辩证行为治疗——基本原理及治疗策略
作者: 李孟潮 / 36471次阅读 时间: 2011年6月06日
标签: DBT 辩证行为疗法 辩证行为治疗 李孟潮
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

Individual Therapy
NA 12&12 Group
NA 12&12 Sponsor
Crisis Intervention
Therapist Consult Meeting
Drug-Replacement
Assessments
Urinalysis (3 times weekly)

Substance Abuse History Interview (SAHI)



DBT vs. CVT+12S: ns
Drug Use, Self-Report
Brief Symptom Inventory
Global Adjustment
Social Adjustment

Integrating DBT into
Community Mental Health

The Mental Health Center of Greater Manchester, New Hampshire

Recipients of the 1998 Gold Award
American Psychiatric Association
Psychiatric Services, 49, 1338-1340
The Mental Health Center of Greater Manchester, New Hampshire
Provided comprehensive DBT in outpatient setting.
Pre-post data collected for first 14 patients receiving DBT.
Team received intensive 10-day training in DBT over six month period of time.
Treatment Costs Cut by More than Half
From $645,000 to $273,000
77% decrease in hospital days, from 479 to 85 days.
76% decrease in partial hospital days, from 173 to 42 days.
56% decrease in crisis beds, from 170 to 73 beds.
80% decrease in face-to-face contact with emergency services, from 61 to 12 days.
Significant increase in outpatient services, from 438 days to 1,387 days.
Non-Randomized Studies On DBT
Stanley, Ivanoff et. al. Study of Suicidal, Self-Mutilators (1998).
Miller & Rathus study of DBT for Suicidal Adoelscents (1996).
McCann & Ball study of DBT for Forensic Inpatients (1996).
Bohus et al. Study of DBT inpatient treatment (2001).
Trupin et al. Study of incarcerated youth (2002).

DBT vs. Treatment-as-Usual
for Suicidal and
Self-Mutilating Behavior

(New York State Psychiatric Institute
& Columbia University)

Stanley, B., Ivanoff, A., Brodsky, B., & Oppenheim, S. (1998)

Design: Matched Control
Subjects: n = 30
BPD
Females
Parasuicidal
The baseline mean number of suicide attempts did not differ between DBT and TAU



DBT < TAU


Self-mutilation
Suicide ideation
Suicidal urges
Urges to self-mutilate


DBT = TAU

Depression
Hopelessness
Global Adjustment



DBT vs. Treatment-as-Usual
for Suicidal Adolescents

The Albert Einstein College of Medicine/
Montefiore Medical Center

Miller, A. L. & Rathus, J. H. (1996)

Design: Parallel Control Group
Subjects: n=111 (DBT=29, TAU=82)
Referrals to the Adolescent Depression and Suicide Program, 78% female and 22% male

Age range 12-19 years

68% Hispanic, 17% African American, 8% Caucasian, 1% Asian, 6% other
Subjects: Assignment to Condition
Subjects were assigned to DBT if they met the following criteria:




DBT < TAU

Treatment drop-out
Inpatient psychiatric days



DBT=TAU: Suicide Attempts
DBT>TAU at pre-treatment:
Number of Axis I disorders
Impulsivity
Number of prior hospitalizations

The fact that DBT subjects were not more suicidal during treatment than TAU is noteworthy.


DBT vs. Treatment-as-Usual
for Forensic Inpatients

Institute for Forensic Psychiatry
Colorado Mental Health Institute at Pueblo

McCann & Ball, 1996

Design: Longitudinal
Subjects: (35 male, 11 female)
Patients on intermediate and medium security forensic wards


Age range 37.6 years

BPD = 50%; ASPD= 33%; 45% either schizophrenic or bi-polar


DBT: Pre < post

Depressed and hostile mood
Paranoia,
Psychotic behaviors,
Maladaptive interpersonal coping styles
Staff burn-out (trend)

TAU: Pre = post
Evaluation of DBT-Inpatient Treatment

University of Freiburg, Germany

Bohus, Haaf, Stiglmayr, Pohl, Bohme, & Linehan 2001

DBT vs. TAU-Waiting List
a Controlled Study
Inclusion: BPD: SCID II; DIB-R>7
Exclusion: lifetime schizophrenia, bipolar I, current substance abuse
Measure points:
pre: admission post: 1 month after discharge
DBT vs. TAU - Waiting List
DBT
n=31
age=29.1
mean DSM-IV 6.81
Comorbidities:
Anxiety disorder 77%
Eating disorder 50%
Depressive
Disorder 80%
TAU - Waiting List
n=19
age=29.5
mean DSM-IV 7.63
Comorbidities:
Anxiety disorder 76%
Eating disorder 41%
Depressive
Disorder 82%
Pre-post comparison and group vs. time differences: Depression
Pre-post comparison and group vs. time differences: Anxiety
Pre-post comparison and group vs. time differences: SCL-90-R
Pre-post comparison and group vs. time differences: Dissociation
Pre-post comparison and group vs. time differences: Anger
Pre-post comparison and group vs. time differences: Social Integration
Effect Sizes TAU-DBT
Responder criteria
Every patient who had values above the median in at least 5 of 9 pre-post-differences (dissociation, GAF, HAMA, STAI, BDI, HAMD, STAXI, SCL-GSI, SCL-Intensity) was allocated to the responder-group
Responder criteria
Discriminant Analysis: All of the 9 variables accounted significantly for the classification into responder- and non-responder-groups and are responsible for 71.8% of the variance between the groups (F8,20=6.35, p=.000***).
GAF
Therapy Response: Effect sizes
Predictor Variables
(Discriminant Analysis)
Clinical variables:
Frequency of comorbid axis I disorders
Frequency and days of lifetime hospitalizations
Frequency of lifetime suicide attempts
Current or lifetime diagnosis of
comorbid anxiety disorder
eating disorder
depression
Predictor Variables
(Discriminant Analysis)
Diagnostic variables:
value of the DIB-R criterias
number of met DSM-IV criterias
severity of pre-assessment symptoms

Predictor Variables
(Discriminant Analysis)
Social variables:
employment
psychological or psychosocial stress at beginning of therapy
age
quality of family relationships
quality of leisure activities
global contentment with social aspects of one’s life
DBT Skills Training vs. No Skills
One Year: Out-patient (Linehan et al.)
DBT skills training + individual non-DBT psychotherapy (DBT Skills) vs.
Individual non-DBT psychotherapy only (NO DBT Skills)

DBT Skills = No DBT Skills: all measures
DBT vs. Treatment-as-Usual
for Incarcerated Juvenile Offenders

Echo Glen Children’s Center

Trupin, Stewart, Boesky, McClung, Beach

Design: Parallel Control Group
Subject Demographic Characteristics



Significant Changes
DBT 80 hrs. training
Reduced severe behavior problems (parasuicide, aggression, class disruptions)
Reduced staff use of punitive actions (compared to previous year)
DBT 16 hrs. training
No reduction in behavior problems
Increased staff use of punitive actions

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谢谢
 

www.psychspace.com心理学空间网
TAG: DBT 辩证行为疗法 辩证行为治疗 李孟潮
«Marsha M. Linehan 馬莎‧林麗韓(林内翰) Marsha Linehan 馬莎‧林麗韓
《Marsha Linehan 馬莎‧林麗韓》
Marsha M. Linehan:Expert on Mental Illness Reveals Her Own Fight»
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