Borderline personality disorder (BPD) is the most prevalent personality disorder encountered in clinical settings. Its lifetime prevalence is estimated to range from 0.5% to 5.9%,1 with the prevalence not significantly different between men and women.2 BPD is associated with mental and physical disability, high rates of comorbid substance abuse, anxiety and mood disorders, other personality disorders, and high mortality rates as a result of suicide.2 Along with instability in impulse control, self-image, and interpersonal relationships, emotion dysregulation is considered a core symptom of BPD.
In BPD, emotion dysregulation has been described to consist of emotion sensitivity, heightened and labile negative affect, a deficit of appropriate regulation strategies, and a surplus of maladaptive regulation strategies.3 Difficulties in awareness, understanding, and acceptance of emotions and difficulties in the ability to control impulsive behaviors indicate emotion dysregulation.4
Deficits in emotion regulation are associated not only with BPD but with various mental health problems,5 including somatoform disorders,6 depression,7 anxiety,8 and eating disorders.9 While some research reported difficulties in emotion regulation to be associated with general psychopathology, rather than being specific for any mental health problem,10,11 other research suggests such a specificity.12,13 Several recent studies that have addressed the question of whether individuals with BPD have distinct emotion regulation problems have reported inconsistent results.14–16
Neuroimaging studies indicate that dysfunctions in prefrontal, limbic, and corticostriatal pathways play a part in emotion regulation and that reduced serotonin neurotransmission in these structures is related to impulsive behavior in BPD.17 The results of a study using functional magnetic resonance imaging specifically suggested that hyperreactivity in the amygdala was responsible for emotion dysregulation in individuals with BPD.18 Other physiological parameters have also been found to be related to emotion regulation in BPD. According to the polyvagal theory,19 the myelinated vagus, a part of the parasympathetic nervous system, normally acts as a brake to the heart rate in social situations, inhibits defensive reactions, and is associated with social engagement behaviors. After having seen emotionally arousing film clips, individuals with BPD showed a physiological state of vagal withdrawal, indicating fight-or-flight behaviors. A control group with no psychiatric diagnoses, on the other hand, showed the opposite physiological state, associated with social engagement behaviors. In line with these results, emotion regulation difficulties may be related to difficulties regulating the vagal brake in social contexts, causing individuals with BPD to show defensive reactions instead of social engagement.19
There are several effective treatments for BPD,20 one of which is dialectical behavior therapy (DBT). DBT is an acceptance-based as well as change-based therapy grounded on dialectical theory. A core element of DBT is the acquisition of emotion regulation skills. Reviews on change mechanisms in DBT for BPD have confirmed that emotion regulation is central for a good outcome.21,22 Most previous outcome studies have investigated DBT for BPD in an outpatient setting. However, DBT can also be applied in an inpatient setting,23 and 11 studies on inpatient DBT for BPD reviewed by Bloom et al24 showed promising outcomes. However, most of these studies investigated a rather long inpatient DBT of 3 months. More recent studies on inpatient DBT have also used a 3-month program.25–27 In the study described in this article, a shorter inpatient DBT program lasting 5 weeks was evaluated in terms of symptom change and change in emotion regulation. As change mechanisms are rather unclear in inpatient DBT for BPD,24 we also examined changes in emotion regulation and the association between changes in emotion regulation and changes in patient-reported BPD symptoms. Our hypotheses were that symptoms related to BPD as well as emotion regulation would improve during a 5-week inpatient DBT for BPD and that changes in emotion regulation would be associated with changes in symptoms related to BPD.
This study was approved by the study center of the Nuremberg Hospital, and all patients gave written informed consent to take part.
Written informed consent to take part in the study was obtained from 44 of 45 patients with BPD, who took part in the 5-week DBT inpatient program for BPD at the unit for psychiatric crisis intervention of the University Clinic for Psychiatry and Psychotherapy Nuremberg (Germany) between September 2015 and August 2016. BPD diagnoses were made by the referring practitioners, the therapeutic staff in the clinic, and through the application of the “International Personality Disorder Examination” (IPDE).28 Thirty-three patients were female (75%) and 11 patients were male (25%), with an average age of 30.16 years (SD=9.39 y). Psychiatric comorbidities were assessed by the therapeutic staff in the clinic, with 6 patients having had 1 additional psychiatric diagnosis, 11 patients having had 2 additional psychiatric diagnoses, and 2 patients having had 3 additional psychiatric diagnoses. The most common comorbid diagnoses were, according to ICD-10, “F4: Neurotic, stress-related and somatoform disorders” (n=8) and “F1: Mental and behavioral disorders due to psychoactive substance use” (n=7).
The 5-week inpatient DBT program implemented at the unit for psychiatric crisis intervention of the University Clinic for Psychiatry and Psychotherapy Nuremberg (Germany) is certified by the “Dachverband Dialektisch Behaviorale Therapie.” The treatment plan is illustrated in Table 1. As can be seen in Table 1, some treatments offered during the 5-week inpatient DBT program are not specific to DBT (eg, ergotherapy, art therapy, acupuncture). In addition to the treatments listed in Table 1, the patients participated in individual body psychotherapy once a week, individual psychotherapy twice a week, and met individually with the responsible nurse once or twice per week. Staff of the inpatient unit was trained to interact with the patients according to the DBT model. Up to 6 patients could participate in each 5-week inpatient DBT program. During the study, 9 groups participated in the 5-week inpatient DBT program: 1 group had 3 patients, 2 groups had 4 patients, 2 groups had 5 patients, and 4 groups had 6 patients The groups differed in size because each 5-week inpatient DBT program starts at a specific month, and the size of the group depended on the number of registrations.
Borderline Symptom List-Short Version
BPD symptom severity was measured with the short version of the Borderline Symptom List (BSL-23),29 a self-rating instrument with good psychometric properties. The BSL-23 has high internal consistency (Cronbach α=0.94 to 0.97) and high test-retest reliability (r=0.82). Its convergent validity is moderate to high, with correlations between the BSL-23 and depression ranging from r=0.83 to 0.87 and correlations between the BSL-23 and general psychopathology ranging from r=0.84 to 0.89. The BSL-23 also has a high ability to discriminate patients with BPD from patients with DSM-IV axis I diagnoses (mean effect size=1.13).29 The BSL-23 consists of 23 statements, with which patients rate their agreement using a 5-point Likert scale ranging from not at all to very much. The mean score on the BSL-23 was analyzed in this study as the patient-reported outcome. BSL-23 scales with>2 missing items were excluded from the analysis.
Self-Report Measure for the Assessment of Emotion Regulation Skills
Emotion regulation was assessed with the Self-Report Measure for the Assessment of Emotion Regulation Skills (SEK-27).30 The SEK-27 consists of 27 items reflecting different emotion regulation skills, with items rated on a 5-point Likert scale ranging from not at all to almost always. The items comprise the following emotion regulation skills: awareness, sensations, clarity, understanding, acceptance, tolerance, self-support, readiness to confront distressing situations, and modification. This study evaluated only the total score on the SEK-27, and scales with more than 2 missing items were excluded from the analysis. The SEK-27 total score has an internal consistency ranging α=0.90 to 0.93, test-retest reliability ranging from 0.75 to 0.78, and moderate construct validity.30
SPSS 25 was used for all statistical analyses. Frequencies (n), percentages (%), means (M), and SD were calculated as descriptive statistics. A Wilcoxon test was performed to evaluate treatment effectiveness (ie, pretreatment BSL-23 scores vs. BSL-23 scores at discharge). We also compared the pretreatment SEK-27 values with the SEK-27 values at discharge using another Wilcoxon test to investigate whether emotion regulation improved during treatment. Finally, pre-post differences were calculated for the BSL-23 and the SEK-23. The posttreatment values were subtracted from the pretreatment values for the BSL-23, whereas the pretreatment values were subtracted from the posttreatment values for the SEK-27, so that higher difference scores represent more improvement for both measures. Correlations (Pearson correlation) between these pre-post differences on the BSL-23 and the pre-post differences on the SEK-27 were investigated to determine whether changes in emotion regulation were associated with symptom changes. A completer analysis and an intention-to-treat analysis were performed. In the completer analysis, only patients with available pretreatment and posttreatment data were included. In the intention-to-treat analysis, all patients with available pretreatment data were included and missing posttreatment data were replaced by the pretreatment data. All inferential statistical tests were performed 2-tailed and the significance value was set at P≤0.05. Effect sizes (d) were calculated according to the following formulas so that more positive effect sizes stand for more improvement: for the BSL-23, (Mpretreatment–Mposttreatment)/SDpretreatment, and, for the SEK-27, (Mposttreatment–Mpretreatment)/SDpretreatment. The effect sizes were interpreted as small d=0.2, medium d=0.5; and large d≥0.8.31
Pretreatment BSL-23 data were available for 43 patients and of these, posttreatment BSL-23 data were available for 33 patients. Pretreatment SEK-27 data were available for 43 patients and of these, posttreatment SEK-27 data were available for 33 patients. Thus, the “completer” sample comprised 33 patients, and the “intention-to-treat” sample 43 patients. The “intention-to-treat” sample did not include all 44 study participants, because 1 patient had >2 items missing on the BSL-23 at pretreatment and another patient had >2 items missing on the SEK-27 at pretreatment. The BSL-23 and the SEK-27 were significantly correlated at pretreatment (r=−0.596; P<0.001) and posttreatment (completer sample: r=−0.534; P=0.001).
Results for changes in symptoms and emotion regulation are summarized in Table 2. The completer analysis showed that BPD symptoms improved significantly (Z=−3.53, P<0.001) with a moderate effect size of d=0.465. Emotion regulation also improved significantly (Z=−3.71; P<0.001), with a large effect size of d=0.837. An intention-to-treat analysis was done to examine if including participants with missing posttreatment data (replaced by the pretreatment data) would change the results. As in the completer analysis, significant reductions in BPD symptoms (Z=−3.53, P<0.001) and improvements in emotion regulation (Z=−3.71, P<0.001) were found but the effect sizes were smaller (BSL-23: d=0.375; SEK-27: d=0.681). Improvements in emotion regulation were significantly associated with improvements in BPD symptoms in the completer (r=0.543; P=0.001) as well as in the intention-to-treat (r=0.590; P<0.001) analysis.
This study found statistically significant reductions in BPD symptoms and statistically significant improvements in self-report emotion regulation at the end of a 5-week inpatient DBT, confirming our first hypothesis. This result is consistent with other research investigating DBT for BPD in an inpatient setting. Kröger et al32 investigated the effectiveness of a 3-month inpatient DBT program on patient-reported outcomes and found that general symptom severity (d=0.68) as well as depressive symptoms (d=0.59) decreased significantly. Kleindienst et al33 found that patient-reported outcomes significantly improved after patients participated in a 3-month inpatient DBT program (effect sizes ranging from d=0.13 to 1.0 after discharge). In a pilot study investigating the effects of a 3-month inpatient DBT program, Bohus et al34 found that patient-reported outcomes significantly improved, with effect sizes between d=0.69 and 1.40. A subsequent controlled study by Bohus et al35 that evaluated the 3-month inpatient DBT program found within-group effect sizes up to d=1.02 for patient-reported outcomes.
One possible reason why the effect sizes in these other studies of inpatient DBT were higher than in our study could be that the treatment the patients received was longer—3 months versus 5 weeks. As noted by Bloom et al24 in their review of studies of inpatient DBT for BPD, 3 months was the modal treatment duration in studies of inpatient DBT, with only 2 studies identified with shorter treatment durations of 2 weeks. The different treatment durations as well as the different patient-reported outcome measures (the studies cited above did not use the BSL) make it somewhat difficult to interpret these benchmark comparisons. Another study by Bohus et al29 that also used the BSL-23 as the patient-reported outcome and evaluated the effects of 3-month DBT found a pre-post effect size of d=0.47. This result resembles our effect size of d=0.465 (completer analysis), although our treatment duration was shorter and the average BPD-symptom severity at intake was slightly lower (M=2.1 vs. 1.9). When the long-form of the BSL (BSL-95) was used to evaluate a 3-month DBT, effect sizes reached d=0.3829 and 0.52.25
We also compared improvements in self-reported emotion regulation after DBT with reports of improvements from previous research. Goodman et al36 measured self-reported emotion regulation with the Difficulties in Emotion Regulation Scale (DERS)4 at baseline and 12 months after outpatient DBT and found a significant improvement in emotion regulation with an effect size of d=0.76, which is comparable to the result in our study (d=0.681 to 0.837). In another study that used the DERS to evaluate changes in emotion regulation after a 3-month inpatient DBT, Mancke reported larger effect sizes that reached d=1.11.25 In our study, changes in self-reported emotion regulation were correlated with changes in BPD symptoms, thus also confirming our second hypothesis. This finding is consistent with previous research that has shown the potential of emotion regulation to reduce psychological distress in patients with BPD. For example, a preliminary study by Gratz and Gunderson37 found that adding an acceptance-based emotion regulation group intervention to outpatient psychotherapy led to more benefits in the outcome measures. Improvements in emotion dysregulation following emotion regulation group therapy have also been shown to mediate a decrease in deliberate self-harm.38 Related to emotion regulation are coping skills, and changes in coping skills have been found to be associated with changes in BPD symptom severity.39
LIMITATIONS AND STRENGTHS
One limitation of our study is its rather low internal validity, as it was not possible to include a control group under the conditions of routine practice. Therefore, we cannot say whether or how much of the effects can be attributed to the DBT treatment or to confounders like extratherapeutic events or spontaneous recovery. Moreover, the extent to which the DBT treatment was actually adhered to could not be assessed. On the other hand, the treatment was certified by the Dachverband Dialektisch Behaviorale Therapie, which can be seen as an argument for the orderly application of DBT. Furthermore, we only investigated associations between changes in emotion regulation and the patient-reported outcome of symptoms associated with BPD. Other aspects besides emotion regulation, such as the therapeutic alliance22 or factors related to the inpatient setting,40 could also be associated with the outcome in our study. Another shortcoming of our study is that we cannot say whether changes in emotion regulation occurred before changes in BPD symptoms or vice versa. Other statistical approaches such as mediation models41 or latent difference score models42 should be applied in future research to examine the direction of these associations in more detail. Our study design and our small sample size did not allow us to perform these kinds of analyses. A final limitation is that all measures are self-reports, and neural correlates would be valuable complementary data sources.25
Despite these shortcomings, the study took place in a psychiatric setting under conditions of routine care, which enhances the external validity/generalizability of the results. Another strong point of this study is the psychometric soundness of the measures that were used. Nevertheless, it should be kept in mind that the 2 scales we used, the BSL-23 and SEK-27, share some similarities in items and were significantly correlated. Therefore, the correlation between changes in emotion regulation (SEK-27) and BPD symptoms (BSL-23) may be overstated. In future studies with larger samples, it would be interesting to conduct a combined factor analysis of the 2 scales to further explore the relationship between them.
Our study indicates that a short 5-week inpatient DBT implemented in a psychiatric setting is an effective treatment for BPD. Furthermore, it seems important to improve emotion regulation as this was associated with reduction in BPD symptoms.
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