Stacy Shaw Welch

Dialectical behavior therapy versus comprehensive validation therapy plus 12-step for the treatment of opioid dependent women meeting criteria for borderline personality disorder

We conducted a randomized controlled trial to evaluate whether dialectical behavior therapy (DBT), a treatment that synthesizes behavioral change with radical acceptance strategies, would be more effective for heroin-dependent women with borderline personality disorder (N = 23) than Comprehensive Validation Therapy with 12-Step (CVT + 12S), a manualized approach that provided the major acceptance-based strategies used in DBT in combination with participation in 12-Step programs. In addition to psychosocial treatment, subjects also received concurrent opiate agonist therapy with adequate doses of LAAM (thrice weekly; modal dose 90/90/130 mg). Treatment lasted for 12 months. Drug use outcomes were measured via thrice-weekly urinalyses and self-report. Three major findings emerged. First, results of urinalyses indicated that both treatment conditions were effective in reducing opiate use relative to baseline. At 16 months post-randomization (4 months post-treatment), all participants had a low proportion of opiate-positive urinalyses (27% in DBT; 33% in CVT + 12S). With regard to between-condition differences, participants assigned to DBT maintained reductions in mean opiate use through 12 months of active treatment while those assigned to CVT + 12S significantly increased opiate use during the last 4 months of treatment. Second, CVT + 12S retained all 12 participants for the entire year of treatment, compared to a 64% retention rate in DBT. Third, at both post-treatment and at the 16-month follow-up assessment, subjects in both treatment conditions showed significant overall reductions in level of psychopathology relative to baseline. A noteworthy secondary finding was that DBT participants were significantly more accurate in their self-report of opiate use than were those assigned to CVT + 12S.

Delivery of evidence-based treatment for multiple anxiety disorders in primary care: a randomized controlled trial.

CONTEXT Improving the quality of mental health care requires moving clinical interventions from controlled research settings into real-world practice settings. Although such advances have been made for depression, little work has been performed for anxiety disorders. OBJECTIVE To determine whether a flexible treatment-delivery model for multiple primary care anxiety disorders (panic, generalized anxiety, social anxiety, and posttraumatic stress disorders) would be better than usual care (UC). DESIGN, SETTING, AND PATIENTS A randomized controlled effectiveness trial of Coordinated Anxiety Learning and Management (CALM) compared with UC in 17 primary care clinics in 4 US cities. Between June 2006 and April 2008, 1004 patients with anxiety disorders (with or without major depression), aged 18 to 75 years, English- or Spanish-speaking, were enrolled and subsequently received treatment for 3 to 12 months. Blinded follow-up assessments at 6, 12, and 18 months after baseline were completed in October 2009. INTERVENTION CALM allowed choice of cognitive behavioral therapy (CBT), medication, or both; included real-time Web-based outcomes monitoring to optimize treatment decisions; and a computer-assisted program to optimize delivery of CBT by nonexpert care managers who also assisted primary care clinicians in promoting adherence and optimizing medications. MAIN OUTCOME MEASURES Twelve-item Brief Symptom Inventory (BSI-12) anxiety and somatic symptoms score. Secondary outcomes included proportion of responders (> or = 50% reduction from pretreatment BSI-12 score) and remitters (total BSI-12 score < 6). RESULTS A significantly greater improvement for CALM vs UC in global anxiety symptoms was found (BSI-12 group mean differences of -2.49 [95% confidence interval {CI}, -3.59 to -1.40], -2.63 [95% CI, -3.73 to -1.54], and -1.63 [95% CI, -2.73 to -0.53] at 6, 12, and 18 months, respectively). At 12 months, response and remission rates (CALM vs UC) were 63.66% (95% CI, 58.95%-68.37%) vs 44.68% (95% CI, 39.76%-49.59%), and 51.49% (95% CI, 46.60%-56.38%) vs 33.28% (95% CI, 28.62%-37.93%), with a number needed to treat of 5.27 (95% CI, 4.18-7.13) for response and 5.50 (95% CI, 4.32-7.55) for remission. CONCLUSION For patients with anxiety disorders treated in primary care clinics, CALM compared with UC resulted in greater improvement in anxiety symptoms, depression symptoms, functional disability, and quality of care during 18 months of follow-up. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00347269.

State affective instability in borderline personality disorder assessed by ambulatory monitoring

BACKGROUND Although affective instability is an essential criterion for borderline personality disorder (BPD), it has rarely been reported as an outcome criterion. To date, most of the studies assessing state affective instability in BPD using paper-pencil diaries did not find indications of this characteristic, whereas in others studies, the findings were conflicting. Furthermore, the pattern of instability that characterizes BPD has not yet been identified. METHOD We assessed the affective states of 50 female patients with BPD and 50 female healthy controls (HC) during 24 hours of their everyday life using electronic diaries. RESULTS In contrast to previous paper-and-pencil diary studies, heightened affective instability for both emotional valence and distress was clearly exhibited in the BPD group but not in the HC group. Inconsistencies in previous papers can be explained by the methods used to calculate instability (see Appendix). In additional, we were able to identify a group-specific pattern of instability in the BPD group characterized by sudden large decreases from positive mood states. Furthermore, 48% of the declines from a very positive mood state in BPD were so large that they reached a negative mood state. This was the case in only 9% of the HC group, suggesting that BPD patients, on average, take less time to fluctuate from a very positive mood state to a negative mood state. CONCLUSION Future ambulatory monitoring studies will be useful in clarifying which events lead to the reported, sudden decrease in positive mood in BPD patients.

Computer-assisted delivery of cognitive behavioral therapy for anxiety disorders in primary-care settings†

Objectives: This article describes a computer‐assisted cognitive behavioral therapy (CBT) program designed to support the delivery of evidenced‐based CBT for the four most commonly occurring anxiety disorders (panic disorder, posttraumatic stress disorder, generalized anxiety disorder, and social anxiety disorder) in primary‐care settings. The purpose of the current report is to (1) present the structure and format of the computer‐assisted CBT program, and (2) to present evidence for acceptance of the program by clinicians and the effectiveness of the program for patients. Methods: Thirteen clinicians using the computer‐assisted CBT program with patients in our ongoing Coordinated Anxiety Learning and Management study provided Likert‐scale ratings and open‐ended responses about the program. Rating scale data from 261 patients who completed at least one CBT session were also collected Results: Overall, the program was highly rated and modally described as very helpful. Results indicate that the patients fully participated (i.e., attendance and homework compliance), understood the program material, and acquired CBT skills. In addition, significant and substantial improvements occurred to the same degree in randomly audited subsets of each of the four primary anxiety disorders (N=74), in terms of self ratings of anxiety, depression, and expectations for improvement. Conclusions: Computer‐assisted CBT programs provide a practice‐based system for disseminating evidence‐based mental health treatment in primary‐care settings while maintaining treatment fidelity, even in the hands of novice clinicians. Depression and Anxiety, 2009. Published 2009 Wiley‐Liss, Inc.

Psychophysiological ambulatory assessment of affective dysregulation in borderline personality disorder.

Many experts now believe that pervasive problems in affect regulation constitute the central area of dysfunction in borderline personality disorder (BPD). However, data is sparse and inconclusive. We hypothesized that patients with BPD, in contrast to healthy gender and nationality-matched controls, show a higher frequency and intensity of self-reported emotions, altered physiological indices of emotions, more complex emotions and greater problems in identifying specific emotions. We took a 24-hour psychophysiological ambulatory monitoring approach to investigate affect regulation during everyday life in 50 patients with BPD and in 50 healthy controls. To provide a typical and unmanipulated sample, we included only patients who were currently in treatment and did not alter their medication schedule. BPD patients reported more negative emotions, fewer positive emotions, and a greater intensity of negative emotions. A subgroup of non-medicated BPD patients manifested higher values of additional heart rate. Additional heart rate is that part of a heart rate increase that does not directly result from metabolic activity, and is used as an indicator of emotional reactivity. Borderline participants were more likely to report the concurrent presence of more than one emotion, and those patients who just started treatment in particular had greater problems in identifying specific emotions. Our findings during naturalistic ambulatory assessment support emotional dysregulation in BPD as defined by the biosocial theory of [Linehan, M.M., 1993. Cognitive-Behavioral Treatment of Borderline Personality Disorder. The Guildford Press, New York.] and suggest the potential utility for evaluating treatment outcome.

Disorder-Specific Impact of Coordinated Anxiety Learning and Management Treatment for Anxiety Disorders in Primary Care

CONTEXT Anxiety disorders commonly present in primary care, where evidence-based mental health treatments often are unavailable or suboptimally delivered. OBJECTIVE To compare evidence-based treatment for anxiety disorders with usual care (UC) in primary care for principal and comorbid generalized anxiety disorder (GAD), panic disorder (PD), social anxiety disorder (SAD), and posttraumatic stress disorder (PTSD). DESIGN A randomized controlled trial comparing the Coordinated Anxiety Learning and Management (CALM) intervention with UC at baseline and at 6-, 12-, and 18-month follow-up assessments. SETTING Seventeen US primary care clinics. PATIENTS Referred primary care sample, 1004 patients, with principal DSM-IV diagnoses of GAD (n = 549), PD (n = 262), SAD (n = 132), or PTSD (n = 61) (mean [SD] age, 43.7 [13.7] years; 70.9% were female). Eighty percent of the participants completed 18-month follow-up. INTERVENTIONS CALM (cognitive behavior therapy and pharmacotherapy recommendations) and UC. MAIN OUTCOME MEASURES Generalized Anxiety Disorder Severity Scale, Panic Disorder Severity-Self-report Scale, Social Phobia Inventory, and PTSD Checklist-Civilian Version scores. RESULTS CALM was superior to UC for principal GAD at 6-month (-1.61; 95% confidence interval [CI], -2.42 to -0.79), 12-month (-2.34; -3.22 to -1.45), and 18-month (-2.37; -3.24 to -1.50), PD at 6-month (-2.00; -3.55 to -0.44) and 12-month (-2.71; -4.29 to -1.14), and SAD at 6-month (-7.05; -12.11 to -2.00) outcomes. CALM was superior to UC for comorbid SAD at 6-month (-4.26; 95% CI, -7.96 to -0.56), 12-month (-8.12, -11.84 to -4.40), and 18- month (-6.23, -9.90 to -2.55) outcomes. Effect sizes favored CALM but were not statistically significant for other comorbid disorders. CONCLUSIONS CALM (cognitive behavior therapy and pharmacotherapy medication recommendations) is more effective than is UC for principal anxiety disorders and, to a lesser extent, comorbid anxiety disorders that present in primary care.

A valence-dependent group-specific recall bias of retrospective self-reports: a study of borderline personality disorder in everyday life.

Recall is an active reconstruction process likely to distort past experiences. This distortion, known as recall bias, seems to manifest itself differently in sick and healthy people. A recall bias has been documented in several disorders, but never investigated in borderline personality disorder (BPD). To determine recall bias in BPD, we assessed momentary and retrospective ratings of specific emotions in 50 patients with BPD and 50 healthy controls (HCs), using the methodology of 24-hour ambulatory monitoring. Our data reveal a group-specific valence-dependent recall bias of retrospective self-report, indicated by a different overall recall pattern in HCs and BPD. BPD patients show an overall negative recall pattern, whereas HCs show a positive recall pattern. A traditional questionnaire approach does not distinguish between symptoms of the disorder and recall bias, although the pathological mechanisms underlying them as well as the appropriate treatment strategies may be different.

Emotional Responses to Self-Injury Imagery Among Adults With Borderline Personality Disorder

Nonsuicidal self-injury (NSSI) and suicide attempts (SAs) are especially prevalent in borderline personality disorder. One proposed mechanism for the maintenance of NSSI and SAs is escape conditioning, whereby immediate reductions in aversive emotional states negatively reinforce the behaviors. Psychophysiological and subjective indicators of negative emotion associated with NSSI and SA imagery were examined in 42 individuals who met criteria for border personality disorder. Personally relevant imagery scripts that involved an NSSI and/or an SA incident were created, as were control scenes involving imagery of an accidental injury, an accidental death, or an emotionally neutral event. Results did not support the hypothesis that decreases in negative emotion would occur during NSSI imagery; however, decreases were found during imagery of the moments after NSSI, which suggests some support for escape conditioning. Support for the model was not found for SAs. Possible implications of patterns that demonstrate decreases in negative emotion during accidental death imagery are discussed.

Pilot trial of dialectical behavior therapy-enhanced habit reversal for trichotillomania

Background: Not all hair pullers improve acutely with cognitive–behavioral treatment (CBT) and few maintain their gains over time. Methods: We conducted an open clinical trial of a new treatment that addresses affectively triggered pulling and emphasizes relapse prevention in addition to standard CBT approaches. Ten female participants satisfying DSM‐IV criteria for trichotillomania (TTM) at two study sites received Dialectical Behavior Therapy (DBT)‐enhanced CBT consisting of 11 weekly sessions and 4 maintenance sessions over the following 3 months. Independent assessors rated hair pulling impairment and global improvement at several study time points. Participants completed self‐report measures of hair pulling severity and emotion regulation. Results: Significant improvement in hair pulling severity and emotion regulation, as well as hair pulling impairment and anxiety and depressive symptoms, occurred during acute treatment and were maintained during the subsequent 3 months. Significant correlations were reported between changes in emotion regulation and hair pulling severity during both the acute treatment and maintenance phases. Conclusions: This study offers preliminary evidence for the efficacy of DBT‐enhanced CBT for TTM and suggests the importance of addressing emotion regulation during TTM treatment. Depression and Anxiety, 2010.

DBT-enhanced cognitive-behavioral treatment for trichotillomania: A randomized controlled trial

Background and aims Limited treatment options are available for trichotillomania (TTM) and most have modest outcomes. Suboptimal treatment results may be due to the failure of existing approaches to address all TTM styles. Methods Thirty-eight DSM-IV TTM participants were randomly assigned across two study sites to Dialectical Behavior Therapy (DBT) -enhanced cognitive-behavioral treatment (consisting of an 11-week acute treatment and 3-month maintenance treatment) or a minimal attention control (MAC) condition. MAC participants had active treatment after the 11-week control condition. Follow-up study assessments were conducted three and six months after the maintenance period. Results Open trial treatment resulted in significant improvement in TTM severity, emotion regulation (ER) capacity, experiential avoidance, anxiety and depression with changes generally maintained over time. In the randomized controlled trial, those with active treatment had greater improvement than those in the MAC condition for both TTM severity and ER capacity. Correlations between changes in TTM severity and ER capacity were not reported at post-treatment but did occur in maintenance and follow-up indicating reduced TTM severity with improved ER capacity. Conclusions DBT-enhanced cognitive-behavioral treatment is a promising treatment for TTM. Future studies should compare this approach to other credible treatment interventions and investigate the efficacy of this approach in more naturalistic samples with greater comorbidity.