Multiple integrated treatment of borderline personality disorders

Abstract

This paper describes a pilot study of the effectiveness of a specific outpatient programme for Cluster B Personality Disorder. According to this model, the patient is offered a pathway of two‐year duration, which includes once a week supportive individual psychotherapy combined with fortnightly group psychotherapy (Dialectical Behavioural Therapy), as well as general psychiatric management.

We present the results of a prospective research study based on data collected on a first group of six patients treated in the programme. The sample, screened by using the Structured Clinical Interview for DSM‐IV Axis II Disorders (SCID II), for presence of a Cluster B disorder, was evaluated at regular intervals using the Symptom Check List‐90 (SCL‐90), for the affective symptoms, the Barratt Impulsiveness Scale, version 11 (BIS‐11) and the Aggression Questionnaire (AQ), for the dimensions of Impulsiveness and Aggression. The level of disability perceived has been measured by the Dissociative Disorders Interview Schedule (DISS). Finally, the referring psychiatrist filled in the Global Assessment of Functioning (GAF) and Brief Psychiatric Rating Scale (BPRS). At the end of treatment improvement was found in all measures. The results, based on a limited sample, suggest that improvements in the dimensions of impulsiveness, affectivity, degree of disability and readmission to hospital can be achieved with Cluster B patients in an outpatient setting by utilizing different concurrent psychotherapeutic approaches. This is encouraging concerning the intensive outpatient psychotherapeutic treatment with severe personality disorder.

Acknowledgements

The training psychiatrists attending the third and fourth year of the Psychiatry Specialization School of Bologna University have brought their large‐scoped, conflicting, generous and decisive contribution to the project: Dr Lucia Bacchiani, Dr Michela Casoria, Dr Enrico Congedo, Dr Chiara D'Ippolito, Dr Stefano Giordani, Dr Lorenzo Gottarelli, Dr Barbara Esempio, Dr Luca Malaffo, Dr Federica Salvatori, Dr Francesca Saracino, and Dr Sara Scaini. We would like to thank Simona Minelli, Psychiatric Nurse, who has been a precious and constant point of reference both for the patients and the working group.

Notes

1. The acronym ICE, in English, seems to suggest the primary objective of a strategy which should always focus on a project essentially cooling and freezing the relational turmoil and the counter‐transference acting out which these patients impose on the service.

2. Outer‐directed aggression: explosive behaviour, rage outbursts, reckless behaviour, little tolerance towards frustration, verbal and physical aggression (more recurrent in B).

3. Self‐directed aggression: suicide attempts, self‐mutilation, food, sex or substance binge (more recurrent in B).

4. Affective dysregulation shows ‘positive’ and ‘negative’ symptoms. The positive ones are: affective lability, dysphoria, unmotivated rage, depression (more recurrent in B). The negative ones are: anhedonia and affective coercion (more recurrent in A). Anxiety is ubiquitous, but more recurrent in C.

5. Trait features, such as suspiciousness, eccentric or bizarre thinking (more recurrent in A), as reaction to subjective affective states (more recurrent in B).

6. Dialectical behaviour therapy entails, in its overall package, a series of interventions at individual and group level. Of the several items comprising the package, we have resorted to the educational part, namely the skills training of DBT.