Barnicot Et Al. 2018 Psych Medicine Accepted Manuscript
Barnicot Et Al. 2018 Psych Medicine Accepted Manuscript
Barnicot Et Al. 2018 Psych Medicine Accepted Manuscript
personality disorder
Kirsten Barnicot,* PhD. Department of Medicine, Imperial College London. Address: Centre
for Psychiatry, Imperial College London, Commonwealth Building, Du Cane Road, London,
*
Corresponding author
Commonwealth Building, Du Cane Road, London, W12 0NN, United Kingdom. Email
Financial Support
The present study was funded by a Postdoctoral Research Fellowship awarded to KB from
1
Background. Dialectical behaviour therapy (DBT) and mentalization based therapy (MBT)
are both widely used evidence-based treatments for borderline personality disorder (BPD),
yet a head-to-head comparison of outcomes has never been conducted. The present study
therefore aimed to compare the clinical outcomes of DBT versus MBT in patients with BPD.
participants receiving DBT reported a significantly steeper decline over time in incidents of
self-harm (adjusted IRR = 0.93, 95% C.I. 0.87 to 0.99, p = 0.02) and in emotional
dysregulation (adjusted β = -1.94, 95% C.I. -3.37 to -0.51, p <0.01) than participants
receiving MBT. Differences in treatment dropout and use of crisis services were no longer
significant after adjusting for confounding, and there were no significant differences in BPD
Conclusions. Within this sample of people using specialist personality disorder treatment
were greater amongst those receiving DBT than amongst those receiving MBT. Experimental
studies assessing outcomes beyond 12 months are needed to examine whether these findings
2
Borderline Personality Disorder (BPD) is a severe mental health problem that is associated
with emotional dysregulation, extreme subjective distress, high levels of psychosocial and
work impairment, and frequent use of A&E and inpatient services linked to self -harm and
suicide attempts (Ansell et al. 2007). Dialectical behaviour therapy (DBT) and mentalization
based therapy (MBT) were developed specifically for the treatment of BPD and an emerging
evidence base for the effectiveness of each of those treatment modalities has been identified
by meta-analyses and Cochrane reviews (Stoffers et al. 2012; Cristea et al. 2016). Both
treatment models are increasingly widely available in the USA, Australasia, UK and Europe
(University College London, 2014; Behavioral Tech, 2017; Dale et al. 2017). However,
regional health localities commonly offer one or another, rather than both (Dale et al. 2017),
and local treatment commissioners have little information to guide them as to which, if either,
will be most effective for their patients. A head-to-head comparison of these two approaches
has never been conducted, and indeed, few evaluations of either approach have compared
outcomes with another specialised psychological treatment for BPD. DBT and MBT have
each arisen from different traditions within psychotherapy and accordingly take differing
approaches to the treatment of BPD, which in turn could render each differentially beneficial
for different aspects of the BPD phenotype. DBT arose out of cognitive behavioural
approaches but has been specifically tailored for BPD by incorporation of validation
strategies, mindfulness and a focus on directly improving patients’ emotion regulation skills
contrast, MBT arose out of the psychodynamic tradition, but has been specifically adapted for
coherently on the mental states of oneself and of other people - in interpersonal contexts
each approach may begin to yield insights on differential outcomes in a context that is
3
representative of everyday clinical practice. The current study therefore aimed to address the
12 months differ between patients receiving dialectical behaviour therapy and those receiving
Methods
Design
specialist personality disorder services, with treatment type determined by local service
Setting
Participants were recruited between March 2014 and September 2016 from six personality
disorder services across five NHS Trusts in London and Southampton, in the United
4
Kingdom. The treatment capacity of the participating services ranged from 6 to 20 patients at
a time. The number of staff delivering treatment at each service ranged from 4 to 7, usually
including some full and some part-time staff, and professional backgrounds included
psychiatry, clinical psychology, social work, mental health nursing and psychotherapy. Three
services provided DBT (12 month course) and three provided MBT (18 month course). All
participants took part in the study only over a 12 month period in order to render clinical
outcomes comparable between the two treatment modalities. The DBT services all provided
weekly individual therapy and group skills training, telephone skills coaching and team
consultation. The MBT services all provided weekly or fortnightly individual therapy and
weekly group therapy. They also provided a short-term group programme which involves
weekly groups delivered over a ten-week period, offering psychoeducation and support aimed
at helping clients get a better understanding of their problems and suggestions for better ways
of dealing with them. These groups serve a dual function of providing a brief intervention to
all those who attend and giving clients and staff an opportunity to consider whether longer
term group treatment may be of benefit. However, they are not part of the MBT intervention
Procedure
At the beginning of their treatment, patients were given verbal information about the study by
their DBT or MBT clinicians and asked for verbal consent to be contacted by the research
team. A researcher then met with the participant to provide written information about the
study and obtain written informed consent. After assessment of participants using the
Structured Clinical Interview for DSM-IV Axis II to confirm that they met criteria for
borderline personality disorder (First et al. 1997), baseline measures were administered.
Follow-up assessments were then conducted with participants at 3, 6, 9 and 12 months after
5
the baseline assessment. Both patients completing treatment and patients dropping out of
treatment were followed up. Participants received a £30 compensation for attending the
Baseline Measures
Personality disorder diagnosis. The Structured Clinical Interview for DSM- IV, Axis II
(SCID-II) (First et al. 1997), was used at baseline to assess participants’ DSM-IV Axis II
al. 1989) was used at baseline to determine whether participants had experienced a Criterion
participants for whom a history of Criterion A trauma was indicated, the PTSD module of the
Structured Clinical Interview for DSM-IV-TR, Axis I (SCID-I) was administered (First et al.
reliability for assessment of PTSD (Skre et al. 1991, Zanarini et al. 2000). The Mini
(Sheehan et al. 1998). This semi-structured diagnostic interview demonstrates good inter-
rater and test–retest reliability and convergent validity (Sheehan et al. 1997).
Outcome measures
treatment were classed as treatment dropouts. Services offering DBT followed a protocol
6
whereby all participants missing four or more consecutive group sessions or four or more
consecutive individual sessions were asked to discontinue treatment, whilst services offering
MBT held team discussions of cases of poor attendance and came to a consensus on whether
Crisis service use. Participants were asked to recall any Accident and Emergency (A&E) and
psychiatric hospital admissions in the 12 months prior to the baseline interview or in the 3
Deliberate self-harm. The Suicide Attempt Self Injury Interview (SASII) was used to
enumerate incidents of self-harm in the 3 and in the 12 months before beginning treatment,
and in the 3 months between each follow-up (Linehan et al. 2006a). This semi-structured
interview demonstrates good inter-rater reliability and adequate concurrent validity (Linehan
et al. 2006a). Self-harm was operationalised as “Any overt, acute, nonfatal self-injurious act
where both act and bodily harm or death are clearly intended (i.e., both the behavioral act and
the injurious outcomes are not accidental) that results in actual tissue damage, illness, or, if
BPD symptom severity. The Borderline Evaluation of Severity over Time (BEST) (Pfohl et
al. 2009), a 15-item self-report measure, was administered at baseline and at each 3-month
follow-up. Each item is answered using a Likert scale from “Not at all” or “Almost never” (1)
through to “Extremely” or “Almost always” (5). Possible scores range from 12 to 72, with
higher scores indicating more severe BPD symptoms. It demonstrates moderate test-retest
reliability, high internal consistency and high discriminant validity (Pfohl et al. 2009).
Emotional dysregulation. The Difficulties in Emotion Regulation Scale (DERS) (Gratz &
Roemer, 2004), a 36-item self-report measure, was administered at baseline and at each 3
7
month follow-up. Each item is answered using a Likert scale from “Almost never” (1) to
“Almost always” (5), and possible scores range from 36 to 180, with higher scores indicating
consistency, good test–retest reliability, and adequate construct and predictive validity (Gratz
Dissociation. The Dissociative Experiences Scale (Bernstein & Putnam, 1986), a 28-item
self-report measure, was administered at baseline and at each 3-month follow-up. Each item
is answered using a Likert scale indicating the percentage of the time that the participant
experiences it, from 0% increasing in 10% increments to 100%. The mean score is used and
thus possible scores range from 0 to 100. It demonstrates good test-retest reliability, split half
reliability, internal consistency and convergent and predictive validity (Bernstein & Putnam,
administered at baseline and at the 12-month follow-up (Pelcowitz et al. 1997; van der Kolk,
reactions to trauma, known as “disorders of extreme stress not otherwise specified”. Each
item has 4 possible responses scored from 0 to 3, with response options personalised to each
repeatedly being hurt by others and repeatedly hurting others. The internal consistency
(Cronbach’s alpha) of these 5 items was 0.68 at baseline and 0.70 at month 12.
8
Analysis
All analyses were conducted using STATA/ SE version 14.2 (StataCorp, 2015). Analyses
were conducted on an intention-to-treat basis whereby data from individuals who dropped out
of treatment was retained in the models. Where the dependent variable was self-harm,
participants with no history of self-harm in the 12 months prior to treatment were omitted
from the analysis. Linear regression was used for continuous dependent variables, logistic
regression for binary dependent variables, and negative binomial regression for overdispersed
dependent variables did not conform to a normal distribution, robust standard errors were
calculated.
It was first established whether there was any difference at the start of the study between
to drop out of treatment, on key sociodemographic and mental health variables. Variable
found to differentiate DBT and MBT patients, or treatment completers and dropouts, were
treatment completion, and on clinical outcomes at month 12, was examined, and multilevel
modelling was used to establish whether there was any difference between participants
receiving DBT versus MBT in the trajectory of change between baseline and 12 months on
any of the outcome variables. The multilevel models included a random effect to adjust for
clustering between repeated measures of variables over time within each participant. If
significant treatment effects were found in initial “basic” models, an “adjusted” model was
run, examining the simultaneous effect of the month 0 measurement of the outcome variable,
time, treatment modality, treatment completion, the interaction of time and treatment
modality, the interaction of time and treatment completion, and any other month 0 mental
9
health measures that had been shown to differ between participants receiving DBT versus
Results
Recruitment into the research and follow-up rates are summarised in Figure 1. Of 98 eligible
individuals approached to take part in the study, 90 consented (consent rate 92%). The
sociodemographic and mental health characteristics of the sample at the start of the study are
summarised in Table 1, which illustrates the high levels of self-harming behaviour, emotional
Fifty-eight participants received DBT and thirty-two received MBT. Participants receiving
DBT were more likely to have engaged in self-harm and/or to have attended A&E in the 12
months before treatment (Self-harm OR = 7.84, 95% C.I. 1.5 to 40.4, p = 0.01; A&E OR =
3.82, 95% C.I. 1.50 to 9.71, p <0.01), more frequently had comorbid post-traumatic stress
disorder (OR = 3.73, 95% C.I. 1.4 to 10.1, p = 0.01), and began treatment with significantly
higher levels of emotional dysregulation (β = 13.9, 95% C.I. 1.3 to 26.6, p = 0.03). There was
a trend for participants initiating MBT to be older than those initiating DBT (β = -5.02, 95%
C.I. -10.65 to 0.61, p <0.10). These baseline differences between participants were adjusted
10
Differences between participants completing treatment and those dropping out
dropped out of treatment before completing 12 months. Participants who went on to complete
at least 12 months of treatment were less likely to have met criteria for substance dependence
(OR = 0.36, 95% C.I. 0.14 to 0.98, p = 0.04), and reported higher levels of dissociation at the
start of treatment (β = 11.5, 95% C.I. 2.0 to 20.9, p = 0.02). There were non-statistically
significant trends towards treatment completers being more likely to be female (OR = 2.60,
95% C.I. 0.99 to 6.77, p = 0.05) and less likely than dropouts to have had a psychiatric
hospital admission in the 12 months before treatment (OR = 0.46, 95% C.I. 0.19 to 1.14, p =
0.09). These differences between participants were adjusted for in subsequent analyses of
Patients receiving DBT were significantly less likely to complete at least 12 months of
treatment than those receiving MBT (completion rate 42% versus 72%; OR = 0.28, 95% C.I.
0.11 to 0.72, p < 0.01). However, this difference was no longer significant after adjusting for
baseline differences between DBT and MBT participants, using multiple regression models in
dependence and PTSD comorbidity, and history of self-harm, A&E admission or psychiatric
hospitalisation in the 12 months before treatment were held constant (adjusted OR = 0.23,
95% C.I. 0.05 to 1.04, p = 0.06). Subsequent analyses of differential outcomes in DBT and
MBT patients adjusted for whether or not a participant had completed treatment.
11
Differences between DBT and MBT on clinical outcome measures at month 12
Clinical outcomes in DBT and MBT patients twelve months after starting treatment are
shown in Table 2. At the 12-month follow-up there were no differences between participants
receiving DBT and those receiving MBT in number of incidents of self-harm, BPD severity,
DBT were more likely to be admitted to A&E (OR = 3.65, 95% C.I. 1.25 to 10.67, p = 0.02)
and were more likely to have a psychiatric hospital admission (OR = 13.74, 95% C.I. 2.59 to
72.76, p < 0.01) in the 12-month study period than patients receiving MBT. However, after
adjusting for the potentially confounding effect of differences in treatment dropout and
baseline differences in age, gender, self-harm, A&E and hospital admission history,
Association between treatment type and trajectory of change in clinical outcomes over
time
The unadjusted associations between treatment type and the trajectory of change in clinical
outcomes over time are shown in Online Supplementary Table 1. In unadjusted models,
participants receiving DBT reported a significantly steeper decline over time in incidents of
self-harm (IRR = 0.94, 95% C.I. 0.89 to 0.99, p < 0.01; Figure 2) and in emotional
dysregulation (β = -1.42, 95% C.I. -2.71 to -0.13, p = 0.03; Figure 2) than participants
receiving MBT. These differences remained significant in the final models which were
adjusted for treatment dropout and for other potentially confounding differences between
12
participants (Table 3). There was no difference between participants receiving DBT or MBT
Discussion
Summary of Findings
that different psychotherapy models tend to achieve equivalent results,27 and indeed a trial
comparing the effects of DBT to another specialised model for BPD, transference-focussed
psychotherapy, also found outcomes were largely equivalent.28 However, despite the
were still exhibiting high levels of emotional dysregulation, dissociation, and interpersonal
dysfunction.
treatment. However, this difference in treatment completion rates was no longer significant
after taking account of differences between participants initiating DBT and those initiating
MBT, such as the higher baseline levels of emotional dysregulation and greater likelihood of
recent self-harm in the DBT participants. Thus, the more severe mental health difficulties of
programmes are likely to have contributed to the higher treatment dropout rate amongst the
DBT participants. Whilst treatment completion rates were substantially higher in US trials of
DBT conducted by the treatment developer (e.g. 81%, Linehan et al. 1991; 83%, Linehan et
13
al. 2006), completion rates in US trials in routine community services tend to be lower,
ranging from 76% to 48% (Landes et al. 2016), and other UK DBT evaluations have also
found low completion rates (e.g. 36%, Zinkler et al. 2007; 42%, Feigenbaum et al. 2012;
48%, Priebe et al. 2012). The considerably higher treatment completion rate of 72% amongst
MBT participants is consistent with the high completion in MBT trials conducted by the
treatment developer (88%, Bateman & Fonagy, 1999; 73%, Bateman & Fonagy, 2009).
Despite their higher treatment dropout rate, DBT participants reported a significantly steeper
decline over time in incidents of self-harm and in emotional dysregulation. This remained
significant after adjusting for treatment dropout, baseline levels of self-harm and emotional
dysregulation – suggesting that this difference was not just an artefact of the greater level of
baseline mental health difficulties amongst DBT patients. A further difference was that just
over half of DBT patients attended A&E and a quarter experienced psychiatric hospitalisation
during the study year – a substantially higher rate of crisis service use than the equivalent
figures of 22% and 4% in MBT patients. Similarly, 43% of DBT patients attended A&E in
the treatment developer’s largest trial, and 20% experienced psychiatric hospitalisation
(Linehan et al., 2006). However, DBT participants were more likely to have had high
baseline levels of emotional dysregulation, a recent history of A&E, and to drop out of
treatment - and after adjusting for these factors, differences in crisis service use between DBT
and MBT were no longer significant. Thus, the findings do not suggest that DBT per se is
less effective than MBT at reducing use of crisis services – but do highlight the more chaotic
presentation of patients initiating DBT programmes than those initiating MBT programmes in
our sample, and the problematic link between dropping out of treatment and poor clinical
outcomes.
14
Implications for Research and Service Provision
Whereas DBT focusses on reducing self-harm as the primary treatment goal, and explicitly
teaches emotion regulation skills (Linehan, 1993a; Linehan, 1993b), MBT aims to achieve
these goals more indirectly, through the promotion of mentalizing (Bateman & Fonagy,
2006). This may explain the more rapid change in these outcomes in DBT patients. Relatedly,
patients’ use of the skills taught in DBT has been shown to mediate reductions in self-
harming behaviour (Neacsiu et al. 2010, Barnicot et al. 2016). Could DBT’s explicit focus on
targeting self-harm reduction and improving emotion regulation skills render it a more
rapidly acting treatment for these difficulties? A large randomised controlled trial of DBT
versus MBT is required to address this question. Such a trial should also evaluate potential
Given the association between treatment dropout and poor outcomes amongst people with
personality disorders (McMurran et al. 2010; Priebe et al. 2012), preventing dropout could
potentially improve outcomes. Yet no research to date has evaluated methods for improving
completion rates when evidence-based psychological treatments for personality disorder are
implemented in routine clinical practice. Previous research has identified that poor
therapeutic alliance is one factor consistently predicting treatment dropout in patients with a
personality disorder (Barnicot et al. 2011), suggesting that patients’ inherent difficulties with
trust and conflict resolution in attachment relationships may contribute. Another contributing
factor could be that in the participating MBT services, only patients who attend the 10-week
group programme, indicate their interest in further group-based treatment, and are judged by
staff to have the potential to benefit from this approach are able to begin the full MBT
programme. Thus, MBT patients were already selected as individuals with both the practical
and emotional capability to sustain the commitment of attending treatment, whereas the DBT
participants were a less selected group of individuals who may have varied more widely in
15
their capabilities to commit. A recent audit at one of the participating MBT services found
that over a 20-month period, 44 people initiated the 10-week group programme, of which 15
(34%) went on to initiate the full 18-month MBT programme. Whilst this figure does not
represent dropout from the 10-week programme per se as some individuals will have
completed the 10-week programme but chosen not to continue to the MBT programme, it
does nonetheless suggest that incorporation of numbers discontinuing during the 10-week
programme would make dropout rates from MBT more similar to those from DBT. However,
individuals attending the 10-week programme did not take part in the present research project
for both conceptual and practical reasons – namely, that the 10-week programme is a separate
intervention in its own right and is not a part of the manualised MBT programme (Bateman &
Fonagy 2006), and also that the lengthy follow-up time required to follow participants up
from the point of initiating the 10-week programme was not feasible within the scope of the
present project and would make comparison with a 12-month DBT programme more
challenging. Future research could investigate whether a similar brief pre-DBT group
programme would improve treatment completion rates amongst patients referred to DBT.
However, if only patients who successfully complete a brief pre-therapy programme are
allowed to begin treatment, would this further limit patients’ access to evidence-based
treatments for personality disorder, which are already difficult to access in many localities
and non-existent in others (Dale et al. 2017)? What alternative treatment will be offered to
Strengths of the present research included the high consent and follow-up rates and
world setting, increasing the ecological validity of the findings. Furthermore, the use of
multi-level modelling to evaluate changes over time allowed use of a relatively large amount
16
of repeated measures data (up to n = 395 datapoints from 90 individuals), increasing the
study’s power to detect differences in outcome trajectory, and allowed the inclusion of
individuals with data missing at some timepoints, which should reduce bias in the model
The major limitation was that allocation to treatment was not randomised. While efforts were
made to control for confounding, it is possible that other unmeasured differences between
study groups exist and these may have been responsible for differences in clinical outcomes.
It is unclear how generalisable data from this study are to services beyond those participating,
and it is possible that apparent differences in outcomes between MBT and DBT are due to the
long-term condition and it is possible that clinical outcomes of patients receiving MBT and
DBT in this study diverged further or converged after completion of the 12-month follow-up.
A further limitation was that it was not possible to evaluate inter-rater reliability for the
SCID, MINI or SAS-II interviews. Finally, we did not assess treatment fidelity in this study
and it is possible that differences in clinical outcomes seen between these DBT and MBT
services reflects differences in the quality of the treatment delivered, rather than to
Conclusion
Patients with borderline personality disorder receiving DBT or MBT in routine community
dissociation and interpersonal relationships. There may be differences in the extent and speed
of reductions in self harm and emotional dysregulation among those offered DBT and MBT,
17
outcomes are needed to fully examine potential differences in the clinical and cost
Acknowledgments
The authors gratefully acknowledge the vital contribution of clinicians and patients from
participating clinical services, and in particular thank Laura Couldrey, Jeantique Hommel and
Conflict of Interest
Ethical Standards The authors assert that all procedures contributing to this work comply
with the ethical standards of the relevant national and institutional committees on human
experimentation and with the Helsinki Declaration of 1975, as revised in 2008. Ethical
approval for the study was granted by the United Kingdom National Health Service National
Research Ethics Service Committee South East Coast – Surrey on 06/02/2014, reference
number 14/LO/0158, and by the Research and Development departments of the participating
NHS Trusts. All participants gave written informed consent for participation.
18
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Figure 1. Participant recruitment and follow-up
N = 3 ineligible to participate
N = 90 patients were eligible
for inclusion and agreed to
participate in the research
Follow-up
25
Table 1. Participant sociodemographics and mental health characteristics at the start of treatment
26
BPD Emotional Alterations Dissociatio Average Number of Number of
severity dysregulation in n (DES) at number of patients patients
(BEST) at (DERS) at relationship month 12 incidents of attending with at
month 12 month 12 s with (N = 77) self-harm A&E least 1
(N = 78) (N = 75) others in months between inpatient
(SIDES) at 10 to 12 months psychiatric
month 12 Median 1 & 12 admission
(N = 68) (IQR) (N = 72) between
(N = 68) a months
1 & 12
(N = 72)
DBT 35.0(11.5) 103.1(33.5) 5.5(3.6) 30.6(23.4) 2 (0-45) 24(51%) 12 (26%)
MBT 35.8(11.6) 108.7(29.4) 5.3(2.9) 26.6(18.9) 12.5 (0 – 6 (22%)*b 1 (4%) **b
Table 2. Clinical outcomes at month 12 90)
a
Includes only participants who had a history of self-harm in the 12 months prior to treatment
(N = 81) and provided sufficient data at month 12 to be included in the analysis.
*
p < 0.05; ** p < 0.01
b
These differences between DBT and MBT recipients were no longer significant after
adjusting for treatment dropout and baseline differences in age, gender, self-harm, A&E and
hospital admission history, emotional dysregulation, dissociation, PTSD and substance
dependence: p > 0.05
27
Table 3. Adjusted associations between treatment type and trajectory of change in self-harm and emotional
dysregulation
28
Table 4. Adjusted associations between treatment type and trajectory of change in self-harm and emotional dysregulation
29
Figure 2. Change in incidents of self-harm and emotional dysregulation over time
45 140
40
35 130
30
25 120
20 110
15
10 100
5
0 90
0 3 6 9 12 0 3 6 9 12
Months after starting treatment (intention to treat
Months after starting treatment (intention to treat
sample)
sample)
Median number of incidents of self-harm per 3 months Mean emotional dysregulation (DERS)
30