Despite the many treatment options for people with BPD, Many professionals in mental health services continue to believe that personality disorders are untreatable. This essay provides evidence the effectiveness of Cognitive Behaviour Therapy (CBT) and Dialectical Behaviour Therapy (DBT) with Borderline Personality Disorder.
To understand BPD, I will attempt to give a historical overview of BPD.
In the 1800s, Philippe Pinel first used the French term manie sans delire (“mania without delirium”) to designate those individuals engaging in deviant behavior but showing no signs of a thought disorder such as hallucinations or delusions, psychiatry began to think about borderline personality disorders as early as 1801. Although the meaning of the term has changed through many writings on the subject over time, the writing of Cleckley and his use of the label “psychopath” in The Mask of Sanity brought the term into accepted usage (Meloy 1998). The Mask of Sanity is a book written by Hervey Cleckley first published in 1941; he gave the most significant clinical description of psychopathy in the 20th century. An expanded edition of the book was published in 1982, when the name was changed from psychopathy to Personality Disorder. In 1972, newer editions of the book reflected a closer alliance with Kernbergs’s (1984) borderline level of personality organization, in particular defining the structural criteria of the psychopath’s identity integration, defensive operations and reality testing.
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The diagnosis “borderline” was introduced in the 1930s to label patients with problems that seemed to fall somewhere in between neurosis and psychosis (Stern, 1938). In 1938, the psychoanalyst Adolph Stern first described most of the symptoms that are now considered as criteria of borderline disorder. He suggested the possible causes of the disorder, and what he believed to be the most successful form of psychotherapy for these patients, he also renamed the disorder again, and he named the disorder by referring to patients with the symptoms he described as “the border line group” (Freidel 2004).
In 1940, the psychoanalyst Robert Knight introduced the concept of ego psychology into his explanation of borderline disorder. Ego psychology deals with mental functions that allow us to effectively combine our thoughts and feelings and to develop helpful responses to life around us. He suggested that people with borderline disorder have impairments in a lot of of these functions, and he referred to them as “borderline states” (Friedel 2004).
The next important input was made by the psychoanalyst Otto Kernberg (1967); he introduced the term ‘borderline personality organisation’. He proposed that mental disorders were determined by three distinctive personality organisations: psychotic, neurotic and “borderline personality.” Kernberg has been a strong promoter of modified psychoanalytic therapy for patients with borderline disorder (Friedel 2004).
Roy Grinker in 1968 published results of the first research conducted on patients with borderline disorder, which he referred to as the “borderline syndrome” (Friedel 2004). The next major advance in the field occurred when Gunderson and Singer (1975) published a widely acclaimed article that synthesized the relevant, published information on borderline disorder, and defined its major characteristics. Gunderson then published a specific research instrument to enhance the accurate diagnosis of borderline disorder. This instrument enabled researchers over the world to verify the validity and integrity of borderline disorder. Subsequently, borderline personality disorder first appeared in DSM-III as a bona fide psychiatric diagnosis in 1980 (Friedel 2004).
Personality disorder categories are not firmly grounded in theory, nor are they empirically based (Livesley, 1998). Some critics say that personality disorder categories are so flawed that the best option is to abolish them and start afresh, but most pragmatists recognise that so much has been invested in them that they are very likely
here to stay (Blackburn 2000a; Livesley, 1998).
Borderline personality disorder is associated with significant impairment, especially in relation to the capacity to sustain stable relationships as a result of personal and emotional instability (NICE 2009). For many, the severity of symptoms and behaviours that characterise borderline personality disorder, correlate with the severity of personal, social and occupational impairments. However, this is not always the case, and some people with what appears to be, in other ways, marked borderline personality disorder may be able to function at very high levels in their careers (Stone, 1993). Paris (1994) stated that about one-third of patients with BPD report severe abuse involving an incestuous perpetrator; about one-third report milder forms of abuse; and about one-third do not report abuse.
Personality disorders are common conditions; studies indicate prevalence of 10-13% of the adult population in the community and are more common among younger age groups (24-44 yrs) and equally distributed between males and females. However, the sex ratio for specific types of personality disorder is variable e.g. antisocial personality disorder is more common among males, and borderline personality disorder more common amongst females (DOH 2003).
Cognitive Behaviour Therapy (CBT) can be seen as an umbrella term for many different therapies that share some common elements. The earliest form of Cognitive Behavior Therapy was developed by Albert Ellis in the early 1950s. Aaron T.Beck independently developed another CBT approach, called Cognitive Therapy, in the 1960s. Cognitive Therapy rapidly became a favorite intervention to study in psychotherapy research in academic settings. In initial studies, it was often contrasted with behavioral treatments to see which was most effective. However, in recent years, cognitive and behavioral techniques have often been combined into cognitive behavioral treatment. This is arguably the primary type of psychological treatment being studied in research today. One specific form of cognitive-behavioural therapy is dialectical behaviour therapy (DBT), a broad-based, cognitive-behavioural programme developed specifically to reduce self-harm in women with borderline personality disorders (Linehan, 1993a; Linehan 1993b). Recent research has shown that dialectical behaviour therapy (DBT) is one of the first therapies that have demonstrated to be effective for treating borderline personality disorder as well as being effective in treating people who display varied symptoms and behaviours associated with mood disorders, including self-harm. DBT combines standard cognitive-behavioural techniques for emotion regulation and reality-testing with concepts of mindful-awareness, distress tolerance, and acceptance.
As a mental health nurse coming from a forensic background, I have experience of working with clients with personality disorder. I feel that by getting more of an understanding of CBT interventions, it will make a huge difference to my future practice in the future. McKenna et al (1999) state that it is unacceptable for health care not to be based on sound evidence of its effectiveness, and back up their practice with research-based evidence (NMC, 2008) to ensure effective clinical practice. Often nurses find it frustrating working with disorders of personality. These clients can be manipulative, socially inappropriate and difficult, for these reasons, such clients’ need all the patience and skills nurses have to offer. Until recently, personality disorder services in the NHS had been diverse, spasmodic and inconsistent (Department of Health, 2003). Besides functional impairment and emotional distress, borderline personality disorder is also associated with significant financial costs to the healthcare system, social services and the wider society (NICE 2009).
1.3 Aims and objectives
The aims and objectives of this project are to review the evidence on the efficacy of Cognitive Behavioural Therapy and Dialectical Behaviour Therapy with people who have Borderline Personality.
1.4 Methodology and parameters
This literature review was conducted using the following resources
Electronic databases: Cochrane library, CINHAL, Medline, Psychinfo, Psychology and Behavioural Sciences and Academic Search Premier
Key journals were hand searched: British Journal of Psychiatry, Journal of Personality Disorders, Mental Health Practice, Journal of Personality and Mental Health
University and Trust libraries
Google & Google scholar
The following types of literature were sought and reviewed where available
Randomised control trials
Systematic and structured review
Quantitative and Qualitative research studies
Position statements/guidelines from professional bodies
Government policies (NICE (2009), NSF (1999)
Inclusion and exclusion criteria
Eligibility for this review was determined by the following criteria:
â- Participants: adults with BPD (diagnosed according to DSM-III/DSM-III-R, DSM-IV, DSM-IV-TR or ICD-10 criteria for BPD), with or without co-morbidity.
â- Intervention: psychological therapies, including CBT, DBT
â- Comparators: CBT/DBT or treatment as usual
â- Outcomes: self-harm, suicide, interpersonal and social functioning
â- Study type: published papers were assessed according to the accepted hierarchy of evidence, whereby systematic reviews of RCT’s are taken to be the most authoritative forms of evidence, with uncontrolled observational studies the least authoritative.
â- Exclusion criteria: papers on personality disorder without separate BPD
The studies were obtained through a number of sources, as above. Searches were performed by entering the key words – “Borderline Personality Disorder”, “Cognitive behaviour therapy” into several databases, which yielded many secondary references of current best evidence. Search filters developed consisted of a combination of subject headings. The topic-specific filters were combined with appropriate research design filters developed for systematic reviews, RCTs and other appropriate research designs. These articles were selected after careful reading of the title and abstract to identify the most useful. I then limited my search to full articles which made my search a lot easier. The definitive text that will be used to aid my search will be NICE Clinical Guidelines for Personality disorder 78. This guideline makes recommendations for the treatment and management of borderline personality disorder in adults and young people (under the age of 18) who meet criteria for the diagnosis in primary, secondary and tertiary care.
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Borderline personality disorder is present in just under 1% of the population, and is most common in early adulthood. Women present to services more often than men. Borderline personality disorder is often not formally diagnosed before the age of 18, but the features of the disorder can be identified earlier. Its course is variable and although many people recover (NICE 2009). This search will comprise both British and international articles. When choosing which articles were going to be relevant, I found it impossible to ignore the amount of articles I had on DBT and as DBT was evolved from CBT and made specifically for BPD, I decided to bring it into my research project.
The articles are mixed quantitative and qualitative research. The qualitative means of gathering subjective data is centred on an individuals experience, beliefs, empowerment and quality of care and does not solely concentrate on clinical outcomes for the individual. One could argue that this is the most appropriate aspect of research for mental health nurses as mental illness is individual for each person involved in the process and although BPD is not a mental illness The National Service Framework for adult mental health sets out our responsibilities to provide evidence based, effective services for all those with severe mental illness, including people with personality disorder who experience significant distress or difficulty (NIMH 2003). While these can be misconceived as an ‘easy option’ form of research, qualitative research offers rich, reflective and exhaustive data that is invaluable and has a profound contribution to make to take to practice. The qualitative evidence was limited with regards to the treatments reviewed, with an emphasis on DBT. Quantitative research is a formal, objective, and rigorous statistical process for generating information about the world (Burns & Grove 1999), whereby the researcher would gather a range of numerical data in order to answer the research question, or prove, disprove a hypothesis (Parahoo 2006).
Philosophies or schools of thought in research are called paradigms (Parahoo 2006). One such paradigm is positivism. Parahoo (2006) asserts that positivism relies on observations by the human senses to create fact (empiricism), and believe in the unity of science, and the notion of cause and effect (determinism). The positivist researcher will endeavour to test a hypothesis or theory using the deductive process of a course of experiments. This paradigm utilises a quantitative approach in its research methods. For the positivists, quantitative research is believed to provide hard evidence and objective fact that can provide knowledge on which to base best practice (Parahoo 2006).
Efficacy studies focus on the usefulness of a specific helping methodology for a particular kind of problem. Comparisons are made between the methodology in question and some other methodology between clients with some disorder who do receive the treatment and those who do not or between two different methodologies for treating the same disorder. These studies are carried out under controlled conditions. Many of the studies are well designed and demonstrate efficacy. In a healthcare context, efficacy indicates the capacity for beneficial change (or therapeutic effect) of a given intervention.
Chapter 2 – The Literature Review
Having undertaken a critical review of the literature, I have come to explore a number of issues which I feel necessary to consider, key themes emerging from this literature review are the impact of CBT & DBT on suicidal behaviours, the impact of CBT & DBT on self-harming behaviours, and the impact of CBT & DBT on engagement. This chapter sets out to explore these themes in more detail. The most appropriate research design to answer this is the RCT; therefore the evidence base reviewed comprised available RCTs undertaken in people with a diagnosis of borderline personality disorder.
The causes of borderline personality disorder are complex and remain uncertain. The following may all be contributing factors: genetics and constitutional vulnerabilities; neurophysiological and neurobiological dysfunctions of emotional regulation and stress; psychosocial histories of childhood maltreatment and abuse; and disorganisation of aspects of the behavioural system, most particularly the attachment system (NICE 2009). The history of specific psychological interventions designed to help people with borderline personality disorder is intertwined with changing conceptions of the nature of the disorder itself.
Given the confusion that surrounds the nature of personality disorder, it is not surprising that this has impacted on NHS care for people with this diagnosis. Until recently, personality disorder services in the NHS had been diverse, spasmodic and inconsistent (Department of Health, 2003). Borderline personality disorder is particularly common among people who are drug and/or alcohol dependent, and within drug and alcohol services there will be more women with a diagnosis of borderline personality disorder than men (Swartz 1990). Borderline personality disorder is also more common in those with an eating disorder (Zanarini et al., 1998), and also among people presenting with chronic self-harming behaviour (Linehan et al., 1991).
2.1 Defining Cognitive Behaviour Therapy and Dialectical Behaviour Therapy
Cognitive behavioural therapy (CBT) is a structured psychological treatment that focuses on helping a person make connections between their thoughts, feelings and behaviour. CBT was originally developed as a treatment for depression, and has since been modified for the treatment of people with personality disorders including borderline personality disorder. CBT focuses on altering the thoughts, emotions, and behaviours of patients by teaching them skills to challenge and modify beliefs, to engage in experimental reality testing, and to develop better coping strategies. The goals of these interventions are to decrease the conviction of delusional beliefs, and hence their severity, and to promote more effective coping and reductions in distress. This essay will attempt to assess the contribution of CBT the disorder by discussing reviews on efficacy and long term effects. Cognitive behavioral therapy for borderline personality disorder (CBT for BPD) was developed on the premise that people with the disorder have learned distorted beliefs and thought patterns. These, in turn, result in the distressing emotional responses and behaviors that characterize borderline personality disorder. It is the initial objective of CBT for BPD to identify the distorted, automatic thoughts and beliefs held by the patient with borderline disorder. Such beliefs outlined by Beck & Freeman(1990) typically include those related to dependency (“I am needy and weak”), distrust (“People will get me if I don’t get them first”), rigid, all-or-nothing (dichotomous) perceptions, and other thought patterns that characterize the main cognitive-perceptual symptoms of the disorder. These distorted thoughts are then modified by self-monitoring, logical analysis and by questioning and testing them. It is adapted for people with borderline personality disorder and pays attention to the structure of the therapy and the problems that can disrupt the therapeutic relationship, such as non-engagement in treatment, shifting problems and goals, losing focus on the aims of therapy, losing structure and lack of compliance with assignments (Davidson, 2000). In addition, CBT for BPD attempts to produce positive change by improving the attitude of the patient toward treatment, the enhancement of specific skills, and the reduction of hopelessness. The CBT therapist and the patient typically construct a list of specific problem areas. They then develop a set of tasks or exercises that generate and reinforce new attitudes, behaviors, and interpersonal strategies that replace the ones that have proven to be ineffective.
Within the past 15 years, another, newer psychosocial treatment termed Dialectical Behaviour Therapy (DBT) was developed. DBT combines standard cognitive behavioural techniques with acceptance based strategies, as well as strategies designed to keep the therapy balanced between change and acceptance (dialectical strategies). Marsha M. Linehan, a psychologist from the University of Washington in Seattle, developed DBT specifically for people with BPD, especially those who engage in frequent self-destructive and self-injurious behaviours. DBT is based on the belief that the symptoms of BPD result from biological impairments in the brain mechanisms that regulate emotional responses. The early behavioural effects of this impairment are magnified, as the person with this biological risk factor interacts with people who don’t validate their emotional pain and don’t help them learn effective coping skills. DBT has gained considerable favour in the treatment of BPD because of the results it has achieved in several research studies. It has been shown that DBT can be taught to and used by many, but not all, mental health professionals. For the time being this seriously limits the broad use of this effective treatment approach. DBT seeks to validate feelings and problems, but it balances this acceptance by gently pushing to make productive changes. DBT also deals with other opposing or ‘dialectical’ tensions or conflicts that arise, such as the patient’s perceived need for a high level of dependence on the therapists and others, and the fear and guilt aroused by such excessive dependency. DBT combines both cognitive and behavioural techniques and designed specifically to treat BPD. It is a combination of individual psychotherapy and psychosocial skills training that has been shown via controlled clinical trial to be effective in treating individuals with BPD (Linehan, 1993b). In practice, the limiting factor in providing access to psychological therapies is the very small proportion of NHS staff trained to deliver these to a competent standard. Fourteen women with borderline personality disorder were interviewed to ascertain what is effective about DBT and why (Cunningham et al., 2004).Participants reported that DBT allowed them to see the disorder as a controllable part of themselves rather than something that controlled them, providing them with tools to help them deal with the illness. Service users reported that DBT had had a positive effect on their relationships in day-to-day interactions, and although problems with friends and family did not disappear, they were more manageable (NICE 2009). Clients also expressed higher levels of hope and a desire to live more independently (Cunningham et al., 2004)
2.2 Suicidal acts
Definition: deliberate; life threatening; resulted in medical attention; medical assessment consistent with suicide attempt.
Suicide is common in people with borderline personality disorder and may occur several years after the first presentation of symptoms (Paris & Zweig-Frank, 2001). A well-documented association exists between borderline personality disorder and depression (Skodol et al., 1999; Zanarini et al., 1998), and the combination of the two conditions has been shown to increase the number and seriousness of suicide attempts (Soloff et al., 2000). People with borderline personality disorder may engage in a variety of destructive and impulsive behaviours including self-harm, eating problems and excessive use of alcohol and illicit substances. Self-harming behaviour in borderline personality disorder is associated with a variety of different meanings for the person, including relief from acute distress and feelings, such as emptiness and anger, and to reconnect with feelings after a period of dissociation. As a result of the frequency with which they self-harm, people with borderline personality disorder are at increased risk of suicide (Cheng et al, 1997), with 60 to 70% attempting suicide at some point in their life (Oldham, 2006). The rate of completed suicide in people with borderline personality disorder has been estimated to be approximately 10% (Oldham, 2006). A behavioural approach to self-harm and suicidality that incorporated skills training in emotion regulation and validation of client experience developed into dialectical behaviour therapy (DBT), a specific intervention for borderline personality disorder. Cognitive-behavioural therapy along the lines of Beck, Freeman, & Associates (1990) has been investigated in at least two uncontrolled trials. Brown, Newman, Charlesworth, and Chrits-Cristoph (2003) found significant decreases on suicide ideation, hopelessness, depression, number of BPD symptoms, and dysfunctional beliefs after 1 year of cognitive-behavioural therapy for suicidal or self-mutilating patients with BPD. Results were maintained at a 6 months follow-up. Effect sizes were moderate (0.22-0.55). Dropout rate was 9.4%. Arntz (1999a) found positive effects of long-lasting cognitive-behavioural therapy in a mixed sample of personality disorders, including 6 patients with BPD. Two patients with BPD dropped out prematurely, but the other four attained good results.
A randomized clinical trial was conducted by Linehan et al. (1991) with 44 subjects to evaluate the effectiveness of DBT for the treatment of chronically parasuicidal women who met criteria for BPD. Patients who received DBT had an average of 8.46 inpatient days per year compared to 38.86 days for the control group. It was also noted that it did not appear that there were differences between the two groups on measures of depression, hopelessness, suicide ideation, or reasons for living. Linehan et al. (1993) conducted a naturalistic follow-up review of 39 of these subjects to determine whether the effects of DBT were maintained over one year post treatment. In the 12 to 18 month period, subjects completing DBT had fewer parasuicidal episodes and fewer medically treated episodes. In the 18- to 24-month period, there were no significant between-group differences on parasuicide measurements, although psychiatric inpatient days during this time were lower for subjects in the DBT group.
Rathus et al. (2002) conducted a study with a group of suicidal adolescents with borderline personality features. Participants included 111 outpatient admissions. Eighty-two participants were assigned to treatment as usual (TAU) and 29 were assigned to DBT. The groups were not randomized, but it was noted that there was more severe pre-treatment symptomtology in the DBT group than the TAU group. The group treated with DBT had significantly fewer inpatient psychiatric hospitalisations during the 12 weeks of treatment. The groups did not differ significantly in number of suicide attempts made during treatment. There was a slightly higher rate of treatment completion in the DBT group.
Hengeveld et al (1996) report a case series of nine female outpatients who had attempted suicide on at least two occasions and were offered up to ten sessions of group CBT. Seven of the nine met criteria for personality disorder and of these four had borderline personality disorder. Ten months after the last session, recurrence of self-harm was examined using telephone contacts with participants and examination of hospital records. Four of the seven participants reported further suicide attempts – all four had borderline personality disorder.
Linehan et al. (2006) conducted a one-year randomized controlled trial with one year of post-treatment follow up. The objective was to evaluate the hypothesis that unique aspects of DBT are more efficacious compared to treatment offered by non-behavioural psychotherapy experts. The study included 101 female participants with recent suicidal and self-injurious behaviours that met DSM-IV criteria. The subjects who received DBT were half as likely to make a suicide attempt.
2.3 Suicidal acts
Definition: deliberate; resulted in visible tissue damage, nursing or medical intervention required.
Self-harming behaviour in borderline personality disorder is associated with a variety of different meanings for the person, including relief from acute distress and feelings, such as emptiness and anger, and to reconnect with feelings after a period of dissociation. As a result of the frequency with which they self-harm, people with borderline personality disorder are at increased risk of suicide (Cheng et al., 1997). Service users have been positive about DBT because it has helped them to improve their relationships and their ability to control their emotions and reduce self harm. However, while some valued the structure of the approach, others preferred the programme to be more tailored and flexible.
In a large sample, Tyrer et al (2003) found that CBT was equivalent to TAU for the treatment of recurrent self-harm and noted that this method was less effective for patients with BPD.
Brown (2004) conducted an uncontrolled cohort study participants with borderline personality disorder who reported suicidal ideation or engaged in self-injurious behaviour received weekly CBT over a 12-month period and were followed up over an 18-month period. Individual sessions lasting 1 hour were supplemented by access to emergency telephone contact with an on-call therapist between sessions.
Verheul et al. (2003) conducted a randomized controlled study for the purpose of comparing the effectiveness of DBT with TAU for patients with BPD and to examine the impact of baseline severity on effectiveness. The study included 58 women who were randomized to either DBT or TAU and who received treatment over one year. The results included: DBT had a substantially lower 12-month attrition rate (37%) compared with TAU (77%); treatment with DBT resulted in greater reduction of self-mutilating and self-damaging impulsive acts than TAU.
Van den Bosch et al. (2005) published a follow-up review of this study that examined whether the treatment results in the Verheul study were sustained over six-month follow-up or up to week 78. It was noted that in the six months after treatment discontinuation, the benefits of DBT over TAU in terms of lower levels of impulsive and self-mutilating behaviours were sustained. However, it must be noted that parasuicide activity had been defined in slightly different ways in the RCTs and therefore might not be comparable across studies.
Alper (2001) presents outcome data on a case series of 15 ‘court committed’ women with a clinical diagnosis of borderline personality disorder that underwent treatment with nurse-led DBT in an inpatient forensic setting. There was a reduction in the frequency of self-harm over the 4-week period. In addition, the authors conducted qualitative interviews with four nurses to describe their experience of administering DBT; their responses were uniformly positive.
Bateman & Tryer (2004) state that the widespread adoption of dialectical behaviour therapy is a tribute both to the energy and charisma of its founder, Marsha Linehan, and to the attractiveness of the treatment, with its combination of acceptance and change, skills training, excellent manualisation, and a climate of opinion that is willing and able to embrace this multifaceted approach. It is not, however, justified by the strength of the evidence (Tyrer, 2002b) and conclusions about the long-term effectiveness of this therapy as a treatment for the personality itself are premature. Since the original trial which was handicapped by many methodological limitations, there has only been one randomised study that supports the findings unequivocally, that of Verheul et al (2003).
For effective treatment, commitment to therapy is required, and research shows that fewer people drop out of DBT than other therapies (verheul et al 2003)
According to service users interviewed by Haigh (2002), services could be improved if: professionals acknowledged that personality disorder is treatable; they received a more positive experience on initial referral as this would make engagement with a service more likely; if the ending of a therapeutic relationship was addressed adequately; and if services were not removed as soon as people showed any signs of improvement, because this tended to increase anxiety and discourage maintenance of any improvement. In a study by Hodgetts and colleagues (2007) of five people with borderline personality disorder being treated in a DBT service, the participants reported that DBT was presented to them as the only treatment for personality disorder. This may have raised anxieties in service users about what was expected of them. While some valued the sense of structure to the treatment, others would have preferred a more tailored and flexible approach. There were also mixed feelings about the combination of individual therapy and group skills training. For one person the challenges of DBT proved too much so she left the programme. Another factor in her leaving was that she believed she was refused supp
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