Supervised team management, with or without structured psychotherapy, in heavy users of a mental health service with borderline personality disorder: a two-year follow-up preliminary randomized study

Federico Amianto, Andrea Ferrero, Andrea Pierò, Elisabetta Cairo, Giuseppe Rocca, Barbara Simonelli, Simona Fassina, Giovanni Abbate-Daga, Secondo Fassino, Federico Amianto, Andrea Ferrero, Andrea Pierò, Elisabetta Cairo, Giuseppe Rocca, Barbara Simonelli, Simona Fassina, Giovanni Abbate-Daga, Secondo Fassino

Abstract

Background: Individuals affected by severe Borderline Personality Disorder (BPD) are often heavy users of Mental Health Services (MHS). Short-term treatments currently used in BPD therapy are useful to target disruptive behaviors but they are less effective in reducing heavy MHS use. Therefore, alternative short-term treatments, less complex than long-term psychodynamic psychotherapies but specifically oriented to BPD core problems, need to be developed to reduce MHS overuse. This study aimed to evaluate the efficacy of adding Sequential Brief Adlerian Psychodynamic Psychotherapy (SB-APP) to Supervised Team Management (STM) in BPD treatment compared to STM alone in a naturalistic group of heavy MHS users with BPD. Effectiveness was evaluated 6 times along a two-year follow-up.

Methods: Thirty-five outpatients who met inclusion criteria were randomly assigned to two treatment groups (STM = 17; SB-APP = 18) and then compared. Clinical Global Impression (CGI) and CGI-modified (CGI-M) for BPD, Global Assessment of Functioning (GAF), State-Trait Anger Expression Inventory (STAXI), and Symptom Checklist-90 Revised (SCL-90-R) were administered at T1, T3, T6, T12, T18 and T24. At T12 the Working Alliance Inventory-Short Form (WAI-S) was also completed. At the one-year follow-up, SB-APP group did not receive any additional individual psychological support. MHS team was specifically trained in BPD treatment and had regular supervisions.

Results: All patients improved on CGI, GAF, and STAXI scores after 6 and 12 months, independently of treatment received. SB-APP group showed better outcome on impulsivity, suicide attempts, chronic feelings of emptiness, and disturbed relationships. We found a good stabilization at the one year follow-up, even after the interruption of brief psychotherapy in the SB-APP group.

Conclusions: Although STM for BPD applied to heavy MHS users was effective in reducing symptoms and improving their global functioning, adding a time-limited and focused psychotherapy was found to achieve a better outcome. In particular, focusing treatment on patients' personality with a specific psychotherapeutic approach (i.e. SB-APP) seemed to be more effective than STM alone.

Trial registration: ClinicalTrials.gov: NCT1356069.

Trial registration: ClinicalTrials.gov NCT01356069 NCT01356069.

Figures

Figure 1
Figure 1
Patients' selection and dropout. The figure displays the flow-chart of patients' selection and dropout during the course of the recruitment, treatment and follow-up.

References

    1. Van Asselt AD, Dirksen CD, Arntz A, Severens JL. The cost of borderline personality disorder: societal cost of illness in BPD-patients. Eur Child Adolesc Psychiatry. 2007;22:354–361.
    1. Bender DS, Skodol AE, Pagano ME, Dyck IR, Grilo CM, Shea MT, Sanislow CA, Zanarini MC, Yen S, McGlashan TH, Gunderson JG. Prospective assessment of treatment use by patients with personality disorders. Psychiatr Serv. 2006;57:254–257. doi: 10.1176/appi.ps.57.2.254.
    1. Ferrero A, Pierò A, Zirilli F, Lanteri A, Fassino S. Clinical and sociodemographic features associated with the high and prolonged utilization of resources by outpatients of a community psychiatric service. Epidemiol Psichiatr Soc. 2008;17:82–87.
    1. Stoffers J, Völlm BA, Rücker G, Timmer A, Huband N, Lieb K. Pharmacological interventions for borderline personality disorder. Cochrane Database Syst Rev. 2010;6:CD005653.
    1. Kerr IB, Dent-Brown K, Parry GD. Psychotherapy and mental health teams. Int Rev Psychiatry. 2007;19:63–80. doi: 10.1080/09540260601109380.
    1. Zanarini MC. Psychotherapy of borderline personality disorder. Acta Psychiat Scand. 2009;20:373–377.
    1. Choi-Kain LW, Fitzmaurice GM, Zanarini MC, Laverdière O, Gunderson JG. The relationship between self-reported attachment styles, interpersonal dysfunction, and borderline personality disorder. J Nerv Ment Dis. 2009;197:816–821. doi: 10.1097/NMD.0b013e3181bea56e.
    1. Paris J. Effectiveness of different psychotherapy approaches in the treatment of borderline personality disorder. Curr Psychiatry Rep. 2010;12:56–60. doi: 10.1007/s11920-009-0083-0.
    1. Linehan MM, Comtois KA, Murray AM, Brown MZ, Gallop RJ, Heard HL, Korslund KE, Tutek DA, Reynolds SK, Lindenboim N. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Arch Gen Psychiatry. 2006;63:757–766. doi: 10.1001/archpsyc.63.7.757.
    1. Choi-Kain LW, Zanarini MC, Frankeburg FR, Fitzmaurice GM, Reich DB. A longitudinal study of the 10-year course of interpersonal features in borderline personality disorder. J Pers Disord. 2010;24(Suppl 3):356–376.
    1. Bender DS. The therapeutic alliance in the treatment of personality disorders. J Psychiatr Pract. 2005;11:73–87. doi: 10.1097/00131746-200503000-00002.
    1. Koekkoek B, van Meijel B, Schene A, Hutschemaekers G. Problems in psychiatric care of 'difficult patients': a Delphi-study. Epidemiol Psichiatr Soc. 2009;18:323–330.
    1. Hadjipavlou G, Ogrodniczuk JS. Promising psychotherapies for personality disorders. Canadian journal of psychiatry. Can J Psychiatry. 2010;55:202–210.
    1. Ansell EB, Sanislow CA, McGlashan TH, Grilo CM. Psychosocial impairment and treatment utilization by patients with borderline personality disorder, other personality disorders, mood and anxiety disorders, and a healthy comparison group. Compr Psychiatry. 2007;48:329–336. doi: 10.1016/j.comppsych.2007.02.001.
    1. Zanarini MC, Weingeroff JL, Frankenburg FR. Defense mechanisms associated with borderline personality disorder. J Pers Disord. 2009;23:113–121. doi: 10.1521/pedi.2009.23.2.113.
    1. First MB, Spitzer RL, Gibbon M, Williams JBW. Structured Clinical Interview for DSM-IV Axis I Disorders OutPatient Edition (SCID-O/P, version 2.0) New York: New York State Psychiatric Institute, Biometric Research; 1996.
    1. First MB, Gibbon M, Spitzer RL, Williams JBW, Benjamin LS. SCID II Personality Questionnaire. Washington DC: American Psychiatric Press; 1997.
    1. American Psychiatric Association. Practice guideline for the treatment of patients with borderline personality disorder. Am J Psychiatry. 2001;158:1–52. doi: 10.1176/appi.ajp.158.1.1.
    1. Fassino S, Amianto F, Ferrero A. Brief Adlerian psychodynamic psychotherapy: theoretical issues and process indicators. Panminerva Med. 2008;50:165–175.
    1. Ferrero A, Cairo E, Fassina S, Pierò A, Simonelli B. Sequential Brief Adlerian Psychodynamic Psychotherapy (SB-APP): technical issues for the treatment of aggressiveness in patients with Borderline Personality Organisation (BPO) Panminerva Med. 2009;51(Suppl 3):39–50.
    1. Gunderson JG. Borderline Personality Disorder: A Clinical Guide. Washington DC: American Psychiatric Association; 2001.
    1. Drapeau M, De Roten Y, Perry JC, Despland JN. A study of stability and change in defensive mechanisms during a brief psychodynamic investigation. J Nerv Ment Dis. 2003;191:496–502. doi: 10.1097/.
    1. Perez V, Barrachina J, Soler J, Pascual JC, Campins MJ, Puigdemont D, Alvarez E. The clinical global impression scale for borderline personality disorder patients (CGI-BPD): a scale sensible to detect changes. Actas Esp Psiquiatr. 2007;35:229–235.
    1. Derogatis LR, Rickels K, Rock AF. The SCL 90 and the MMPI: a step in the validation of a new self-report scale. Br J Psychiatry. 1976;128:280–289. doi: 10.1192/bjp.128.3.280.
    1. Spielberger CD. State-Trait Anger Expression Inventory: Professional Manual. Odessa FL: Psychological Assessment Resources; 1996.
    1. Horvath AO, Greenberg LS. Development and validation of the Working Alliance Inventory. J Couns Psychol. 1989;36:223–233.
    1. Verheul R, Herbrink M. The efficacy of various modalities of psychotherapy for personality disorders: a systematic review of the evidence and clinical recommendations. Int Rev Psychiatry. 2007;19:25–38. doi: 10.1080/09540260601095399.
    1. Hilton NZ, Simmons JL. Adverse effects of poor behavior management of an inpatient's difficult behaviors. Psychiatr Serv. 1999;50:964–966.
    1. Soloff PH, Fabio A. Prospective predictors of suicide attempts in borderline personality disorder at one, two, and two-to-five year follow-up. J Pers Disord. 2008;22:123–134. doi: 10.1521/pedi.2008.22.2.123.
    1. Davidson KM, Tyrer P, Norrie J, Palmer SJ, Tyrer H. Cognitive therapy v. Usual treatment for borderline personality disorder: prospective 6-year follow-up. Br J Psychiatry. 2010;197:456–462. doi: 10.1192/bjp.bp.109.074286.
    1. Bateman A, Fonagy P. Randomized controlled trial of outpatient mentalization based treatment versus structured clinical management for borderline personality disorder. Am J Psychiatry. 2009;166(Suppl 12):1355–1364.
    1. Doering S, Hörz S, Rentrop M, Fischer-Kern M, Schuster P, Benecke C, Buchheim A, Martius P, Buchheim P. Transference-focused psychotherapy v. treatment by community psychotherapists for borderline personality disorder: randomized controlled trial. Br J Psychiatry. 201;196(Suppl 5):389–395.
    1. Davidson KM, Norrie J, Tyrer P, Gumley A, Tata P, Murray H, Palmer SJ. The effectiveness of cognitive behaviour therapy for borderline personality disorder: results from borderline personality disorder study on cognitive therapy (BOSCOT) trial. J Pers Disord. 2006;20(Suppl 5):450–465.
    1. Stanley B, Brodsky B, Nelson JD, Dulit R. Brief Dialectical Behavior Therapy (DBT-B) for suicidal behavior and non-suicidal self injury. Arch Suicide Res. 2007;11:337–341. doi: 10.1080/13811110701542069.
    1. Gilbert SB. Psychiatric crash cart: treatment strategies for the emergency department. Adv Emerg Nurs J. 2009;31:298–308.
    1. Bateman A, Fonagy P. 8-year follow-up of patients treated for borderline personality disorder: mentalization-based treatment versus treatment as usual. Am J Psychiatry. 2008;165:631–638. doi: 10.1176/appi.ajp.2007.07040636.
    1. Weinberg I, Ronningstam E, Goldblatt MJ, Schechter M, Maltsberger JT. Common factors in empirically supported treatments of borderline personality disorder. Curr Psychiatry Rep. 2011;13(Suppl 1):60–8.
    1. Weinberg I, Ronningstam E, Goldblatt MJ, Schechter M, Wheelis J, Maltsberger JT. Strategies in treatment of suicidality: identification of common and treatment-specific interventions in empirically supported treatment manuals. J Clin Psychiatry. 2010;71(Suppl 6):699–706.
    1. Clarkin JF, Levy KN, Lenzenweger MF, Kernberg OF. Evaluating three treatments for borderline personality disorder: a multiwave study. Am J Psychiatry. 2007;164(Suppl 6):922–8.
    1. Ferrero A, Pierò A, Fassina S, Massola T, Lanteri A, Abbate Daga G, Fassino S. A 12-month comparison of brief psychodynamic psychotherapy and pharmacotherapy treatment in subjects with generalised anxiety disorders in a community setting. Eur psychiatry. 2007;22:530–539. doi: 10.1016/j.eurpsy.2007.07.004.
    1. Fassino S, Abbate Daga G, Pierò A, Rovera GG. Dropout from brief psychotherapy in anorexia nervosa. Psychother Psychosom. 2002;71:200–206. doi: 10.1159/000063645.
    1. Allen JG, Fonagy P, Bateman W. Mentalizing in clinical practice. Washington DC & London: American Psychiatric Publishing; 2008.
    1. Lyons-Ruth K. The Process of Change Study Group. Implicit relational knowing: its role in development and psychoanalytic treatment. Infant Mental Health J. 1998;19:282–289. doi: 10.1002/(SICI)1097-0355(199823)19:3<282::AID-IMHJ3>;2-O.
    1. Van Asselt AD, Dirksen CD, Arntz A, Giesen-Bloo JH, van Dyck R, Spinhoven P, van Tilburg W, Kremers IP, Nadort M, Severens JL. Out-patient psychotherapy for borderline personality disorder: cost-effectiveness of schema-focused therapy versus transference-focused psychotherapy. Br J Psychiatry. 2008;192:450–457. doi: 10.1192/bjp.bp.106.033597.
    1. Clarkin JF, Levy KN, Lenzenweger MF, Kernberg OF. Evaluating three treatments for borderline personality disorder: a multiwave study. Am J Psychiatry. 2007;164:922–928. doi: 10.1176/appi.ajp.164.6.922.
    1. Beecham J, Sleed M, Knapp M, Chiesa M, Drahorad C. The costs and effectiveness of two psychosocial treatment programmes for personality disorder: a controlled study. Eur Psychiatry. 2006;21:102–109. doi: 10.1016/j.eurpsy.2005.05.006.

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