (PDS), Symptom Checklist 90-Revised, Beck Depression Inventory, and State Trait Anxiety Inventory were administered prior to, at the end of, and 6 weeks after 3 months of intensive residential treatment. An effect size of 1.22 on the PDS was found between baseline and follow-up. Effect sizes for secondary outcomes ranged from medium to large. The results suggest that DBT-PTSD has promise for reducing severe and chronic PTSD after CSA.

Body image disturbance in patients with borderline personality disorder: Impact of eating disorders and perceived childhood sexual abuse

Body image disturbances occur in women with borderline personality disorder (BPD). Systematic research on these characteristics in well-defined BPD groups is lacking. It is unknown, if the disturbances are related to eating disorders and childhood sexual abuse (CSA), which frequently co-occur in patients with BPD. In the present study, cognitive-affective and behavioral components of body image for 89 female patients with BPD (49 with lifetime eating disorders) and 41 healthy participants were assessed via Body Image Avoidance Questionnaire (BIAQ) and Multidimensional Body-Self Relations Questionnaire (MBSRQ). Within the BPD group, 43 patients reported a history of CSA. Compared to healthy controls, BPD patients reported significantly more negative scores in the BIAQ and the MBSRQ. Both a history of CSA and a comorbid eating disorder were independently associated with an even more negative body image. Results suggest a disturbance of cognitive-affective and behavioral components of body image in female BPD patients.

Dialektisch Behaviorale Therapie für Posttraumatische Belastungsstörung nach sexualisierter Gewalt in der Kindheit und Jugend (DBT-PTSD)

So far, no specifically tailored and empirically evaluated psychological treatment program exists, which is tailored for adult survivors with posttraumatic stress disorder (PTSD) after childhood sexual abuse. At the Central Institute of Mental Health, Mannheim we developed Dialectical Behavioral Therapy for PTSD (DBT-PTSD) as a residential intensive program, which is specifically tailored to the needs of these patients and which is acceptable as well as tolerable for patients and therapists. The treatment program is mainly based on the principles and methods of Dialectical Behavior Therapy according to M. Linehan and integrates methods of traumafocused cognitive-behavioural therapy. An overview is given on the treatment rational, the dynamic hierarchy of treatment focusses and the interventions used. In the internet version of this article treatment application is exemplified in a case study.

State dissociation moderates response to dialectical behavior therapy for posttraumatic stress disorder in women with and without borderline personality disorder

Background Patients with posttraumatic stress disorder (PTSD) are prone to dissociation, which in theory should interfere with successful treatment. However, most empirical studies do not substantiate this assumption. Objective The primary objective was to test whether state dissociation predicts the success of an adaptation of dialectical behavior therapy designed for the treatment of patients with PTSD after childhood sexual abuse (CSA) (DBT-PTSD). We further explored whether the operationalization of dissociation as state versus trait dissociation made a difference with respect to prediction of improvement. Methods We present a hypothesis-driven post hoc analysis of a randomized controlled trial on the efficacy in patients with PTSD after CSA. Regression analyses relating pre–post improvements in the Clinician-Administered PTSD Scale (CAPS) and the Posttraumatic Diagnostic Scale (PDS) to dissociation were applied to the women who participated in the active treatment arm (DBT-PTSD). Multivariate models accounting for major confounders were used to relate improvements in both the CAPS and the PDS to (1) state dissociation as assessed after each treatment session and (2) trait dissociation as assessed at baseline. Results State dissociation during psychotherapy sessions predicted improvement after DBT-PTSD: patients with low state dissociation during treatment had a higher chance to show substantial improvement. This relation consistently emerged across subgroups of PTSD patients with and without borderline personality disorder. The operationalization of dissociation as state versus trait dissociation made a difference as improvement was not significantly predicted from trait dissociation. Conclusions Dissociation during treatment sessions may reduce success with trauma-focused therapies such as DBT-PTSD. Accordingly, clinical studies aimed at improving ways to address dissociation are needed. Highlights of the article The article investigates whether state dissociation during psychotherapeutic sessions moderates the success of an established treatment for PTSD. Patients were much more likely to substantially improve with respect to PTSD symptomatology if state dissociation during psychotherapeutic sessions was low. The article suggests that the relation between low dissociation and good response in highly symptomatic patients is stronger than previously thought. Future studies investigating the extent to which outcome might be improved when treating dissociation more vigorously than usually are necessary.

Frequency of intrusions and flashbacks in patients with posttraumatic stress disorder related to childhood sexual abuse: an electronic diary study.

Intrusions and flashbacks are core features of posttraumatic stress disorder (PTSD). The frequency of these symptoms is usually assessed through retrospective questionnaires, which may be subject to recall bias of unknown magnitude. Electronic diaries that enable real-time assessment have been used to address recall biases in several psychiatric disorders. However, to our knowledge, this is the first study to apply this method to assess intrusions and flashbacks in PTSD related to childhood sexual abuse (CSA). Female patients with PTSD related to CSA (n = 28) were provided with electronic diaries for repeated real-time assessment of intrusions and flashbacks over the period of 1 week. At the end of this period, they were asked to retrospectively report how many such symptoms they recalled having experienced over the past week. The total number of symptoms reported in the electronic diaries (74.5 ± 62.0 intrusions and 24.4 ± 36.0 flashbacks for the week) was substantially higher than those reported in previous studies. Furthermore, electronic diaries revealed the occurrence of about 50% more intrusions and flashbacks than did the retrospective assessment (74.5 vs. 49.5 for intrusions, and 24.4 vs. 13.4 for flashbacks). Such high frequencies are not captured with existing assessment instruments and suggest a possible ceiling effect. Future research needs to clarify whether these high numbers are specific to highly symptomatic PTSD patients or might generalize to other populations of PTSD patients.

Psychotherapie der Posttraumatischen Belastungsstörung nach sexuellem Missbrauch

There is an ongoing debate how to treat posttraumatic stress disorder related to childhood sexual abuse. In Germany patients mostly receive a psychodynamically oriented treatment with a long-lasting stabilization before the use of exposure-based interventions. The number of randomized controlled trials on posttraumatic stress disorder related to childhood sexual abuse is quite limited. The results of these studies show that cognitive-behavioral trauma-focussing interventions are very efficacious with large effect sizes. 2 controlled studies on psychodynamically oriented treatment found only small improvements in posttraumatic symptoms. The high dropout rates in prolonged exposure especially in patients with co-occurring personality disorders point towards the need of a emotion regulation training before the exposure phase. Future studies should include subgroup-analyses and the assessment of adverse effects during therapy.

Women with exposure to childhood interpersonal violence without psychiatric diagnoses show no signs of impairment in general functioning, quality of life and sexuality

BackgroundChildhood interpersonal violence is a major risk factor for developing Posttraumatic Stress Disorder (PTSD), other axis-I disorders or Borderline Personality Disorder (BPD). Individuals with a history of childhood sexual abuse (CSA) and childhood physical abuse (CPA) who meet the criteria of any axis-I disorder usually also exhibit general psychopathologic symptoms and impairments in quality of life and sexuality. The present study investigates whether women with a history of potentially traumatic CSA/CPA without any axis-I disorder or BPD show subthreshold symptoms of PTSD-specific and general psychopathology and impairments in global functioning, quality of life, and sexuality.MethodsData were obtained from N = 92 female participants: n = 31 participants with a history of potentially traumatic CSA/CPA (defined as fulfilling PTSD criterion A) without any axis-I disorder or BPD; n = 31 participants with PTSD related to CSA/CPA; and n = 30 healthy controls without any traumatic experiences. All three groups were matched for age and education. Those with a history of CSA/CPA with and without PTSD were further matched with regard to severity of physical and sexual abuse.ResultsWhile women with a history of potentially traumatic CSA/CPA without axis-I disorder or BPD clearly differed from the PTSD-group in the collected measures, they did not differ from healthy controls (e.g., GAF:87, BSI:0.3, BDI-II:4.5). They showed neither PTSD-specific nor general subthreshold symptoms nor any measurable restrictions in quality of life or sexual satisfaction.ConclusionsWomen with a history of potentially traumatic childhood interpersonal violence without axis-I disorder or BPD show a high level of functioning and a low level of pathological impairment that are comparable to the level of healthy controls. Further studies are needed to identify what helped these women survive these potentially traumatic experiences without developing any mental disorders.Trial registrationGerman Clinical Trials Registration ID: DRKS00006095. Registered 21 May 2014.

Dialektisch Behaviorale Therapie – Weiterentwicklungen und empirische Evidenz

OBJECTIVE Dialectical Behavior Therapy has been initially designed and evaluated as an outpatient-treatment program for chronic suicidal female patients. Within the last years, several adaptations of DBT for specific comorbidities, other settings or other disorders related to emotion dysregulation have been developed. This report reviews conceptual aspects and the scientific evidence of initially designed Dialectical Behavior Therapy and the adaptations. METHODS Systematic literature search and systematic review. RESULTS Recently, two meta-analyses which are based on randomized controlled trials conclude robust and stabile effects of DBT Evidence from further RCTs and other studies show promise for the properties of many DBT adaptations. CONCLUSION The current review of the literature suggests a good effectiveness of DBT, especially on complex disorders with deficits in the field of emotion regulation.

Body self-evaluation and physical scars in patients with borderline personality disorder: an observational study

BackgroundData from general psychology suggest that body self-evaluation is linked to self-esteem and social emotions. Although these emotions are fragile in individuals with borderline personality disorder (BPD), body self-evaluation is clearly understudied in BPD research.MethodsA total of 200 women took part in the study: 80 female BPD patients, and 47 healthy and 73 clinical controls including post-traumatic stress disorder (PTSD) after childhood sexual abuse (CSA). Diagnoses were established through standardised interviews conducted by experienced psychologists. The participants used the Survey of Body Areas to indicate which areas of their own bodies they liked or disliked and to mark the locations of physical scars.ResultsCompared to healthy controls, both BPD patients and patients with PTSD after CSA had a predominantly negative body self-evaluation (Cohen’s d = 1.42 and 1.38, respectively). As indicated by multilevel analyses, scars were related to a negative evaluation of the affected areas in BPD patients, but not in the control groups. Subgroup analyses revealed that the negative body self-evaluation applies to both BPD patients with and without PTSD or reported CSA.ConclusionsBPD patients show a negative body self-evaluation which is associated with the presence of scars but not with CSA.