www.psychspace.com心理学空间网 10BPD的药物治疗、MBT及DBT的研究
10.1药物治疗
Pharmacotherapy
Treatments for BPD: Paul Soloff, MD
Soloff, P. H. (2000). Psychopharmacology of borderline personality disorder. Psychiatric Clinics of North America, 23 (1), 169-92.
Medications Algorithm & Rules
Target specific problem area
Cognitive/perceptual
Affective
Impulsive dyscontrol
Strong empirical support
Safe
Act rapidly
Soloff’s Medication Algorithm: Treating Cognitive/Perceptual Symptoms
Soloff, P. H. (2000). Psychopharmacology of borderline personality disorder. Psychiatric Clinics of North America, 23 (1), 169-92.
START with low-dose typical neuroleptic
If poor/partial response, INCREASE dose.
If response still poor, RECONSIDER DIAGNOSIS. If symptoms are mood congruent, treat for affective symptoms.
If symptoms do NOT have a major mood component, SWITCH to clozapine or another atypical anti-psychotic.
Soloff’s Medication Algorithm: Treating Affective Symptoms
Soloff, P. H. (2000). Psychopharmacology of borderline personality disorder. Psychiatric Clinics of North America, 23 (1), 169-92.
START with SSRI or related and antidepressant.
If response inadequate, SWITCH to different SSRI or related antidepressant.
If response still poor, AUGMENT with a benzodiazepine or a low-dose neuroleptic.
If response remains inadequate, SWITCH to MAOI.
FINALLY, add/switch to lithium or a mood stabilizer.
Soloff’s Medication Algorithm: Treating Impulsive Symptoms
Soloff, P. H. (2000). Psychopharmacology of borderline personality disorder. Psychiatric Clinics of North America, 23 (1), 169-92.
START with SSRI (if rapid response is needed, a low-dose conventional neuroleptic).
If response to SSRI monotherapy inadequate, ADD/SWITCH to low-dose neuroleptic.
If response remains poor, ADD/SWITCH to lithium or MAOI.
SWITCH to carbamazepine or valproate, if no response.
If necessary, ADD atypical neuroleptic.
Consensus By Experts on Pharmacotherapy for BPD
No “magic bullet” medication for BPD patients
Soloff’s algorithm is method of choice where drugs target domain of dysfunction.
Pharmacotherapy alone is insufficient to treat BPD; must be combined with psychosocial treatment.
10.2MBT Vs. DBT
Bateman & Fonagy’s 18-month
Partial Hospitalization Program (PHP)
PHP Treatment:
3x/week group psychotherapy
1x/week individual psychotherapy, expressive therapy, and community meeting
1x/month meeting with psychiatrist and case administrator
Control: Standard Psychiatric Care
2x/month meeting with psychiatrist and visiting psychiatric nurse
Bateman & Fonagy’s 18-month
Partial Hospitalization Program (PHP)
PHP<Control
Frequency of suicide attempts and self-mutilation
Number and duration of inpatient admissions
Use of psychotropic medications
Self-report measures of depression, anxiety
PHP>Control
Improvements on self-report measures of social and interpersonal functioning
Critique of Bateman & Fonagy’s PHP
1. Methodological Confounds
PHP patients received considerably more treatment per week (6+ hours) compared to TAU (3 hours/month).
2. No treatment manual currently exists
limiting further investigation by others.
3. No studies have replicated original
findings.
4. PHP may be more expensive than DBT.
(18 months vs. 12 months; PHP vs. outpatient).
10.3DBT研究结果
DBT Randomized
Controlled Trials
Linehan, et. al. study of chronically suicidal patients with BPD (1991, 1992, 1993, 1994).
Koons, Robins et al. study of BPD women in VA setting (2001).
Linehan, et al. study of drug-dependent women with BPD (1999).
Linehan, et al. study of heroin-addicted BPD women (2002).
Randomized Controlled Trial:
DBT vs. Treatment-as-Usual
With Chronically Suicidal
BPD Women
(University of Washington)
Linehan, et al., 1991, 1992, 1993, 1994
DBT < TAU
% with parasuicide
# parasuicides
medical risk of parasuicide
treatment drop-outs
psychiatric inpatient days
anger
DBT vs. TAU: ns
Depression
Hopelessness
Suicide ideation
Efficiency & Costs
Of DBT v. TAU
Cost for DBT is about 50% of TAU
Significantly fewer inpatient days
Fewer and less severe parasuicidal behaviors
Fewer emergency medical visits
Less therapy dropout
DBT vs. Treatment-as-Usual
for BPD
(Durham VA Medical Center)
Koons, Robins, et al. , 2001
Design: RCT
Subjects
Women veterans, total N = 20
BPD on SCID-II
Mean Age = 35
Lifetime history of parasuicide = 75%
Parasuicide within 6 months = 40%
Overall, a less parasuicidal, less frequently hospitalized group than studied in Linehan’s (1991) study.
DBT < TAU at Post-Treatment
# parasuicides (<.10)
Suicide Ideation
Depression (BDI)
Hopelessness
Anger Out
Reduction in Mean Number of Parasuicide Acts Over Time for Each Condition Analyzed Separately
DBT vs. Treatment-as-Usual
With BPD Substance Abusers
(University of Washington)
Linehan, Schmidt, Dimeff, Kanter, Craft,
Comtois, McDavid, 1999
Design: RCT
Subjects: n=28
BPD
SUD for opiates, cocaine, amphetamines, sedatives, hypnotics, or anxiolytics or Polysubstance Use Disorder
Female
Did not meet criteria for:
Schizophrenia or other Psychotic Disorder
Bipolar Disorder
Mental Retardation
Matching Variables
Age
Severity of Highest Drug Dependence
Readiness to Change
Global Adjustment (Axis V, DSM-IV)
Proportion of Urinalyses DIRTY
by Condition
Interviewer-Assessed Proportion of DAYS
USING Drugs and Alcohol by Condition
DBT < TAU
Drug use
DBT > TAU
Global Adjustment (at 16-month)
Social Adjustment (at 16-month)
DBT gains continued at follow-up
DBT vs. TAU: ns
Parasuicide Episodes
Anger
DBT vs. Comprehensive Validation (1 Year)
with BPD Heroin Addicts
University of Washington
Linehan, Dimeff, Reynolds, Comtois,
McDavid, & Kivlahan
Subjects: n=23
BPD on SCID II and PDE
Met criteria for Heroin Dependence
18-45 Years
Female
Did not meet criteria for:
Schizophrenia or other Psychotic Disorder
Bipolar Disorder
Mental Retardation
Matching Variables
Age
Cocaine Dependence
Anti-Social Personality Disorder
Global Assessment of Functioning (GAF)
Design: RCT
Treatment Conditions
Individual Therapy
Group Skills Training
Homework Review
Phone Coaching
Therapist Consult Meeting
Drug-Replacement
10.1药物治疗
Pharmacotherapy
Treatments for BPD: Paul Soloff, MD
Soloff, P. H. (2000). Psychopharmacology of borderline personality disorder. Psychiatric Clinics of North America, 23 (1), 169-92.
Medications Algorithm & Rules
Target specific problem area
Cognitive/perceptual
Affective
Impulsive dyscontrol
Strong empirical support
Safe
Act rapidly
Soloff’s Medication Algorithm: Treating Cognitive/Perceptual Symptoms
Soloff, P. H. (2000). Psychopharmacology of borderline personality disorder. Psychiatric Clinics of North America, 23 (1), 169-92.
START with low-dose typical neuroleptic
If poor/partial response, INCREASE dose.
If response still poor, RECONSIDER DIAGNOSIS. If symptoms are mood congruent, treat for affective symptoms.
If symptoms do NOT have a major mood component, SWITCH to clozapine or another atypical anti-psychotic.
Soloff’s Medication Algorithm: Treating Affective Symptoms
Soloff, P. H. (2000). Psychopharmacology of borderline personality disorder. Psychiatric Clinics of North America, 23 (1), 169-92.
START with SSRI or related and antidepressant.
If response inadequate, SWITCH to different SSRI or related antidepressant.
If response still poor, AUGMENT with a benzodiazepine or a low-dose neuroleptic.
If response remains inadequate, SWITCH to MAOI.
FINALLY, add/switch to lithium or a mood stabilizer.
Soloff’s Medication Algorithm: Treating Impulsive Symptoms
Soloff, P. H. (2000). Psychopharmacology of borderline personality disorder. Psychiatric Clinics of North America, 23 (1), 169-92.
START with SSRI (if rapid response is needed, a low-dose conventional neuroleptic).
If response to SSRI monotherapy inadequate, ADD/SWITCH to low-dose neuroleptic.
If response remains poor, ADD/SWITCH to lithium or MAOI.
SWITCH to carbamazepine or valproate, if no response.
If necessary, ADD atypical neuroleptic.
Consensus By Experts on Pharmacotherapy for BPD
No “magic bullet” medication for BPD patients
Soloff’s algorithm is method of choice where drugs target domain of dysfunction.
Pharmacotherapy alone is insufficient to treat BPD; must be combined with psychosocial treatment.
10.2MBT Vs. DBT
Bateman & Fonagy’s 18-month
Partial Hospitalization Program (PHP)
PHP Treatment:
3x/week group psychotherapy
1x/week individual psychotherapy, expressive therapy, and community meeting
1x/month meeting with psychiatrist and case administrator
Control: Standard Psychiatric Care
2x/month meeting with psychiatrist and visiting psychiatric nurse
Bateman & Fonagy’s 18-month
Partial Hospitalization Program (PHP)
PHP<Control
Frequency of suicide attempts and self-mutilation
Number and duration of inpatient admissions
Use of psychotropic medications
Self-report measures of depression, anxiety
PHP>Control
Improvements on self-report measures of social and interpersonal functioning
Critique of Bateman & Fonagy’s PHP
1. Methodological Confounds
PHP patients received considerably more treatment per week (6+ hours) compared to TAU (3 hours/month).
2. No treatment manual currently exists
limiting further investigation by others.
3. No studies have replicated original
findings.
4. PHP may be more expensive than DBT.
(18 months vs. 12 months; PHP vs. outpatient).
10.3DBT研究结果
DBT Randomized
Controlled Trials
Linehan, et. al. study of chronically suicidal patients with BPD (1991, 1992, 1993, 1994).
Koons, Robins et al. study of BPD women in VA setting (2001).
Linehan, et al. study of drug-dependent women with BPD (1999).
Linehan, et al. study of heroin-addicted BPD women (2002).
Randomized Controlled Trial:
DBT vs. Treatment-as-Usual
With Chronically Suicidal
BPD Women
(University of Washington)
Linehan, et al., 1991, 1992, 1993, 1994
DBT < TAU
% with parasuicide
# parasuicides
medical risk of parasuicide
treatment drop-outs
psychiatric inpatient days
anger
DBT vs. TAU: ns
Depression
Hopelessness
Suicide ideation
Efficiency & Costs
Of DBT v. TAU
Cost for DBT is about 50% of TAU
Significantly fewer inpatient days
Fewer and less severe parasuicidal behaviors
Fewer emergency medical visits
Less therapy dropout
DBT vs. Treatment-as-Usual
for BPD
(Durham VA Medical Center)
Koons, Robins, et al. , 2001
Design: RCT
Subjects
Women veterans, total N = 20
BPD on SCID-II
Mean Age = 35
Lifetime history of parasuicide = 75%
Parasuicide within 6 months = 40%
Overall, a less parasuicidal, less frequently hospitalized group than studied in Linehan’s (1991) study.
DBT < TAU at Post-Treatment
# parasuicides (<.10)
Suicide Ideation
Depression (BDI)
Hopelessness
Anger Out
Reduction in Mean Number of Parasuicide Acts Over Time for Each Condition Analyzed Separately
DBT vs. Treatment-as-Usual
With BPD Substance Abusers
(University of Washington)
Linehan, Schmidt, Dimeff, Kanter, Craft,
Comtois, McDavid, 1999
Design: RCT
Subjects: n=28
BPD
SUD for opiates, cocaine, amphetamines, sedatives, hypnotics, or anxiolytics or Polysubstance Use Disorder
Female
Did not meet criteria for:
Schizophrenia or other Psychotic Disorder
Bipolar Disorder
Mental Retardation
Matching Variables
Age
Severity of Highest Drug Dependence
Readiness to Change
Global Adjustment (Axis V, DSM-IV)
Proportion of Urinalyses DIRTY
by Condition
Interviewer-Assessed Proportion of DAYS
USING Drugs and Alcohol by Condition
DBT < TAU
Drug use
DBT > TAU
Global Adjustment (at 16-month)
Social Adjustment (at 16-month)
DBT gains continued at follow-up
DBT vs. TAU: ns
Parasuicide Episodes
Anger
DBT vs. Comprehensive Validation (1 Year)
with BPD Heroin Addicts
University of Washington
Linehan, Dimeff, Reynolds, Comtois,
McDavid, & Kivlahan
Subjects: n=23
BPD on SCID II and PDE
Met criteria for Heroin Dependence
18-45 Years
Female
Did not meet criteria for:
Schizophrenia or other Psychotic Disorder
Bipolar Disorder
Mental Retardation
Matching Variables
Age
Cocaine Dependence
Anti-Social Personality Disorder
Global Assessment of Functioning (GAF)
Design: RCT
Treatment Conditions
Individual Therapy
Group Skills Training
Homework Review
Phone Coaching
Therapist Consult Meeting
Drug-Replacement