Treatment of shame in borderline personality disorder

Thesis (Ph. D.)--University of Washington, 2004Research on the emotion of shame has increased dramatically in recent years. Shame has been found to be associated with suicidal behavior, interpersonal difficulties, deficits in problem solving, and problems with other negative affect such as anger and depression. However, despite empirical evidence that the experience of shame is linked to psychopathology, a focus on shame has been largely absent in clinical approaches. Nowhere is this more apparent than in the field of borderline personality disorder (BPD), a disorder proposed to be associated with the presence of intense and chronic levels of shame. This study sought to develop and test a short-term intervention for shame in BPD, using the skill of "Opposite Action," from Dialectical Behavior Therapy. This skill was expanded upon and developed into a 8--10 week intervention during which clients were exposed to cues that evoked shame, maladaptive responses were blocked, and adaptive, opposite responses were elicited and strengthened. A pilot case was used to further refine the treatment manual and consequently, five clients were treated with the intervention using a single-subject, multiple baseline design. There were several noteworthy results. First, repeated measurement led to the finding that state ratings of shame are highly variable, independent of any treatment effect. Second, within-session changes in shame indicate that it is possible to reduce shame about a specific event over a short period of time using the technique of opposite action. A shame checklist that was created for this study verified this finding. Scores on the checklist showed a significant reduction in shame intensity by the end of treatment, suggesting that this intervention was successful at reducing shame about specific events that was not necessarily accounted for in the weekly, unstable ratings. Finally, the method for developing the treatment manual was successful in that it produced a short-term intervention, based on empirical principles of behavior change, that was highly acceptable to participants. There were no dropouts during the intervention and rates of overall compliance were extremely high. These findings have several implications for the treatment of shame in BPD and other clinical populations

The Case of "Sonia" Through the Lens of Dialectical Behavior Therapy

Scherb (2014) describes the case of Sonia, a 44-year-old woman with severe and complex presentation of borderline personality disorder, along with diagnoses of bipolar disorder, trichotillomania, borderline intellectual functioning, and obesity. At the end of 10 years of therapy with decreasing frequency, Sonia has made a dramatic recovery from almost all of her presenting symptoms. Scherb's therapeutic approach was based on Fernández-Álvarez's Integrative Psychotherapy Model, which incorporates behavioral, cognitive, and emotional components. In this commentary we look at Sonia's psychopathology and treatment through the lens of Dialectical Behavior Therapy, a highly developed treatment model that has shown impressive success in treating individuals with borderline personality disorder and that also combines behavioral, cognitive, and emotional components. A comparison of a DBT approach to Sonia's case with the approach Scherb actually employed reveals many similarities in proposed treatment strategies, as well as differences in the format and delivery of treatment.

Randomized Trial of Behavioral Activation, Cognitive Therapy, and Antidepressant Medication in the Prevention of Relapse and Recurrence in Major Depression

This study followed treatment responders from a randomized controlled trial of adults with major depression. Patients treated with medication but withdrawn onto pill-placebo had more relapse through one year of follow-up, compared to patients who received prior behavioral activation, prior cognitive therapy, or continued medication. Prior psychotherapy was also superior to medication withdrawal in the prevention of recurrence across the second year of follow-up. Specific comparisons indicated that patients previously exposed to cognitive therapy were significantly less likely to relapse following treatment termination than patients withdrawn from medication, and patients previously exposed to behavioral activation did almost as well relative to medication withdrawal at the level of a nonsignificant trend. Differences between behavioral activation and cognitive therapy were small in magnitude and not significantly different across the full two-year follow-up, and each was at least as efficacious as continuation medication. These findings suggest that behavioral activation may be nearly as enduring as cognitive therapy, and that both psychotherapies are less expensive and longer-lasting alternatives to medication in the treatment of depression

Ethical and methodological challenges slowing progress in primary care-based suicide prevention: Illustrations from a randomized controlled trial and guidance for future research.

IntroductionDespite the pressing need for primary care-based suicide prevention initiatives and growing acknowledgement of recruitment difficulties and Institutional Review Board (IRB) challenges in suicide research, we are aware of no illustrative examples describing how IRB decisions in the design of a primary care trial can compound recruitment challenges.MethodsThe CDC-funded trial (NCT02986113) of Men and Providers Preventing Suicide aimed to examine the effects of a tailored computer program encourage men with suicidal thoughts (n = 304, ages 35-64) to discuss suicide with a primary care clinician and accept treatment. Before a visit, participants viewed MAPS or a non-tailored control video. Post-visit, both arms were offered telephone collaborative care, as mandated by the institutional review board (IRB). We previously showed that exposure to MAPs led to improvements in communication about suicide in a primary care visit. In this paper, we report data on the study's primary outcome, suicide preparatory behaviors.ResultsAfter screening nearly 4100 men, 48 enrolled. Recruitment challenges, which were exacerabted by an IRB mandate narrowing post-intervention patient management differences between trial arms, limited detection of the effects of MAPS on suicide preparatory behaviors.ConclusionsWhile primary care settings are key sites for suicide prevention trials, issues such as recruitment difficulties and overly restrictive IRB requirements may limit their utility. Methodological innovation to improve recruitment and ethical guidance to inform IRB decision-making are needed