Tim Guimond

A Randomized Trial of Dialectical Behavior Therapy Versus General Psychiatric Management for Borderline Personality Disorder

OBJECTIVE The authors sought to evaluate the clinical efficacy of dialectical behavior therapy compared with general psychiatric management, including a combination of psychodynamically informed therapy and symptom-targeted medication management derived from specific recommendations in APA guidelines for borderline personality disorder. METHOD This was a single-blind trial in which 180 patients diagnosed with borderline personality disorder who had at least two suicidal or nonsuicidal self-injurious episodes in the past 5 years were randomly assigned to receive 1 year of dialectical behavior therapy or general psychiatric management. The primary outcome measures, assessed at baseline and every 4 months over the treatment period, were frequency and severity of suicidal and nonsuicidal self-harm episodes. RESULTS Both groups showed improvement on the majority of clinical outcome measures after 1 year of treatment, including significant reductions in the frequency and severity of suicidal and nonsuicidal self-injurious episodes and significant improvements in most secondary clinical outcomes. Both groups had a reduction in general health care utilization, including emergency visits and psychiatric hospital days, as well as significant improvements in borderline personality disorder symptoms, symptom distress, depression, anger, and interpersonal functioning. No significant differences across any outcomes were found between groups. CONCLUSIONS These results suggest that individuals with borderline personality disorder benefited equally from dialectical behavior therapy and a well-specified treatment delivered by psychiatrists with expertise in the treatment of borderline personality disorder.

Dialectical Behavior Therapy Compared With General Psychiatric Management for Borderline Personality Disorder: Clinical Outcomes and Functioning Over a 2-Year Follow-Up

OBJECTIVE The authors conducted a 2-year prospective naturalistic follow-up study to evaluate posttreatment clinical outcomes in outpatients who were randomly selected to receive 1 year of either dialectical behavior therapy or general psychiatric management for borderline personality disorder. METHOD Patients were assessed by blind raters 6, 12, 18, and 24 months after treatment. The clinical effectiveness of treatment was assessed on measures of suicidal and nonsuicidal self-injurious behaviors, health care utilization, general symptom distress, depression, anger, quality of life, social adjustment, borderline psychopathology, and diagnostic status. The authors conducted between-group comparisons using generalized estimating equation, mixed-effects models, or chi-square statistics, depending on the distribution and nature of the data. RESULTS Both treatment groups showed similar and statistically significant improvements on the majority of outcomes 2 years after discharge. The original effects of treatment did not diminish for any outcome domain, including suicidal and nonsuicidal self-injurious behaviors. Further improvements were seen on measures of depression, interpersonal functioning, and anger. However, even though two-thirds of the participants achieved diagnostic remission and significant increases in quality of life, 53% were neither employed nor in school, and 39% were receiving psychiatric disability support after 36 months. CONCLUSIONS One year of either dialectical behavior therapy or general psychiatric management was associated with long-lasting positive effects across a broad range of outcomes. Despite the benefits of these specific treatments, one important finding that replicates previous research is that participants continued to exhibit high levels of functional impairment. The effectiveness of adjunctive rehabilitation strategies to improve general functioning deserves additional study.

An exploratory study of the relationship between changes in emotion and cognitive processes and treatment outcome in borderline personality disorder

Abstract This exploratory study examined specific emotion processes and cognitive problem-solving processes in individuals with borderline personality disorder (BPD), and assessed the relationship of these changes to treatment outcome. Emotion and cognitive problem-solving processes were assessed using the Toronto Alexithymia Scale, the Linguistic Inquiry Word Count, the Derogatis Affect Balance Scale, and the Problem Solving Inventory. Participants who showed greater improvements in affect balance, problem solving, and the ability to identify and describe emotions showed greater improvements on treatment outcome, with affect balance remaining statistically significant under the most conservative conditions. The results provide preliminary evidence to support the theory that specific improvements in emotion and cognitive processes are associated with positive treatment outcomes (symptom distress, interpersonal functioning) in BPD. The implications for treatment are discussed.

FACTORS RELATED TO DROPOUT FROM TREATMENT IN TWO OUTPATIENT TREATMENTS FOR BORDERLINE PERSONALITY DISORDER

Patients with borderline personality disorder frequently drop out prematurely from psychotherapy. This study examined factors related to treatment attrition in 180 patients enrolled in a randomized controlled trial comparing 1 year of Dialectical Behavior Therapy (DBT) to General Psychiatric Management (GPM). Completers and dropouts were compared on a range of variables, including demographics, Axis I and Axis II disorders, anger and impulsivity, therapeutic alliance, and treatment condition. The participants were on average 30.36 years old and 86% were female. Regression analyses revealed that individuals who dropped out had higher levels of anger (p = .01), greater Axis I comorbidity (p = .03), poorer therapeutic alliance (p = .003), and a higher number of lifetime suicide attempts (p = .05). An interaction was also found between Axis I comorbidity and treatment condition, with significantly lower rates of dropout seen in individuals with high Axis I comorbidity who were assigned to GPM compared to those assigned to DBT (p < .001).

Interrupting the social processes linked with initiation of injection drug use: Results from a pilot study

BACKGROUND Injection drug use is a skill learned in social settings. Change the Cycle (CTC), a peer-delivered, one-session intervention, is designed to reduce among people who inject drugs (PIDs) injection initiation-related behaviours (i.e., speaking positively about injecting to non-injectors, injecting in front of non-injectors, explaining or showing a non-injector how to inject) and initiation of non-injectors. We hypothesized that participation in CTC would lead to reductions in initiation-related behaviours six months later. METHODS Using respondent driven sampling (RDS), 98 PIDs were recruited in Toronto, Canada to participate in pilot testing of CTC. The baseline session consisted of a structured interview, the peer-delivered CTC intervention, instructions regarding RDS coupon distribution, and an invitation to return in six months for a follow-up interview. For the 84 PIDs completing the six-month interview, we compared initiation-related behaviours at baseline with six-month follow-up. RESULTS The proportion of PIDs offering to initiate a non-injector was reduced from 8.4% (95% CI: 2.5, 15.9) at baseline to 1.59% (95% CI: 0.4, 3.7) at 6-month follow-up. The prevalence of speaking positively about injection to non-injectors also decreased significantly. The proportion of PIDs who helped a non-injector with a first injection at baseline was 6.2% (95% CI: 2.1, 11.3) and at follow-up was 3.5% (95% CI: 0.8, 7.1). Paired analyses of initiator baseline versus follow-up data showed a 72.7% reduction in initiation (95%CI: 47.7, 83.1). CONCLUSIONS While further refinements remain to be tested, pilot study results suggest that CTC holds promise as a prevention intervention.

Prospective Risk Factors for Suicide Attempts in a Treated Sample of Patients with Borderline Personality Disorder

Objective: People with borderline personality disorder (BPD) are at high risk for attempting suicide. There are some data to suggest that risk factors for suicide attempts change over time. We conducted a prospective cohort study to examine risk factors for suicide attempts in a treated sample of patients with BPD. Method: One hundred eighty participants with BPD were followed over a year-long course of dialectical behaviour therapy or general psychiatric management and then for 2 more years in naturalistic follow-up. Participants were assessed for suicidal and self-injurious behaviours at baseline, every 4 months over the 1-year treatment phase, and every 6 months over a 2-year follow-up period. Participants were classified as suicide or nonsuicide attempters based on their behaviour at the end of the 1-year treatment phase and after the 2-year follow-up period. Groups were then compared on baseline clinical and demographic variables. Results: Nearly 26% of participants made a suicide attempt during the 1-year treatment phase, while 16.7% reported a suicide attempt over the 2-year follow-up period. Baseline number of suicide attempts during the 4 months prior to study and severity of childhood sexual abuse predicted suicide attempts during the treatment year. Similarly, baseline suicide attempts, severity of childhood sexual abuse, and number of hospitalizations in the 4 months prior to study entry predicted suicide attempts during the 2-year follow-up. Conclusions: Risk factors for suicide attempts in this treated sample of patients with BPD were fairly stable, largely nonmodifiable, and unrelated to psychopathology or psychosocial functioning at baseline.

A randomized trial of brief dialectical behaviour therapy skills training in suicidal patients suffering from borderline disorder

Evidence‐based therapies for borderline personality disorder (BPD) are lengthy and scarce. Data on brief interventions are limited, and their role in the treatment of BPD is unclear. Our aim was therefore to evaluate the clinical effectiveness of brief dialectical behaviour therapy (DBT) skills training as an adjunctive intervention for high suicide risk in patients with BPD.

The effect of brief case management on emergency department use of frequent users in mental health: Findings of a randomized controlled trial

Frequent users of hospital emergency departments (EDs) are a medically and socially vulnerable population. The Coordinated Access to Care from Hospital EDs (CATCH-ED) study examined the effectiveness of a brief case management intervention in reducing ED use and improving health outcomes among frequent ED users with mental health or addiction challenges in a large urban centre. Adults (≥18 years of age) who had five or more ED visits in the past 12-months, with at least one visit for mental health or addictions problems were randomized to either brief case management (N = 83) or usual care (N = 83) and followed for 12 months. The primary outcome of effectiveness was the frequency of ED visits during 12 months after study enrolment. Secondary outcomes included days in hospital, mental health and addiction symptom severity and health-related quality of life, measured by the SF-12. Compared to usual care, CATCH-ED participants saw a 14% reduction in frequency of ED visits during the 12-month post-randomization period [rate ratio (RR) = 0.86, 95% CI 0.64–1.15)], however, this finding did not reach statistical significance. There were also no statistically significant differences between the groups at 12 months in the number of days spent in hospital (RR = 1.16, 95% CI 0.59–2.29), physical (1.50, 95% CI -2.15–5.15) or mental (-3.97, 95% CI -8.13–0.19) component scores of the SF-12, severity of psychiatric symptoms (-0.41, 95% CI -2.30–1.49), alcohol (0.053 95% -0.017–0.12) or drug (-0.0027, 95% CI -0.0028–0.023) use. Compared to usual care, a brief case management intervention did not result in significantly reduced ED use or improved health outcomes among frequent ED users with mental health or addictions challenges in a large urban centre in Canada. Future studies need to evaluate the availability and accessibility of community-based resources for individuals with frequent ED use.

Clinical and psychological features of children and adolescents diagnosed with avoidant/restrictive food intake disorder in a pediatric tertiary care eating disorder program: a descriptive study

BackgroundAvoidant/Restrictive Food Intake Disorder (ARFID) is an eating disorder first described in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) [American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2013]. Patients with ARFID do not fear gaining weight or have body image distortions. ARFID involves a persistent disturbance in feeding and eating that results in an inability to meet nutritional and/or energy needs with one of the following: weight loss or failure to achieve appropriate weight gain, nutritional deficiency, dependence on enteral feeding or nutritional supplements and significant interference with psychosocial functioning. To date, studies on patients with ARFID have retrospectively applied the DSM-5 diagnostic criteria for ARFID to reclassify patients diagnosed with DSM-IV eating disorders.MethodsA descriptive retrospective chart review was completed on patients less than 18-years diagnosed with ARFID after a comprehensive eating disorder assessment between May 2013 and March 2016. The data collected included demographics, anthropometrics, historical information, clinical features, co-morbid diagnoses, need for inpatient hospitalization and psychometric measures.ResultsThree hundred and sixty-nine patients were assessed for an eating disorder between May 2013 and March 2016. Of these, 31 (8.4%) received a DSM-5 diagnosis of ARFID. A full chart review was performed on 28 (90.3%) patients. Weight loss or failure to achieve appropriate weight gain was the reason for diagnosis in 96.4% (27/28). All of our patients had 2 or more physical symptoms at the time of diagnosis and 16 (57.1%) had a co-morbid psychiatric disorder. Twenty (71.4%) reported a specific trigger for their eating disturbance. Admission for inpatient hospitalization occurred in 57.1% (16/28) of patients. Thirteen (46.4%) patients had been previously assessed by another specialist for their eating disturbance. None of the patients had elevated scores on commonly used psychometric tests used to assess eating disorders.ConclusionThis is the first study to retrospectively determine the incidence of ARFID in children and adolescents using the DSM-5 diagnostic criteria at assessment. The clinical presentation of patients with ARFID is complex with multiple physical symptoms and comorbid psychiatric disorders. Commonly used pediatric eating disorder psychometric measures are not specific for making a diagnosis of ARFID, and may not be sensitive as assessment tools.