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Behaviour Research and Therapy 44 (2006) 1211–1217

Shorter communication

Effectiveness of dialectical behaviour therapy for

borderline personality disorder in an inpatient setting

Christoph Kro¨ger

a,

,1

, Ulrich Schweiger

b

, Valerija Sipos

b

, Ruediger Arnold

b

,

Kai G. Kahl

b

, Tanja Schunert

b

, Sebastian Rudolf

b

, Hans Reinecker

c

a

Christoph-Dornier-Foundation for Clinical Psychology, Konstantin-Uhde-StraXe 4, 38106 Braunschweig, Germany bDepartment of Psychiatry and Psychotherapy, University of Lu¨beck, Ratzeburger Allee 160, 23538 Lu¨beck, Germany

cDepartment of Psychology, University of Bamberg, Markusplatz 3, 96045 Bamberg, Germany

Received 11 February 2004; received in revised form 11 August 2005; accepted 30 August 2005

Abstract

This study evaluates the effectiveness of dialectical behaviour therapy (DBT) for borderline personality disorder (BPD) in an unselected, comorbid population seeking 3-month inpatient treatment. We studied 50 consecutively admitted individuals (44 women, six men) with BPD as defined by DSM-IV at three time points (at admission, at discharge, and at the 15-month follow-up). For the clinical diagnoses, we used the Structured Clinical Interview for DSM-IV (SCID) and compared the frequencies of comorbid axis I and axis II disorders at admission and at the 15-month follow-up. Overall, participants showed a high degree of comorbidity. Psychopathology was significantly reduced at post-treatment and at follow-up. Effect sizes for outcome measures were within the range of those of previous studies. Our findings support the notion that the results of the DBT efficacy research can be generalized to an inpatient setting and to patients with BPD disorder with high comorbidity.

r2005 Elsevier Ltd. All rights reserved.

Keywords:Borderline personality disorder; Dialectical behaviour therapy; Effectiveness; Comorbidity

Introduction

Although the prevalence of borderline personality disorder (BPD) in the general population is approximately 1%, BPD has the highest prevalence worldwide among inpatients treated for personality

disorders (PD) (Loranger et al., 1994). In addition, inpatients with BPD have more lifetime comorbid

disorders of axis I and more additional PDs than inpatients with other PDs (Zanarini et al., 1998a, b). In

general, BPD lifetime comorbidity for axis I disorders in inpatient settings ranges from 1.8 to 5.1 comorbid

disorders (Coid, 1993; Links, Steiner, Offord, & Eppel, 1988; Shearer, 1994; Zanarini et al., 1998a;

Zimmerman & Mattia, 1999). Comorbidity of BPD with other PDs is lower in this setting, ranging from 0.5 to www.elsevier.com/locate/brat

0005-7967/$ - see front matterr2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.brat.2005.08.012

Corresponding author. Tel.: +49 531 391 2865; fax: +49 531 391 8195.

E-mail address:[email protected] (C. Kro¨ger).

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1.6 on average (Becker, Grilo, Edell, & McGlashan, 2000;Coid, 1993;Zanarini et al., 1998b). In spite of this high prevalence among inpatients and their severe symptoms, few options for inpatient treatments are currently available.

According to the American Psychiatric Association’s practice guidelines (American Psychiatric Association,

2001), dialectical behaviour therapy (DBT)—a manualized outpatient treatment (Linehan, 1993a, b)—is one

psychotherapeutic approach that has been shown to be efficacious in randomized controlled trials (Koons

et al., 2001;Linehan, Armstrong, Suarez, Allmon, & Heard, 1991;Linehan et al., 1999, 2002;Verheul et al.,

2003). Although these trials have demonstrated the efficacy, they suffer from a number of limitations. For

example, they typically utilized small sample sizes of between 11 and 27 individuals. Furthermore, none of them investigated the effect of comorbidity of axis I and II disorders on treatment outcome. In most studies,

rates of comorbid diagnoses were not reported; only Linehan et al. (1999, 2002) mentioned the average

number of comorbid axis I diagnoses for their samples in an outpatient setting (2.6 and 2.4, respectively).

The original outpatient model has been successfully modified for inpatients (Bohus et al., 2000, 2004). In

both studies, participants in a 3-month inpatient treatment reduced global symptoms, depression, anxiety, and dissociation in self-ratings, and self-mutilating behaviour. In the controlled trial, 31 patients in the DBT group

were compared to 19 participants placed on a waiting list (Bohus et al., 2004). No changes on measures of

psychopathology and frequency of self-mutilating acts were found in the waiting list group. The DBT group improved significantly more than participants on most of the above-mentioned variables. The average number of comorbid axis I diagnoses for this inpatient sample was 2.2. No follow-up is currently available.

It should be noted that individuals with substance use disorders were excluded from the above investigation. However, individuals meeting criteria for BPD are more likely to also meet criteria for substance abuse than

individuals with other PDs, with the exception of anti-social personality disorder (Linehan et al., 1999). For

example, lifetime comorbidity with alcohol abuse/dependence ranged from 31% to 52% and drug abuse/

dependence from 23% to 46% in inpatient samples (Coid, 1993;Links et al., 1988; Shearer, 1994; Zanarini

et al., 1998a). In addition, individuals with BPD and comorbid substance disorders had more severe

psychopathology than individuals with BPD only (Links, Heslegrave, Mitton, van Reekum, & Patrick, 1995).

Therefore, excluding patients with this kind of comorbidity likely leads to a less severe sample of inpatient individuals suffering from BPD than a sample in which this comorbidity is allowed. The above-mentioned range from 1.8 to 5.1 of comorbid disorders of axis I in inpatients and the average number of 2.5 diagnoses in the efficacy studies indicate that different subgroups were probably treated. We assume that DBT was less effective for participants with a high number of comorbid diagnoses, especially with substance-related disorders.

The present study incorporates the following critical features. First, in a semi-structured interview, participants seeking treatment were assessed according to well-defined research criteria. Second, the frequencies of the full range of axis I and II disorders were reported after admission and at follow-up. Third, participants were assessed at three time points (at admission, at discharge, and at the 15-month follow-up) by means of two self-report measures and the Global Assessment of Functioning Scale (GAF) contained in DSM-IV. Due to the thorough assessment of comorbidity with inclusion of substance-related disorders, we expected to find a higher comorbidity and a more severe general psychopathology in our inpatient sample than in previous studies focusing on the efficacy (Linehan et al., 1999, 2002) or effectiveness of DBT (Bohus et al.,

2000). The aim of the present study was therefore to evaluate the effectiveness of DBT in a more severe and

broader disturbed sample of BPD individuals in a clinical service setting. The generalizability of findings in DBT efficacy studies and their applicability for an inpatient setting are important for both clinicians and researchers.

Method

Recruitment of participants

All participants were inpatients at the Department of Psychiatry and Psychotherapy of the University of Luebeck, admitted between August 2000 and August 2001. Each consecutive patient seeking treatment for BPD was initially screened in a clinical interview to determine that he or she (1) was older than 18 years of age,

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(2) was of normal or higher intelligence, (3) had no history or current symptoms or signs of a serious organic condition that may be associated with the development of psychiatric symptoms (e.g., multiple sclerosis, epilepsy), or selected psychiatric disorders (dementia, schizophrenia, substance abuse or dependence without motivation for abstinence, or bipolar I disorder), and (4) had been given a definite or probable diagnoses of BPD by the admitting physician. Written informed consent was obtained from each patient.

Patient flow

Seventy-nine admitted individuals met criteria for BPD based on the German version of the Structured

Clinical Interview for DSM-IV (SCID) Personality Disorders (Fydrich, Renneberg, Schmitz, & Wittchen,

1997) and were treated with DBT. Of these, 26 were excluded because of alcohol or drug withdrawal (23),

mental retardation (1) or schizophrenia (2), and three refused to give written informed consent. Fifty met all inclusion criteria and volunteered for the present study. Of these, six participants dropped out during the first 3 weeks. Thirteen participants were lost by follow-up, from which nine could not be reached and four refused to provide written informed consent.

Treatment

In 1999, a 3-month inpatient treatment for BPD was conceptualized according to the guidelines of DBT. A weekly 1-h session of individual therapy integrated validation (acceptance, empathy) and problem-orientated techniques (skill training, cognitive modification, contingency management, exposure to emotional cues). The problem focus of each individual session was determined by a target hierarchy and the patient’s behaviour in the target domains. Individuals met in group therapy three times a week for sessions of 100 min. There, behaviour skills were taught in the following five domains: (1) mindfulness, (2) emotion regulation skills, (3) interpersonal effectiveness, (4) distress tolerance, and (5) self-management strategies.

Individual therapy and group therapy were carried out by four psychiatrists and three psychologists (three women and four men). All therapists took part in a continuous programme of cognitive-behavioural training. Two therapists participated twice in a 1-week training of DBT by M. Bohus. Additionally, written and visual materials from Linehan’s and Bohus’ laboratories were used. Therapy was supervised by the senior authors (V.S. and U.S.) who are recognized supervisors of cognitive-behaviour therapy and DBT supervisors recognized by the German association for DBT (DDBT). They trained all therapists, listened to videotapes at regular intervals, and conducted weekly individual and group supervision. Medication use was monitored by nurses and psychiatrists, but not controlled by the protocol. Thirty-one participants (62%) received antidepressive medication (selective serotonin reuptake inhibitors and tricyclic antidepressants). Benzodia-zepines were given as a crisis intervention in case of long-standing dissociative states or acute suicidality for a maximum of 3 days; none received mood stabilizers or neuroleptics.

Measures

Assessment points were at pre-treatment, at discharge, and at the 15-month follow-up. Semi-structured interviews and assessments were administered by two of the authors (C.K., R.A.). The German adaptations of

the following interviews were utilized: the SCID (Wittchen, Wunderlich, Gruschitz, & Zaudig, 1997)—a

semi-structured interview designed to assess the lifetime frequency of many of the most common axis I disorders

described in DSM-IV, and the Structured Clinical Interview for DSM-IV Personality Disorders (Fydrich et al.,

1997)—a semi-structured interview that reliably assesses the presence of the 10 axis II disorders and

self-defeating PD described in DSM-IV. Depressive PD was not assessed because of the high comorbidity with affective disorders at admission and at follow-up. All interviewers had been trained in the administration and scoring of these instruments by a collaborator who was himself trained by the first author of the German adaptation of the SCID-I. They met twice a week at the admission and follow-up phase and discussed the ratings of diagnoses from the video tape. Interrater reliabilities for the interviews or each disorder were not computed. A broad range of psychopathology was expected in the present inpatient sample. Although the principal disorder was BPD and, hence, self-mutilating behaviours often occur, parasuicidal behaviour was not used as

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an outcome criterion for two reasons: (1) Self-ratings of general psychopathology estimate the outcome more conservatively. As seen in previous studies, DBT was more effective in reducing parasuicidal behaviour (e.g.,

Linehan et al., 1991), especially for patients in the high-severity group (Verheul et al., 2003). (2) BPD patients differ considerably in their baseline frequencies of parasuicidal behaviour with one major group reporting few of those behaviours. Specifically, in those participants, treatment changes are better captured by general

psychopathology measures (Koons et al., 2001). Therefore, we adopted an assessment of general

psychopathology. The German version of the Symptom Checklist (SCL-90-R) (Franke, 1995) and the

German version of the GAF from the DSM-IV were used to obtain information on the general symptom strain. The German version of the Beck Depression Inventory (BDI) measured symptoms and the degree of depression (Hautzinger, Bailer, Worral, & Keller, 1995).

Data analyses

We used the Wilcoxon test to compare the frequency distributions of axis I and II disorders at pre-treatment and at follow-up. Comparisons of the categorical data at pre-treatment and follow-up were analysed using the

Wilcoxon test. The Mann–Whitney U-test was used for comparing categorical data in disorder-related

subgroups at pre-treatment. No significant differences were found between treated participants and drop-outs nor between treated participants and participants not contacted at follow-up on any of the variables. Given these findings, we used an intention-to-treat sample for further analyses. To examine the effect of DBT on the course of general symptoms, psychosocial functioning, and depression, a repeated-measurement multivariate analyses of variance was applied. To compute effect sizes, we used a formula considering dependent variables

and variance changes (McGaw & Glass, 1980):

ES¼ Mtreatt1Mtreatt2 ffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi ðs2 t1þs2t22rt1t2st1st2Þ q . Results Patient characteristics

Six men and 44 women were included in the present study. The mean age of the sample was 30.5 (SD¼7.7)

years. Thirty-one participants (62%) were single, eight (16%) cohabitated, seven (14%) divorced or seperated, and only four (8%) married. Thirteen patients (26%) were never employed, nine (18%) were currently out of work, eight (16%) were craftsmen, 15 (30%) were employed, and five (10%) were public servants or self-employed.

Treatment after 3-month DBT inpatient setting

During the follow-up period, 29 out of 37 individuals (78%) received outpatient psychotherapy an average of once a week. Most of them were treated by cognitive-behavioural therapists (62%), the remaining received insight focused therapy. However, no individuals were treated by the guidelines of DBT despite the general CBT orientation. Fifteen patients (41%) had to be readmitted as inpatients within the 15 months time period, 24% of those for crisis intervention for a maximum of 2 weeks. From all 37 individuals, 10 (27%) were not on medication. The others received mainly antidepressive medication (selective serotonin reuptake inhibitors and tricyclic antidepressants, 65%), benzodiazepines (8%), mood stabilizers (19%), or neuroleptics (8%).

Comorbidity

All participants displayed a high degree of comorbidity with axis I and axis II disorders.2 On average,

they had 6.2 (SD¼3.4) axis I lifetime disorders and 5.5 (SD¼3.2) current disorders at pre-treatment.

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At 15-month follow-up, a reduction to 4.2 (SD¼2.2) axis I disorders was observed (Wilcoxon test:z¼ 2:59,

p¼0:01). In addition to BPD, 1.3 PD (SD¼1.14) occurred on average at pre-treatment, and 2.8 (SD¼1.8)

at follow-up. This represents a significant increase (Wilcoxon test: z¼ 4,po0:001).

Outcome

Table 1lists the means, standard deviations, and effect sizes (ES) for the three outcome measures. The score of the Global Severity Index (GSI) of the SCL-90-R decreased over time (F½1;47 ¼10:66,p¼0:002) as well

as the score of the BDI (F½1;47 ¼20:77, po0:001). The score of the GAF significantly increased

(F½1;47 ¼162:58, po0:001). The ES range from 0.28 to 0.91 in the self-ratings and from 1.29 to 2.16 in

the GAF.

Subgroup analyses

Thirteen participants had substance dependences (10 participants with benzodiazepine, one with cocaine, one with heroine, three with cannabis, two with amphetamine dependence), not counting alcohol dependence

(22 participants). These 13 had more comorbid axis I disorders (median¼9) than the other inpatients

(median¼4, U-test: U¼84:5; po:001) and were more impaired in the GAF (F½1;48 ¼6:43 p¼0:015).

There was a trend for higher scores on the GSI (F½1;48 ¼2:95p¼0:092), but not for the scores of depression (F½1;48 ¼0:153p¼0:697). No difference in groups with and without major depression disorder or with and

without alcohol dependence were found, respectively. No timegroup interaction was found in any outcome

measures.

Discussion

The sample of this effectiveness study differs in three ways from the above-mentioned randomized controlled trials and the pilot study with inpatients. First, a larger consecutive sample size of 50 individuals was used in an intention-to-treat sample. Other studies had a sample size of 11–31 participants in the DBT condition. Second, our drop-out rate was 12% and thus lower than those studies mentioned above with a drop-out rate between 17% and 45%. Third, participants in our study were more impaired by comorbidity of axis I diagnoses. They had 5.5 current axis I diagnoses compared to 2.5 diagnoses on average in efficacy

studies (Linehan et al., 1999, 2002) and 2.2 diagnoses in the controlled trial with inpatients (Bohus et al.,

2004). The high number of comorbid axis II disorders, especially of Cluster C, is also consistent with other

findings (Grilo, Sanislow, & McGlashan, 2002;Zanarini et al., 1998b).

There was a remarkably higher score of general symptoms in our study compared to the previous studies of

DBT with inpatients (Bohus et al., 2000, 2004), probably because of the above-mentioned exclusion criteria.

As measured by the GAF, a similar level of functional impairment as in the current study was reported in

three previous studies (Kemperman, Russ, & Shearin, 1997; Linehan, Tutek, Heard, & Armstrong, 1994;

Shearer, 1994); a lower level was found in the controlled trial with inpatients (Bohus et al., 2004). The scores of Table 1

Means, standard deviations, and effect sizes for the symptom severity index scale scores (GSI), the assessment of global functioning ratings (GAF), and Beck Depression Inventory scores (BDI) at pre-treatment, at discharge, and at 15-month follow-up of 50 inpatients with borderline personality disorder who received dialectical behaviour therapy

Pre Post Follow-up Effect sizes

Mean SD Mean SD Mean SD Pre-Post Pre-follow-up

GSI 1.80 0.68 1.38 0.82 1.52 0.83 0.68 0.44

GAF 35.16 10.11 50.86 13.24 64.00 13.44 1.33 1.85

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depression on the BDI in our study were also similar to the results of three previous studies (Bohus et al., 2000, 2004; Comtois, Cowley, Dunner, & Roy-Byrne, 1999), but lower than those in the pilot study of DBT (Linehan et al., 1991). The psychopathology was significantly reduced at post-treatment and at follow-up. All groups benefited in the same way from the treatment. Inpatients with BPD and substance dependences were

more impaired than inpatients with BPD as reported in a previous study (Links et al., 1995). ES were similar

to those obtained in previous studies of DBT with inpatients (Bohus et al., 2000, 2004). In all studies, the

treated individuals with BPD continued to suffer from pathological levels of symptoms at the end of the treatment and at follow-up.

This study has a number of limitations. First, no control group was included in the present study design. The reduction of the symptoms and diagnoses could therefore be due to a regression to the mean. Although this seems to be unlikely considering that the efficacy studies and the controlled trial with inpatients (Bohus et al., 2004) showed that there is no significant symptom reduction in control groups despite high initial levels of distress, this alternative interpretation of the present results cannot be ruled out. Second, the interviewers were not blind to treatment and a computation of an interrater reliability was not feasible in the present clinical setting. Third, the lack of assessment of parasuicidal behaviour limits the present study. Although we believe that a reduction in these behaviours is among the best known outcome of DBT, and therefore made the decision to not collect the parasuicidal behaviour, it might have been better to at least obtain a rough estimation for these behaviours, especially when considering the follow-up assessment. Fourth, the outcome at follow-up was confounded by outpatient psychotherapy and inpatient treatments. Fifth, confounding by medication use is possible. Sixty-two percent of participants received antidepressive medication in the present

study. This is similar to what is reported in a study byVerheul et al. (2003), in which no differences between

participants using selective serotonin reuptake inhibitors in the DBT condition (52%) and in the control group

(61%) were found.Verheul et al. (2003) therefore assumed no confounding influence by medication.

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Figure

Table 1 lists the means, standard deviations, and effect sizes (ES) for the three outcome measures

References

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