(A paper on the BOSCOT Trials--A form of CBT, Dialectical Behavior Therapy vs. Treatment as Usual) Includes Abstract AbstractThis is the outcome of a study in which 106 participants who met the diagnostic criteria for Borderline Personality Disorder, or BPD, were randomized into two groups. The first group, or the control group, received treatment as usual (TAU). The second group received treatment as usual along with a form of cognitive behavioral therapy known as dialectical behavioral therapy. The study was conducted over the course of two years; the first year was for treatment and the second year for follow-up. The primary research hypothesis was that the cognitive behavioral therapy group would have a decreased amount of suicidal acts, which proved to be true. Also that this group would have less accident and emergency room visits. This could not be proven. The secondary research hypothesis was that the overall quality of life would be improved for these patients and this was true for some aspects such as changing dysfunctional core beliefs and state anxiety, yet no improvement was gained in overall depression.IntroductionBorderline Personality Disorder, or BPD, is a serious mental illness, which affects up to 2% of Americans over the age of 18 (NIMH, 2008). It is characterized by pervasive instability in moods, interpersonal relationships, self-image and behavior. Those who are diagnosed with borderline personality disorder, mostly young women, suffer from intense bouts of anger, depression, and anxiety. These symptoms may last for hours, or at most, a full day. Patients with borderline personality disorder view themselves as fundamentally bad, or unworthy. These distortions in cognitive processes and self awareness can lead to drastic changes in values, belief systems, careers, friends, gender identity, and long term goals. In some cases, these maladaptive thoughts can lead to other disorders such as; substance abuse, self-injury, and in severe cases, suicide (NIMH, 2008).Borderline personality disorder is placed by the DSM-IV-TR in the cluster of "dramatic" personality disorders (Comer, 2008). This is a disorder of emotion regulation. Borderline personality disorder patients often need long-term mental health inpatient services, and this disorder alone account for 20% of all psychiatric hospitalizations (Davidson, et al, 2006).Treatment for borderline personality disorder can be difficult. Intense psychotherapy appears to have some degree of effectiveness, but it can be difficult for the therapist to find a balance in the relationship. Constantly dealing with outbursts of anger and fluctuating emotional states, while attempting to build a trusting, working relationship, can make therapy extremely difficult (Comer, 2008). Borderline patients are known to often violate therapeutic boundaries, such as calling the emergency number for non-emergency situations, just for the attention (Comer, 2008).With less than 2% of the population using 20% of the psychiatric services, through no fault of their own. How can these people be helped? The answer seems to lie in Cognitive Behavioral Therapy, or CBT, a psychotherapeutic approach that aims to influence problematic and dysfunctional emotions, behaviors and thoughts, through goal-oriented, systematic procedures. This is a direct, collaborative, and problem-focused therapy which concentrates on the "here and now," as well as symptom removal (NIMH, 2008).A form of cognitive behavioral therapy that, according to M. Linehan (1991), has been especially helpful with the treatment of borderline personality disorder is called dialectical behavioral therapy, or DBT. This approach is an action oriented, collaborative approach which teaches clients to explore, identify, analyze, and change dysfunctional patterns of thinking, feeling, and acting (Dewan, et al, 2004). This approach is considered a form of "brief therapy", meaning it can be accomplished in a very short time frame, as opposed to long-term psychotherapy.Borderline personality disorder patients are not easy populations with which to work, and do not always respond well to treatment. This form of cognitive behavioral therapy, dialectical behavioral therapy, when added to treatment as usual, may be extremely helpful to these patients, thus improving their self awareness, by enhancing their sense of self and thereby reducing acts of deliberate self-harm and suicide attempts.MethodBetween 2002 and 2005, 106 participants who had been previously diagnosed with borderline personality disorder, according to Axis II of the DSM-IV-TR, "were randomized to two treatment conditions, either treatment as usual alone (TAU), or cognitive behavioral therapy, in addition to treatment as usual (CBT plus TAU) (Davidson, et al, 2006). The type of cognitive behavioral therapy received was described in the introduction to this paper. It is known as dialectical behavioral therapy. Treatment as usual (TAU) included general practitioner care; contact with mental health services, including psychiatric nurses, across three various sites, depending upon residential areas. The authors found "reasonable consistency across sites," (Davidson, et al, 2006).The authors' primary hypothesis was directional (Smith & Davis, 2007), stating that a combination of cognitive behavioral therapy plus treatment as usual would "decrease the number of psychiatric in-patient hospitalizations, accident and emergency room contacts, or suicidal acts over twelve months treatment and twelve months follow-up" (Davidson, et al, 2006). The secondary hypothesis was that cognitive behavioral therapy plus treatment as usual would lead to superior improvement in social, cognitive, and mental health functioning as compared to treatment as usual alone. This is also a causal hypothesis in that the independent variable (dialectical behavioral therapy) causes the suicidal actions to decrease and self-awareness to increase (Davidson, et al, 2006). .ResultsOut of the 106 patients originally recruited, follow-up data was obtained for 102. Over the course of the treatment, all participants attended an average of 16 sessions. Therapist competence was assessed using the Cognitive Therapy Rating Scale.For the primary hypothesis, there was no significant difference for cognitive behavioral therapy plus treatment as usual as compared to just treatment as usual alone for both the occurrence and the number of events for both in-patient psychiatric hospitalization and accident and emergency room contacts. However, the researchers were not given access to the reasons for the emergency room contacts and they may not have been the result of the borderline diagnosis. There was a significant reduction over the two-year period in the mean number of suicidal acts in favor of cognitive behavioral therapy plus treatment as usual, with a mean difference of -0.91(95% CI -1.67 to -0.15, p=0.020) (Davidson, et al, 2004). With this in mind, dialectical behavioral therapy has the ability to save lives.The results of the secondary hypothesis showed some significant differences in the CBT plus TAU over treatment as usual alone at one year using the Brief Symptom Inventory positive symptom distress index and, at two-year follow-up, on dysfunctional core beliefs and state anxiety (Davidson, et al, 2006). However, no significant difference was noted in levels of depression in the two groups over the two-year period.StrengthsSome of the strengths of this experiment were in the therapist training, the randomization process for the group selection, and the fact that it was a single-blind study. Although no one therapist would consider him/herself an expert in cognitive behavioral therapy, all of the therapist who treated patients in this fashion were considered very competent, (with the exception of one therapist who only treated one patient with one session) (Davidson, et al, 2006) Both participant groups were randomized so that every participant had an equal chance of being in either group. Also, this was a single blind experiment, and any "experimenter expectancies cannot influence the participants responses"(Smith & Davis, 2007).LimitationsThe limitations of this study included that some patients were difficult to engage. This aspect of therapy can be common with borderline personality disorder (Comer, 2008). The study shows that some of the patients simply did not attend the CBT sessions regularly. This pattern seems to be consistent with attendance that is often found in mental health clinics in the National Health Service (UK) (NHS), with some patients never attending, some attending chaotically, and around half attending regularly. (Davidson, et al, 2006). Another limitation noted was that "there was no attempt to screen out those who might be unsuitable" (Davidson, et al, 2006).DiscussionThe interpretation of this research is consistent with the results. The authors anticipated that the cognitive behavioral therapy plus treatment as usual (CBT plus TAU) patients would decrease their suicidal acts after a 12-month treatment period and a 12-month follow up. This is exactly what they found.A similar study by Marsha Linehan, et al (2006), shows similar, if not slightly better, results. According to these and previous studies, "CBT (or more exactly dialectical behavioral therapy) appears to be uniquely effective in reducing suicide attempts" (Linehan, et al, 2006).In this author's opinion, this was a highly ethical study. No deception was used, participant safety was thoroughly taken into account, and no coercion existed. The participants and the therapists agreed that the treatment was worthwhile in the cognitive behavioral therapy plus treatment as usual group. However, the participants generally had a higher approval rating than the therapists.This was an actively controlled, interventional, two-armed study. The experimental arm was the cognitive behavioral therapy plus the treatment as usual group and the active comparator was the control group, which received treatment as usual.Validity was established by the measurement of the suicidal acts or more importantly, the lack thereof, of the participants (Smith & Davis, 2007). The measurably significant decrease of these acts by the cognitive behavioral therapy group is consistent with the authors' hypothesis.It is the opinion of this author that this experiment is internally valid. The independent variable, cognitive behavioral therapy, is directly responsible for the decrease in suicidal acts. This established a direct cause and effect relationship (Smith & Davis, 2007). The secondary hypothesis was not so clear; yet it is apparent that the cognitive behavioral therapy group had a significant reduction in dysfunctional beliefs, state anxiety, and psychiatric symptom distress.This experiment is also reliable. The treatment period lasted for one year, as did the follow-up period. The measurement of suicidal acts consisted of a self-report by the patient and was backed up by hospital records.Other studies, also randomized, controlled trials that investigated the effectiveness of dialectical behavioral therapy, had similar outcomes (Turner, 2000; Verheul, et al, 2003). However, one of these studies (Verheul, et al, 2003) had a 37% mortality rate. Only 4 out of 106 people dropped out of this study, all at the beginning, because they failed to provide proper follow-up contact information. The authors of this study feel that the patients who received the cognitive behavioral therapy plus treatment as usual were given only the bare minimum amount of dialectical behavioral therapy required to produce benefits, but this is merely opinion (Davidson, et al, 2006).ConclusionBorderline personality disorder patients are not easy populations with which to work, and do not always respond well to treatment. This form of cognitive behavioral therapy, dialectical behavioral therapy, when added to treatment as usual, may be extremely helpful to these patients, by enhancing their sense of self and thereby reducing acts of deliberate self-harm and suicide attempts.Usually, long-term follow-up of patients with borderline personality disorder show improvement over time, but this improvement is never dramatic (Zanarini, et al, 2005). Although the participants in this study clearly improved over the course of two years, they still experienced high levels of dysfunction.This study shows that cognitive behavioral therapy, when added to treatment as usual, can contribute to the reduction of the volume of suicidal acts and overall improvement in some areas of life. The authors of this study asked if CBT could provide beneficial results in clinical settings, and found that good improvement can be achieved without placement into long-term inpatient psychiatric hospitals. Out patient therapists can receive training in CBT for personality disorders rather easily, with enough supervision and support (Davidson, et al, 2006). This can save time, money, and ultimately, lives. So, with all things considered, cognitive behavioral therapy is a necessary addition to treatment as usual for borderline patients. For now, it is the best hope to allow this population the ability to avoid lengthy psychiatric hospital stays and to deal with maladaptive thoughts and behaviors.ReferencesComer, Ronald J. (2008). Fundamentals of abnormal psychology. (5th Edition). New York; Worth.Davidson, Kate, Norrie, John, Tyrer, Peter, Gumley, Andrew, et al (2006). The effectiveness of cognitive behavior therapy for borderline personality disorder: Results from the borderline personality disorder study of cognitive therapy (BOSCOT) trial. Journal of Psychiatric Disorders. New York: Oct. 2006. 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Naturalistic evaluation of dialectical behavior therapy-oriented treatment for borderline personality disorder. Cognitive and Behavioral Practice, 7, 413-419.Verheul, R, Vanden Bosch, L.M.C., Koeter, W.J., DeRidder, M.A., Stijnen, T., & Vanden Brink, W. (2003). Dialectical behavior therapy with women with borderline personality disorder. 12 month randomized clinical trials in the Netherlands. British Journal of Psychiatry, 182, 135-140.Zanarini, M. C., Frankenberg, F. R., Hennen, J., Reich, B., & Silk, K.R. (2005). Psychosocial functioning of borderline patients and Axis II comparison subjects followed prospectively for six years. Journal of Personality
