A feasibility randomised controlled trial with an embedded qualitative evaluation of perinatal emotional skills groups for women with borderline personality disorder : protocol for the EASE study

Background Borderline personality disorder (BPD) is a severe mental disorder characterised by emotional instability, impaired interpersonal functioning and an increased risk of suicide. There is no clear evidence about how best to help women with BPD during the perinatal period. Perinatal Emotional Skills Groups (ESGs) consist of 12 group sessions, focussing on core skills in emotion regulation, interpersonal effectiveness, distress tolerance and mindfulness and how these skills can best be utilised during the perinatal period. Prior observational research has shown that perinatal ESGs may help women with BPD. We set out to test the feasibility of conducting a randomised controlled trial to investigate the clinical effectiveness of perinatal ESGs. Methods A two-arm, parallel-group, feasibility randomised controlled trial of Perinatal ESGs in addition to Treatment as Usual (TAU) versus TAU for women aged over 18 years, who are likely to have a diagnosis of BPD and are either pregnant or are within 12 months of having a live birth. We will exclude women who have a co-existing organic, psychotic mental disorder or substance use dependence syndrome; those with cognitive or language difficulties that would preclude them from consenting or participating in study procedures; those judged to pose an acute risk to their baby and those requiring admission to a mother and baby unit. After consenting to participation and completing screening assessments, eligible individuals will be randomly allocated, on a 1:1 ratio, to either ESGs + TAU or to TAU. Randomisation will be stratified according to recruitment centre. Feasibility outcomes will be the proportion of participants: (1) consenting; (2) completing baseline measures and randomised; (3) completing the intervention and (4) completing follow-up assessments. All study participants will complete a battery of self-report measures at 2 and 4 months post-randomisation. A nested qualitative study will examine participants’ and therapists’ experiences of the trial and the intervention. Discussion Evidence is lacking about how to help women with BPD during the perinatal period. Perinatal ESGs are a promising intervention and if they prove to be an effective adjunct to usual care, a large population of vulnerable women and their children could experience substantial health gains. Trial registration ISRCTN80470632

Personality Disorder Diagnoses in ICD-11: Transforming Conceptualisations and Practice

[Background] Until the advent of the ICD-11, classification of personality disorders was based on categorical prototypes with a long history. These prototypes, whilst familiar, were not based in the science of personality. Prototypical classifications were also complex to administer in non-specialist settings requiring knowledge of many signs and symptoms. [Method] This article introduces the new structure of ICD-11 for personality disorders, describing the different severity levels and trait domain specifiers. Case studies illustrate the main aspects of the classification. [Results] The new ICD-11 system acknowledges the fundamentally dimensional nature of personality and its disturbances whilst requiring clinicians to make categorical decisions on the presence or absence of personality disorder and severity (mild, moderate or severe). The connection between normal personality functioning and personality disorder is established by identifying five trait domain specifiers to describe the pattern of a person’s personality disturbance (negative affectivity, detachment, dissociality, disinhibition, and anankastia) that connect to the Big 5 personality traits established in the broader study of personality. [Conclusions] Whilst new assessment measures have been and are in development, the success of the new system will rely on clinicians and researchers embracing the new system to conceptualise and describe personality disturbances and to utilise the classification in the investigation of treatment outcome

Reducing suicidal behaviour in people with complex needs: Addressing the challenge of implementing dialectical behaviour therapy

Dialektisk atferdsterapi (DBT) er en evidensbasert psykoterapimetode som opprinnelig ble utviklet som en behandling for mennesker med emosjonelt ustabil personlighetsforstyrrelse med særlig fokus på selvmords- og selvskadingsatferd. Denne artikkelen beskriver hvordan DBT spesifikt behandler både vedvarende risikofaktorer som bidrar til selvmords- og selvskadingsatferd, og akutte selvmordskriser når de oppstår. Til tross for at Dialektisk atferdsterapi har betydelig effekt i behandlingen av selvmords- og selvskadeatferd, byr DBT på noen utfordringer for implementering i daglig klinisk praksis. Artikkelen diskuterer disse utfordringene og hvordan de kan løses.Dialectical Behaviour Therapy (DBT) is an evidence-based psychological therapy, originally developed for the treatment of people with a diagnosis of borderline personality disorder, that specifically focuses on the treatment of suicidal and self-harm behaviours. This paper describes how DBT, uniquely, both treats long-standing factors contributing to suicidal and self-harm behaviour as well as providing an explicit protocol for treating suicidal crises when they arrive. Despite its success in treating suicidal and self-harm behaviours DBT presents some challenges to implementation in routine practice. The paper concludes by outlining these difficulties and how to solve them

Psychological processes of change in adolescents in a residential treatment setting.

Recent evidence indicates that the proportion of young people developing significant psychosocial problems is increasing (Rutter, 1995). This thesis focuses upon a small percentage of the growing number of adolescents who experience significant psychopathology; adolescents admitted to a regional inpatient psychiatric unit. Chapter 1 provides the theoretical background to the thesis; reviewing the literature on both the methodology and outcome of studies conducted with adolescents in inpatient adolescent psychiatric services. It suggests that future investigations take account of the practical impossibility of conducting high quality, standard double-blind control trials in such settings and outlines four empirical alternatives to such designs; evaluation of components of the therapy employed in residential settings; the use of problem-oriented case records; prediction of outcome across time; investigating the reasons for the effectiveness of established predictors of outcome. The next four chapters describe a series of studies utilising the last three of these suggested approaches in a cohort of adolescents admitted to a regional psychiatric unit. Chapter 2 is a cross-sectional study describing the sample upon which the remainder of the thesis is based. It focuses principally upon describing the psychopathology of the adolescents from three perspectives; that of the adolescent, their parents and the therapeutic team. It examines the interrelationships between mood, behaviour and family functioning. Chapter 3 describes the results of an investigation into the relationships between selfesteem, autobiographical memory, attributional style, social problem-solving and the experience of depression and hopelessness. Chapter 4 examines the clinical effectiveness of the treatment at the unit as assessed by problem severity as rated by adolescents and their parents and standardised measures of mood and self-esteem. Chapter 5 examines to what extent outcome can be predicted on the basis of initial problem severity, mood and cognitive style (autobiographical memory, attributional stye, problem-solving and selfesteem). Each chapter is written as a separate paper with abstract, literature review, method, results and discussion; however, reference to the overall findings is made throughout for ease of reading. The final chapter draws together themes from the whole thesis and discusses the psychological processes which mediate change during the adolescent treatment programme described here. It concludes that the cognitive and meta-cognitive processes which mediate change are best understood as related to internal working models derived from attachment experiences. A model for understanding individual variation in these processes is outlined and strategies for testing the proposed model are advanced

The survivability of dialectical behaviour therapy programmes: a mixed methods analysis of barriers and facilitators to implementation within UK healthcare settings

Abstract Background Dialectical Behaviour Therapy (DBT) is an evidence-based intervention that has been included in the National Institute of Health and Care Excellence guidelines as a recommended treatment for Borderline Personality Disorder in the UK. However, implementing and sustaining evidence-based treatments in routine practice can be difficult to achieve. This study compared the survival of early and late adopters of DBT as well as teams trained via different training modes (on-site versus off-site), and explored factors that aided or hindered implementation of DBT into routine healthcare settings. Methods A mixed-method approach was used. Kaplan-Meier survival analyses were conducted to quantify and compare survivability as a measure of sustainability between early and late implementers and those trained on- and off-site. An online questionnaire based on the Consolidated Framework for Implementation Research was used to explore barriers and facilitators in implementation. A quantitative content analysis of survey responses was carried out. Results Early implementers were significantly less likely to survive than late implementers, although, the effect size was small. DBT teams trained off-site were significantly more likely to survive. The effect size for this difference was large.  An unequal amount of censored data between groups in both analyses means that findings should be considered tentative. Practitioner turnover and financing were the most frequently cited barriers to implementation. Individual characteristics of practitioners and quality of the evidence base were the most commonly reported facilitators to implementation. Conclusions A number of common barriers and facilitators to successful implementation of DBT were found among DBT programmes. Location of DBT training may mediate programme survival