A randomized trial of shortterm inpatient Dialectic Behaviour Treatment (DBT)versus longterm outpatient DBT

A randomized study of the efficacy of dialectical behavioural therapy with
young adults (18-40 years old) with a borderline personality disorder, executed
in an intensified, intramural treatment, with a maximum duration of 3 months.

Research proposal Short-termed intramural DBT,
Centrum Persoonlijkheidsstoornissen Jelgersma Leiden / Oegstgeest

Summary:
Borderline Personality Disorder (BPD) is a serious condition characterized by
unstable relationships, self-image and affects and by clear impulsivity, with a
high mortality through suicide (Skodol e.a. 2002). People with BPD experience
emotions in a very intense way and are very vulnerable. They are the ones who
often seek help with the health care system. Prevalence varies from 0.5 to 2.0%
in de general population (Van den Bosch, 2005b). In de mental health care and
care for addicts the prevalence is much higher (over 14% within psychiatric
population, and 22 % with addiction care, and even higher percentages in the
forensic psychiatry). BPD is extremely painful for the clients, for those who
love them and for the society as well. BPD is perceived as one of the
personality disorders that contribute the most to the economical burden, which
follows personality disorders (estimated at 3.6 to 7 billion euros a year:
Soeterman, Verheul, Busschbach, 2008). These costs are medical, judicial and
work related costs.
There is a lot to gain with an effective treatment of the disorder. Most
importantly reducing suicidality, self-destructive symptoms and the societal
costs comes first. Though increase of harmony in work and family life and with
that the prospects of the next generation are also important. With the
acceptation of the Guideline Personality Disorders (GPD) (Trimbos, 2008)
psychotherapy has become the first-choice treatment for people with BPD, being
intensive (2x7) and long termed, therefore expensive. Four outpatient
psychotherapeutic interventions (possibly in combination with group therapy)
are appointed to the treatment of clients with a BPD by the Guideline:
Dialectical Behavioural Therapy (DBT), Mentalisation Based Therapy (MBT),
Scheme Focused Psychotherapy (SFP), and Transference Focused Therapy (TFT).
When the focus shifts to adolescents/young adults, the situation becomes more
worrisome. Suicide is the second most common cause of death (Centraal Bureau
voor de Statistiek Voorburg, 2006; National Centre for Health Statistics,
1996). After a suicide attempt there is repetition with 31-50% of the
adolescents within 3 months (Lewinsohn e.a., 1996) and a repetition of 14%
within 6 months. Suicide attempts and auto-mutilation increase the chance for a
later suicide (Brent e.a., 1988). It is disturbing that the number of clients
who come into treatment after a suicide attempt is just 50% (Spirito e.a.,
1989; Spirito e.a., 2002). Moreover 77% of these clients cease treatment
prematurely and are also shorter in treatment that other clients whom apply for
ambulant treatment (Trautman e.a., 1993). These facts state clearly that within
this group of adolescents heightened compliance in the treatment is of vital
importance.

This document aims to be a proposal for a research into the efficacy of
inpatient DGT. Research results of standard outpatient DGT (executed within
minimal one year, without aftercare) in treating chronically impulsive and/or
self harming behaviour with adults with BPD are promising (Emmelkamp &
Kamphuis, 2007; Linehan et al., 2006; Van den Bosch 2005). However, the
recognized treatment methods take a long time and are costly, and the
population of people with the diagnosis BPD is a heterogeneous group, varying
in level of functioning and degree of severity of borderline symptoms (suicidal
and self-destructive behaviour). Which specific intervention fits whom? Which
indication is effective? How can the treatment programs be executed the most
cost-effective?
Until now there are no clear guidelines or evidence based treatment protocols
for the treatment of adolescents/young adults whom show symptoms of BPD
(impulsive self harming and suicidal behaviour). At the same time the idea of
short intensive clinical treatment in combination with long-term ambulant after
care seems to gain attention as it could lead to a decrease of symptoms (Bohus
et al., 2000, 2004; Yen et al., 2009).

Description of the study

The aim of this study is to investigate to what extent the intensive inpatient
DBT, for young adults, with a duration of maximal three months, followed by
outpatient after care, is effective compared with standard inpatient DBT in
reducing destructive and suicidal behaviours.
Design: In a randomized, controlled research design patients will be assigned
to two treatment conditions: short intensive inpatient DBT vs. outpatient DBT.
After six months a follow up measurement will be implemented in both conditions.
Randomization: Clients in both groups will be exposed to similar treatments.
Participation takes place on the basis of an informed consent. For assignment
to the experimental outpatient DBT condition the cut-off score of the BPDSI (>
24) will be used. Beside it, for the comparison of the results with standard
DBT, databases from previous DBT research (van den Bosch et.al., 2005b; Koons
et.al., 2001; Bohus, et.al., 2004) will be used.
Therapists: Therapists per condition need to meet the highest quality
requirements of good training, experience and supervision. Treatment integrity
is protected by systematic evaluation of video recorded individual -and skill
training sessions.
Time duration: Treatment takes place in the period of 01-09-2010 until
01-09-2011.
Diagnosis: The diagnosis is indicated according to the guidelines. Clinicians
on the basis of the SCID-I en SCID-II determine DSM-IV classification. The
self-destructive and suicidal behaviours are reported in two ways: with the
help of BPDSI (Borderline Personality Severity Index) and the LPC (Life Time
Para suicide Count, Lineman, 1996). The BPDSI indicates the severity of the
borderline symptomatology. The LPC is applied because previous research
(Verheul et al., 2003) showed that the LPC offers an accurate report on the
nature and frequency of the self-destructive and suicidal behaviour of the
BPDSI.
Inclusion criteria: young adults (18-28 years) showing suicidal or
self-destructive behaviour meeting a minimum of five criteria for BPS (co
morbidity is not excluded), coming from Leiden and its surroundings and a good
command of the Dutch language is required. Exclusion criteria: IQ < 80, a
chronic psychotic condition, bipolar disorder and hard drugs addiction.
Measurement moments: Three measurement moments are distinguished: week 0, week
12, week 24.
Results outcome: diaries/ self-monitoring of problematic behaviour, borderline
symptomatology (severity, para suicidal behaviour) presence at the treatment
modules, degree of the self-destructive behaviours, degree of depression,
degree of hostility, degree of impulsivity, character and appliance of coping
skills.

no risks