Kathryn E. Korslund

Dialectical behavior therapy for high suicide risk in individuals with borderline personality disorder: a randomized clinical trial and component analysis.

IMPORTANCE Dialectical behavior therapy (DBT) is an empirically supported treatment for suicidal individuals. However, DBT consists of multiple components, including individual therapy, skills training, telephone coaching, and a therapist consultation team, and little is known about which components are needed to achieve positive outcomes. OBJECTIVE To evaluate the importance of the skills training component of DBT by comparing skills training plus case management (DBT-S), DBT individual therapy plus activities group (DBT-I), and standard DBT which includes skills training and individual therapy. DESIGN, SETTING, AND PARTICIPANTS We performed a single-blind randomized clinical trial from April 24, 2004, through January 26, 2010, involving 1 year of treatment and 1 year of follow-up. Participants included 99 women (mean age, 30.3 years; 69 [71%] white) with borderline personality disorder who had at least 2 suicide attempts and/or nonsuicidal self-injury (NSSI) acts in the last 5 years, an NSSI act or suicide attempt in the 8 weeks before screening, and a suicide attempt in the past year. We used an adaptive randomization procedure to assign participants to each condition. Treatment was delivered from June 3, 2004, through September 29, 2008, in a university-affiliated clinic and community settings by therapists or case managers. Outcomes were evaluated quarterly by blinded assessors. We hypothesized that standard DBT would outperform DBT-S and DBT-I. INTERVENTIONS The study compared standard DBT, DBT-S, and DBT-I. Treatment dose was controlled across conditions, and all treatment providers used the DBT suicide risk assessment and management protocol. MAIN OUTCOMES AND MEASURES Frequency and severity of suicide attempts and NSSI episodes. RESULTS All treatment conditions resulted in similar improvements in the frequency and severity of suicide attempts, suicide ideation, use of crisis services due to suicidality, and reasons for living. Compared with the DBT-I group, interventions that included skills training resulted in greater improvements in the frequency of NSSI acts (F1,85 = 59.1 [P < .001] for standard DBT and F1,85 = 56.3 [P < .001] for DBT-S) and depression (t399 = 1.8 [P = .03] for standard DBT and t399 = 2.9 [P = .004] for DBT-S) during the treatment year. In addition, anxiety significantly improved during the treatment year in standard DBT (t94 = -3.5 [P < .001]) and DBT-S (t94 = -2.6 [P = .01]), but not in DBT-I. Compared with the DBT-I group, the standard DBT group had lower dropout rates from treatment (8 patients [24%] vs 16 patients [48%] [P = .04]), and patients were less likely to use crisis services in follow-up (ED visits, 1 [3%] vs 3 [13%] [P = .02]; psychiatric hospitalizations, 1 [3%] vs 3 [13%] [P = .03]). CONCLUSIONS AND RELEVANCE A variety of DBT interventions with therapists trained in the DBT suicide risk assessment and management protocol are effective for reducing suicide attempts and NSSI episodes. Interventions that include DBT skills training are more effective than DBT without skills training, and standard DBT may be superior in some areas. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00183651.

Treating PTSD in suicidal and self-injuring women with borderline personality disorder: Development and preliminary evaluation of a Dialectical Behavior Therapy Prolonged Exposure Protocol

This study focused on the development and pilot testing of a protocol based on Prolonged Exposure (PE) that can be added to Dialectical Behavior Therapy (DBT) to treat PTSD in suicidal and self-injuring individuals with borderline personality disorder (BPD). Women with BPD, PTSD, and recent and/or imminent serious intentional self-injury (n = 13) received one year of DBT with the DBT PE Protocol, plus three months of follow-up assessment. The treatment was associated with significant reductions in PTSD, with the majority of patients no longer meeting criteria for PTSD at post-treatment (71.4% of DBT PE Protocol completers, 60.0% of the intent-to-treat sample). A minority of patients (27.3%) engaged in intentional self-injury during the study. Improvements were also found for suicidal ideation, dissociation, trauma-related guilt cognitions, shame, anxiety, depression, and social adjustment. There was no evidence that the DBT PE Protocol led to exacerbations of intentional self-injury urges or behaviors, PTSD, treatment dropout, or crisis service use. Overall, the results indicate that this integrated BPD and PTSD treatment is feasible to implement within one year of treatment, highly acceptable to patients and therapists, safe to administer, and shows promise as an effective intervention for PTSD in this complex and high-risk patient population.

A pilot randomized controlled trial of Dialectical Behavior Therapy with and without the Dialectical Behavior Therapy Prolonged Exposure protocol for suicidal and self-injuring women with borderline personality disorder and PTSD

OBJECTIVE This study evaluates the efficacy of integrating PTSD treatment into Dialectical Behavior Therapy (DBT) for women with borderline personality disorder, PTSD, and intentional self-injury. METHODS Participants were randomized to DBT (n=9) or DBT with the DBT Prolonged Exposure (DBT PE) protocol (n=17) and assessed at 4-month intervals during the treatment year and 3-months post-treatment. RESULTS Treatment expectancies, satisfaction, and completion did not differ by condition. In DBT+DBT PE, the DBT PE protocol was feasible to implement for a majority of treatment completers. Compared to DBT, DBT+DBT PE led to larger and more stable improvements in PTSD and doubled the remission rate among treatment completers (80% vs. 40%). Patients who completed the DBT PE protocol were 2.4 times less likely to attempt suicide and 1.5 times less likely to self-injure than those in DBT. Among treatment completers, moderate to large effect sizes favored DBT+DBT PE for dissociation, trauma-related guilt cognitions, shame, anxiety, depression, and global functioning. CONCLUSIONS DBT with the DBT PE protocol is feasible, acceptable, and safe to administer, and may lead to larger improvements in PTSD, intentional self-injury, and other outcomes than DBT alone. The findings require replication in a larger sample.

The utility of interdisciplinary training and service: Psychology training on a psychiatry consultation-liaison service

Increasing numbers of psychologists work in medical settings because of the growing acceptance of a biopsychosocial approach to illness. Do training programs prepare sufficient numbers of graduates to function effectivelyin medical settings? The authors describe the process of adding an inpatient medical-surgical consultation-liaison (C-L) service to a psychology internships training rotations, the learning objectives used, and issues in the preparation of trainees for work in medical settings. Psychology trainees added significant capacity to the C-L service. These data may help facilitate the development of C-L training experiences for other programs.

Communication patterns in a psychotherapy following traumatic brain injury: A quantitative case study based on symbolic dynamics

BackgroundThe role of psychotherapy in the treatment of traumatic brain injury is receiving increased attention. The evaluation of psychotherapy with these patients has been conducted largely in the absence of quantitative data concerning the therapy itself. Quantitative methods for characterizing the sequence-sensitive structure of patient-therapist communication are now being developed with the objective of improving the effectiveness of psychotherapy following traumatic brain injury.MethodsThe content of three therapy session transcripts (sessions were separated by four months) obtained from a patient with a history of several motor vehicle accidents who was receiving dialectical behavior therapy was scored and analyzed using methods derived from the mathematical theory of symbolic dynamics.ResultsThe analysis of symbol frequencies was largely uninformative. When repeated triples were examined a marked pattern of change in content was observed over the three sessions. The context free grammar complexity and the Lempel-Ziv complexity were calculated for each therapy session. For both measures, the rate of complexity generation, expressed as bits per minute, increased longitudinally during the course of therapy. The between-session increases in complexity generation rates are consistent with calculations of mutual information. Taken together these results indicate that there was a quantifiable increase in the variability of patient-therapist verbal behavior during the course of therapy. Comparison of complexity values against values obtained from equiprobable random surrogates established the presence of a nonrandom structure in patient-therapist dialog (P = .002).ConclusionsWhile recognizing that only limited conclusions can be based on a case history, it can be noted that these quantitative observations are consistent with qualitative clinical observations of increases in the flexibility of discourse during therapy. These procedures can be of particular value in the examination of therapies following traumatic brain injury because, in some presentations, these therapies are complicated by deficits that result in subtle distortions of language that produce significant post-injury social impairment. Independently of the mathematical analysis applied to the investigation of therapy-generated symbol sequences, our experience suggests that the procedures presented here are of value in training therapists.

Parental validation and invalidation predict adolescent self-harm.

This study was designed to evaluate family processes theoretically implicated in the onset and maintenance of adolescent self-harm. We focused on understanding parental validation and invalidation in response to their adolescent children to estimate the association between parental responses and self-harm in a high-risk group of adolescents. We also sought to determine the influence of psychotherapy on parental validation and invalidation over time during participation in a randomized clinical trial of psychotherapy designed to reduce self-harm. Teens (N = 38, Mage = 14.85, 94.1% female, 55.3% Caucasian, and 17.5% Latino) and their parents participated in three assessments over a 6-month period corresponding to pretreatment, midtreatment, and end of treatment in the trial. Results indicate a robust association between parental validation, invalidation, and adolescent self-harm. There were no significant associations observed between parental validation, invalidation, and adolescent suicidal ideation. Observed levels of parental validation and invalidation were not changed during the 6-month course of psychotherapy.

Predictors of Adoption and Reach Following Dialectical Behavior Therapy Intensive Training

Dialectical behavior therapy (DBT) is an evidence-based treatment for borderline personality disorder. The DBT Intensive Training™ is widely used to train community clinicians to deliver DBT, but little is known about its effectiveness. This study prospectively evaluated predictors of adoption and reach of DBT among 52 community teams (212 clinicians) after DBT Intensive Training™. Pre-post training questionnaires were completed by trainees and a follow-up survey by team leaders approximately 8 months later. Overall, 75% of teams adopted all DBT modes and delivered DBT to an average of 118 clients. Lower training and program needs, fewer bachelor’s-level clinicians, and greater prior DBT experience predicted adoption of more DBT modes. More prior DBT experience, smaller team size, more negative team functioning, and staff with lower job satisfaction, growth, efficacy, and influence predicted greater DBT reach. DBT Intensive Training™ appears effective in promoting DBT adoption and reach in routine clinical practice settings.

Treating PTSD and Borderline Personality Disorder

Borderline personality disorder (BPD) is a severe and complex psychological disorder characterized by pervasive emotion dysregulation, unstable relationships, impulsive behavior, and recurrent suicidal and non-suicidal self-injury (NSSI). PTSD is one of the most common co-occurring disorders among individuals with BPD, with comorbidity rates ranging from approximately 30 % in community samples (Grant et al. 2008; Pagura et al. 2010) to 50 % in clinical samples (Harned et al. 2010; Zanarini et al. 1998). There are several theoretical models to explain the high comorbidity between BPD and PTSD. Some models focus on the common etiological factors between the two disorders. For example, childhood abuse has been implicated in the development of both BPD and PTSD (Widom 1999; Widom et al. 2009). Other models propose that PTSD mediates the relationship between trauma exposure and BPD criterion behaviors. For example, PTSD symptoms of reexperiencing and avoidance/numbing have been found to mediate the relationship between childhood sexual abuse and NSSI (Weierich and Nock 2008). Finally, some models suggest a reciprocal relationship such that each disorder functions to maintain the other. For example, PTSD has been shown to exacerbate BPD criterion behaviors, such as emotion dysregulation, suicide attempts, and NSSI (Pagura et al. 2010; Harned et al. 2010; Marshall-Berenz et al. 2011) and to decrease the likelihood of achieving diagnostic remission from BPD over 6 and 10 years of naturalistic follow-up (Zanarini et al. 2004, 2006). Conversely, BPD is associated with high experiential avoidance (Iverson et al. 2012), which is likely to maintain PTSD (Shenk et al. 2014). Given the multiple and complex relationships between PTSD and BPD suggested by these models, successful treatment of both disorders is likely necessary to achieve optimal outcomes for individuals with this comorbidity. In this chapter, we will review research on treatment approaches for individuals with PTSD and BPD, discuss common challenges that arise during trauma-focused treatment with this population, and present a case example.

The Use of Dialectical Behavior Therapy and Prolonged Exposure to Treat Comorbid Dissociation and Self-Harm: The Case of a Client With Borderline Personality Disorder and Posttraumatic Stress Disorder: Integrating DBT and PE

There is a high rate of comorbidity between borderline personality disorder (BPD) and posttraumatic stress disorder (PTSD; Pagura et al., 2010). Preliminary studies have evaluated the treatment of PTSD in a BPD population and found positive outcomes for the integration of dialectical behavior therapy (DBT) and prolonged exposure (PE). This case study illustrates the implementation of a PE protocol into standard DBT treatment, specifically focusing on the management of self-harm and severe dissociation for a client with co-occurring PTSD and BPD. The client entered into treatment with severe and persistent dissociation and a recent history of self-harm, and the case includes consideration of two separate pauses in PTSD treatment related to elevated dissociation and self-harm behaviors. The client successfully completed the DBT PE protocol and results indicate significant improvements in PTSD symptoms as well as outcomes related to self-harm and dissociation. These findings demonstrate the efficacy of combining DBT with PE for clients with comorbid BPD and PTSD and exemplify how complex clients with BPD who present with severe dissociation and self-harm behavior can safely and successfully receive treatment for PTSD.

The Use of Dialectical Behavior Therapy and Prolonged Exposure to Treat Comorbid Dissociation and Self-Harm

There is a high rate of comorbidity between borderline personality disorder (BPD) and posttraumatic stress disorder (PTSD; Pagura et al., 2010). Preliminary studies have evaluated the treatment of PTSD in a BPD population and found positive outcomes for the integration of dialectical behavior therapy (DBT) and prolonged exposure (PE). This case study illustrates the implementation of a PE protocol into standard DBT treatment, specifically focusing on the management of self-harm and severe dissociation for a client with co-occurring PTSD and BPD. The client entered into treatment with severe and persistent dissociation and a recent history of self-harm, and the case includes consideration of two separate pauses in PTSD treatment related to elevated dissociation and self-harm behaviors. The client successfully completed the DBT PE protocol and results indicate significant improvements in PTSD symptoms as well as outcomes related to self-harm and dissociation. These findings demonstrate the efficacy of combining DBT with PE for clients with comorbid BPD and PTSD and exemplify how complex clients with BPD who present with severe dissociation and self-harm behavior can safely and successfully receive treatment for PTSD.