Metacognitive therapy for borderline personality disorder: An open trial Hans M. Nordahl, Professor, Department of Psychology, Norwegian University of Science and Technology, N-7491 Trondheim, Norway, E-mail: [email protected] The author describes metacognitive approach (MCT; Wells, 2008) in treating borderline personality disorder for patients with moderate to severe. According to MCT there are three problem domains that must be primarily targeted in treatment. First, the patient's perception of deprivation, abandonment and control in interpersonal settings. Second, the self-regulatory deficits creating emotional and behavioural instability with poor impulse control. Third the maladaptive coping styles in form of self-harming behaviours, withdrawal/attacking behaviour and sustained worry and rumination related to control and abandonment. The author presents four cases with borderline personality disorder using MCT and the treatment format is relatively brief—using only 24 sessions, integrating psychiatric nurses from the community health services early in the treatment. After the initial treatment phase the psychiatric nurse at the community health services followed up the patient on a monthly basis. This case study report evaluated the efficacy of MCT on the targeted problem domains, and relapse for these two cases. MCT seems to be easily adapted to patients with BPD. Three months after treatment, the patients were showing far better emotional regulation and stress management, lower level of maladaptive coping behaviours and maintaining better social relationships. However, it is too early to report on the long-term effects. Suggestions for further research will be made.
Cognitive–behavioural therapy of insomnia Fred Holsten, Prof.dr.med., Institute for Clinical Medicine, Section of Psychiatry, Haukeland University Hospital, University of Bergen, N-5021 HUS, Norway, E-mail: [email protected] Approximately 10% of the population complains of chronic insomnia and up to 95% of psychiatric patients have sleep complaints. Especially in patients with affective disorders insomnia confers a risk of exacerbation of depression and other affective symptoms. Psychophysiological insomnia is the most frequently presenting form of persistent primary insomnia, behavioural profile comprising elements of conditioned arousal, preoccupation of sleep and poor sleep habits. Key elements of cognitive–behavioural therapy of insomnia comprises psychoeducation of the patient concerning the main factors governing sleep: circadian rhythms, the homeostatic factor and behavioural aspects, use of cognitive techniques on conditioned arousal, preoccupation of sleep and poor sleep habits, and use of sleep restriction to heighten the homeostatic drive for sleep. Numerous studies indicate that non-pharmacological interventions produce reliable and durable changes in the sleep patterns of patients with chronic insomnia. CBT is best documented, and is shown to work just as well as pharmacotherapy in the short run, and the effect is shown to persist in studies up to 24 months.
The classification and understanding of eating disorders—Advances and challenges Jan H. Rosenvinge, Professor, Department of Psychology, University of Tromsø, Norway, E-mail: [email protected] Ever since the appearance of the DSM-III over 25 years ago, suggestions have been put forward in terms of minor criteria revisions. In recent years, however, the critique has also been focusing on the structure and basic ideas of classification per se. Indeed the current classification runs into many problems, e.g. crossovers within the eating disorder diagnoses, comorbidity, as well as leaving the majority of eating disorder patients in clinical settings as “not otherwise specified”. In principle, there are two pathways of progress, i.e. to diversify and split up into more diagnostic categories, or to make broader categories based on some more or less unified theoretical frame or empirical evidence. The first pathway runs the risk of creating evidence-based characteristics that are remotely relevant to treatment decisions, treatment effect and long term outcome, and may increase unwanted medicalizations. The second one stands the risk of being too “etiologic” in nature, thus making diagnostic decisions reliant on psychological tests and specialized clinical competence. Indeed, a simple solution for the forthcoming DSM-V would be to just slacken the existing criteria to include more of the “not otherwise classified” patients into the categories “anorexia nervosa”, “bulimia nervosa”, and the current, provisional, “binge eating disorder” category. Another solution is represented by a “transdiagnostic” “eating disorder” construct, based on cognitive core beliefs specific to all the DSM-IV eating disorder categories and based on studies of treatment effect. However, a transdiagnostic solution is refuted by studies using latent class analyses and cluster analysis studies, largely supporting the DSM-categories. Also, transdiagnostics does not offer a solution of comorbidity problems. A model of understanding and classification is put forward, suggesting eating disorder as a subgroup of anxiety disorders.
From exposure to metacognition: New developments in the treatment of obsessive–compulsive disorder (OCD) Patrick A. Vogel1, Bjarne Hansen, 1Professor, Department of Psychology, Norwegian University of Science and Technology, N-7491 Trondheim, Norway, E-mail: [email protected] OCD was long considered a treatment resistant anxiety disorder with a very poor prognosis. The cognitive–behavioural treatment of exposure with response prevention (ERP) has become the treatment of choice for OCD. The background for the introduction of this treatment in Norway will be presented. Research has focused on ways of improving outcome through the introduction of other techniques. More elements from cognitive therapy were added to ERP in the first controlled treatment trial of OCD in Norway. The results indicated that additional cognitive therapy improved the outcomes for patients with certain forms of anxiety comorbidity. ERP has also been successfully employed in a study which treated children with OCD. The method is currently being studied in a group therapy format. In another study, psychology student-therapists with little prior training have achieved good outcomes with this method. New research has found that metacognitive factors play a significant role in the therapeutic change processes. New metacognitive therapies are being developed that may improve outcomes for OCD patients that do not respond to ERP interventions. In addition to these research developments, the Norwegian OCD Foundation, Ananke, has played an important role in increasing the availability of effective treatments for OCD. It has helped in recruiting patients to research projects, distributed self-help materials, held information seminars for the public, and organized professional courses for therapists across the entire country. The cooperation in Norway between researchers and the OCD patient organization can serve as an example of how to develop and disseminate psychological treatments.
Cognitive–behavioural therapy, Dissemination, Obsessive–compulsive disorder.
The efficacy of short-term dynamic psychotherapy and cognitive therapy in the treatment of cluster C personality disorders Martin Svartberg1, M.D., Ph.D., Tore C. Stiles, Ph.D, 1Attending Psychiatrist, Diakonhjemmet Hospital, Vinderen DPS, Norway, E-mail: [email protected] In this presentation, the background, design and main results of a randomized clinical trial of the effects of short-term dynamic psychotherapy (STDP) and cognitive therapy (CT) with Cluster C personality disorders will be described. Fifty patients who met criteria for one or more cluster C personality disorders and not for any other personality disorders were randomly assigned to receive 40 weekly sessions of STDP or CT. The most common axis I disorders were social phobia, generalized anxiety disorder and major depressive disorder. Therapists were experienced, full-time clinicians, specifically trained to treat these disorders. Outcome variables included symptom distress, interpersonal problems and core personality pathology. Measures were administered repeatedly during treatment and a 2-year follow up period. Results will be presented for the whole sample of patients as well as for avoidant and compulsive–obsessive personality disorders specifically. The clinical significance of the findings will be underscored.
Group schema therapy for personality disorders Gunilla Klensmeden Fosse, M.D., Ph.D., St. Olavs Hospital, Trondheim University Hospital, Leistad DPS, Norway, E-mail: [email protected] Jeffrey E. Young developed schema therapy to treat patients with chronic characterological problems who were not being helped by traditional cognitive–behavioral therapy. Schema therapy is a systematic approach that expands on cognitive–behavioral therapy by integrating techniques drawn from several different schools of therapy. The schema model combines aspects of cognitive, behavioral, attachment, psychodynamic and Gestalt models. This presentation will highlight the key differences—and similarities—between cognitive–behavioral therapy and schema therapy. In addition, preliminary results from an ongoing RCT comparing group schema therapy with psychiatric treatment as usual in outpatients with borderline personality disorders will be presented.