Few studies have examined the prevalence, characteristics, and outcomes of treatment-seeking-suicidal adolescents with borderline personality disorder (BPD). To address this, we evaluated 108 suicidal adolescents seen in a specialized outpatient program and treated with Dynamic Deconstructive Psychotherapy (DDP) and examined changes in the severity of their BPD symptoms and suicide ideation over 6 months. Of these 108 adolescents, 81% (n = 87) met criteria for BPD on structured interviews. Adolescents with BPD had more frequent suicide attempts and recreational drug use, greater functional impairment and childhood adversity, and worse therapeutic alliance. However, they showed large improvements in BPD severity and suicide ideation on intent-to-treat analyses (d = 1.59 and .96, respectively), with 38% (n = 33) dropping out of treatment. These findings underscore the need for better identification of BPD among suicidal adolescents and additional research to evaluate the efficacy of DDP as a promising treatment for this population.

Suicidal behavior and demand for services have been increasing in adolescents. Many of the current treatments are focused on symptom mitigation, crisis management, and safety planning; however, few are aimed at remediating underlying vulnerabilities that may be contributing to suicide risk. Dynamic Deconstructive Psychotherapy (DDP) has been found to be effective for suicidal adults but has never been studied for adolescents. The present study examined real-world outcomes of 65 suicidal adolescents, aged 13–17 years, receiving weekly DDP in an outpatient clinic. The primary outcome was change in suicide ideation from baseline to 6 months of treatment as assessed by the Suicide Ideation Subscale of the Columbia Suicide Severity Rating Scale. In intent-to-treat analyses, suicide ideation significantly decreased over the 6 months with a large treatment effect (d = 1.19). Secondary measures, such as suicide attempts, self-harm, depression, anxiety, disability, self-compassion, and inpatient utilization, also improved significantly. Among the 42 adolescents (65%) who completed at least 6 months of treatment, suicide attempts decreased by 84%. DDP may be effective in reducing suicide ideation and other risk factors in suicidal adolescents and may be cost-effective given reduced inpatient utilization. These initial promising findings warrant further research and development.

Dynamic Deconstructive Psychotherapy has used neuroscience findings to propose the specific neuroaffective deficits in processing of the emotion experiences as etiology of the borderline personality disorder. The purpose of this study was to evaluate the efficacy of the Dynamic Deconstructive Psychotherapy to improve the symptoms in patients diagnosed with the borderline personality disorder by remediation of neuro-affective defects. This study was designed as a randomized controlled trial using the pre-test, post-test and a control group. Thirty patients who were diagnosed with borderline personality disorder meeting the inclusion criteria, randomly divided into two groups. Both groups evaluated using both Borderline Evaluation of Severity over Time (BEST) and Patient Health Questionnaire Mood Scale (PHQ-9) questionnaires at the baseline and the over course of the treatment. Data analysis using repeated measures ANOVA indicated that the effect of measuring time (p=0.001) and time/group (p=0.010) on linear combination of the severity of borderline disorder and depression were significant. This result supports the efficacy of Dynamic Deconstructive Psychotherapy based on the neurocognitive remediation of the emotion processing using association, attribution and alterity techniques.

Suicide prevention efforts have focused primarily on screening, education, and brief interventions rather than on treatment of underlying vulnerabilities. The Psychiatry High Risk Program (PHRP) is a specialized outpatient program for suicidal youths and young adults that facilitates transitions in care and provides comprehensive treatment aimed at healing and recovery. The authors evaluated the program's impact on inpatient utilization and suicide risk for patients (N=32) who were referred to the PHRP after psychiatric hospitalization for suicidality. Results indicate that program participants had large reductions in depression and suicidal ideation over 180 days postdischarge; they also had significantly fewer rehospitalizations than did a matched historical cohort, with an average savings of >6 hospital days per patient. These preliminary results suggest that a recovery-based suicide prevention program can be feasible and sustainable and may be cost-effective in a value-based system of care.

Borderline personality disorder (BPD) is associated with high risk of suicidality and high rates of health care utilization; however, the prevalence and characteristics of BPD among inpatients admitted for suicidality are unknown. In the present study of 72 adult psychiatric inpatients admitted for suicide risk, BPD was highly prevalent (n = 31; 43.1%), but 68% were misdiagnosed by admitting providers. Compared to patients without BPD, those with BPD were significantly younger, were prescribed more psychiatric medications, were more depressed, and had greater suicide ideation. Patients with BPD were also three times as likely to be readmitted to a psychiatric hospital at 30, 90, and 180 days postdischarge for an average of almost 9 days of inpatient care per patient for the first 180 days. In this sample, BPD was highly prevalent, underdiagnosed, and associated with frequent readmissions, findings that highlight the importance of improved recognition and access to specialized treatments.

Several psychotherapy models for borderline personality disorder (BPD) have demonstrated efficacy in randomized controlled trials (RCT). However, these treatment models were developed in Western countries and have seldom been evaluated in non-Western countries, such as Iran. Dynamic deconstructive psychotherapy (DDP) is a weekly individual psychotherapy that has demonstrated efficacy in clinical trials, but its efficacy has never been tested by an independent research group outside of the United States. In the present study, 30 participants diagnosed with BPD were randomly assigned to either 12 months of DDP, or to enhanced usual care (EUC), and then followed naturalistically for an additional 3 months. The primary outcome was symptom severity of borderline personality disorder. Secondary outcomes included maturity of object relations, level of personality organization, and depressive symptom severity. Results indicated that in the intent-to-treat sample, participants receiving DDP demonstrated a large and statistically significant reduction in BPD symptom severity relative to those receiving EUC. The difference in outcome was sustained after ending treatment during the naturalistic follow-up period. Improvement in BPD severity from beginning DDP to follow-up was nearly two standard deviations (d = 1.93), with 80% retention. DDP demonstrated medium to large effects on improvement of secondary outcomes. The results of this study suggest that this therapeutic model may effect changes in both symptoms and personality structure that are sustained over time, and may be used for individuals across different cultures, backgrounds, and languages.

Back to table of contents Previous article Next article ViewpointFull AccessShould Psychotherapy Become a Subspecialty of Psychiatry?Robert J. Gregory, M.D., David Mintz, M.D.,, Jessica Yakeley, F.R.C.PsychRobert J. Gregory, M.D., David Mintz, M.D.,, Jessica Yakeley, F.R.C.PsychPublished Online:12 Jun 2019https://doi.org/10.1176/appi.psychotherapy.20180044AboutSectionsView articleView PDFView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail View articlePsychotherapy can be both effective and life-transforming for individuals with mental disorders, but this modality may be losing ground in psychiatric practice and identity. Meta-analytic studies indicate that psychotherapy treatment effects for most disorders are equivalent to or stronger than those of psychopharmacology (1). However, the proportion of time spent by psychiatrists practicing psychotherapy has diminished steadily over recent decades (1, 2). Insurers and the general public often no longer consider psychotherapy as part of the core identity and skill set of psychiatrists, and arguably, neither do psychiatrists. Factors contributing to this trend include relatively poor reimbursement for psychotherapy, pressure from employers for psychiatrists to assume a strictly prescriber role, the reduced status of psychotherapy, and a vicious cycle in psychiatric residency training of diminishing time and resources spent teaching psychotherapy combined with fewer psychiatrist supervisors, mentors, and role models practicing psychotherapy. In this Viewpoint, we argue that by developing a subspecialized discipline of psychotherapy within psychiatry, we may build educational structures to ensure adequate training of psychiatrists in the psychotherapies, help to improve the status of psychotherapy, provide opportunities for advocacy, and maintain psychotherapy as a core skill set.The biopsychosocial model is increasingly giving way to a dichotomous approach that dismisses the importance of the interpersonal aspects of psychiatric care. Marketing of pharmaceuticals and other factors have led medication to gain increasing favor in public opinion. For example, the National Institute of Mental Health has almost exclusively emphasized funding for biologically based mechanisms and psychopharmacology for "brain disorders" (3). A biologically reductionist perspective, however, cannot account for the complex interactions between biological and psychosocial determinants of illness and may disregard the impact of psychotherapy in remediating neural networks and restoring neurophysiology (4).In the current environment, psychiatrists are encouraged to practice "at the top of their license," while psychotherapy (now commonly referred to as counseling) is relegated to the least educated member of the interdisciplinary treatment team (5), thus further eroding the valuation of psychotherapy. There is evidence that combined treatment by a psychiatrist who provides both medication and psychotherapy may actually be more cost-effective than splitting the treatment among providers (6). Such combined treatment may be especially important for patients who have complex biological and psychosocial determinants to their illness. Despite its cost-effectiveness, a practice of combined treatment is currently difficult to sustain, because Medicare reimbursement for an hour of psychotherapy evaluation and management (E&M) services (codes 90836 and 99213) is 25% less than reimbursement for the same hour spent performing two E&M visits involving psychopharmacology (code 99214), and reimbursement is even less for an hour of psychotherapy without E&M services.The preparedness of psychiatric graduates to practice psychotherapy is another factor eroding the role of psychotherapy in psychiatric practice. Psychotherapy, unlike psychopharmacology, is largely skill-based rather than knowledge-based and requires extensive one-on-one faculty time educating, observing, and providing feedback. The resource intensiveness of psychotherapy training, together with an increasing focus on neuroscience in psychiatric education, leads financially strapped programs to redistribute training resources away from psychotherapy, and few psychiatric residents graduate feeling truly competent to practice it.With so many forces at work moving psychotherapy outside the realm of psychiatric practice and identity, a vicious cycle has been created. With diminishing time spent teaching and conducting psychotherapy, and a growing proportion of psychotherapy faculty from disciplines other than psychiatry, a dearth of mentors and role models gives residents the implicit message that psychotherapy is not part of what psychiatrists do. It will take strong advocacy, higher reimbursement, and higher status given to psychotherapy within psychiatry to reverse this course. One possible means to achieve these aims may be to recognize the specialized expertise that effective psychotherapy requires through creation of a board-certified subspecialized discipline in the field of psychiatry.An argument against this proposal is that creating a subspecialty will move psychotherapy out of mainstream psychiatric training and practice, relegating it to an arcane art practiced by only a few psychiatrists. However, it can be argued that this is already happening, and at a rapid pace. As of 2008, less than a third of psychiatrist visits included psychotherapy (2). The creation of other subspecialties within psychiatry, such as geriatric, addiction, and consultation-liaison psychiatry, has not diminished residency training in these areas, which in contrast have mostly increased and gained status and influence through the establishment of specific councils within the American Psychiatric Association. This increased status has also been the experience in the United Kingdom, where medical psychotherapy is a recognized subspecialty of psychiatry and has become a platform for advocating for enhanced psychotherapy training during the general psychiatry residency.There are many challenges to overcome in successfully implementing this subspecialty, including finding funding for psychotherapy fellowships and integrating the many competing schools of psychotherapy into a single training standard, and these challenges will require innovative solutions. In the United Kingdom, the first 3 years of training in psychiatry provide core training (which includes treatment of at least two psychotherapy clients) for all psychiatrists, and a further 3 years of training are for general adult psychiatry or one of five subspecialties: forensic psychiatry, child and adolescent psychiatry, geriatric psychiatry, intellectual disability psychiatry, or medical psychotherapy. The medical psychotherapy curriculum requires mastery of at least one psychotherapy modality within one of the three recognized major models (i.e., psychodynamic, cognitive-behavioral, and family and systemic therapy). It also requires understanding of the theoretical bases of all major modalities; ability to formulate and tailor treatments to different settings, disorders, and individual needs; and basic competency in applying at least two other psychotherapy modalities (7).We believe the U.K. requirements provide a useful framework for structuring psychiatric psychotherapy fellowships in the United States. We propose that by the end of a psychotherapy fellowship, graduating psychiatrists will be able to do the following:achieve high empathic capacity, emotional intelligence and sophisticated interviewing and observational skills;integrate history and observations of patients with complex treatment needs into a biopsychosocial formulation;demonstrate familiarity with the theories and methods of the major schools of psychotherapy and recommend different psychotherapy modalities based on the formulation;demonstrate proficiency in one psychotherapy modality, including provision of effective delivery of the treatment in various settings when initiating, sustaining, and ending episodes of care; and demonstrate competent application of core skills in at least two additional psychotherapy modalities.There are many advantages of creating a single certification mechanism for psychotherapy expertise, regardless of the particular psychotherapy modality that the psychiatrist emphasizes. Bringing all psychiatrists with special interest and expertise in psychotherapy together under one umbrella may create opportunities for advocacy with a single unified voice, greater status and recognition of enhanced psychotherapy skills, provision of psychotherapy training for all psychiatrists, and the potential for enhanced insurance reimbursement for psychotherapy in recognition of a higher skill set through fellowship training.Department of Psychiatry and Behavioral Sciences, Upstate Medical University, Syracuse, New York (Gregory); Austen Riggs Center, Stockbridge, Massachusetts (Mintz); Tavistock and Portman National Health Service Foundation Trust, London (Yakeley).Send correspondence to Dr. Gregory ([email protected]).Dr. Yakeley receives royalties on a book she edited on a related subject. The other authors report no financial relationships with commercial interests.References1 Huhn M, Tardy M, Spineli LM, et al.: Efficacy of pharmacotherapy and psychotherapy for adult psychiatric disorders: a systematic overview of meta-analyses. JAMA Psychiatry 2014; 71:706–715Crossref, Medline, Google Scholar2 Mojtabai R, Olfson M: National trends in psychotherapy by office-based psychiatrists. Arch Gen Psychiatry 2008; 65:962–970Crossref, Medline, Google Scholar3 Insel TR, Quirion R: Psychiatry as a clinical neuroscience discipline. JAMA 2005; 294:2221–2224Crossref, Medline, Google Scholar4 Abbass AA, Nowoweiski SJ, Bernier D, et al.: Review of psychodynamic psychotherapy neuroimaging studies. Psychother Psychosom 2014; 83:142–147Crossref, Medline, Google Scholar5 Angermeyer MC, van der Auwera S, Carta MG, et al.: Public attitudes towards psychiatry and psychiatric treatment at the beginning of the 21st century: a systematic review and meta-analysis of population surveys. World Psychiatry 2017; 16:50–61Crossref, Medline, Google Scholar6 Dewan M: Are psychiatrists cost-effective? An analysis of integrated versus split treatment. Am J Psychiatry 1999; 156:324–326Medline, Google Scholar7 Yakeley J, Adshead G, Allison L, et al.: (eds): Medical Psychotherapy. Oxford, Oxford University Press, 2016Crossref, Google Scholar FiguresReferencesCited byDetailsCited ByNone Volume 72Issue 2 June 01, 2019Pages 36-37 Metrics KeywordsEducationResidencyPsychotherapy History Received 23 November 2018 Revised 14 March 2010 Accepted 19 April 2019 Published online 12 June 2019 Published in print 1 June 2019

This chapter presents a contemporary psychodynamic understanding of addictive behaviors among individuals with cooccurring personality disorders. Biomedical and behavioral theories inadequately explain the profound personal and interpersonal aspects of addiction. The chapter attempts to fill this epistemological gap, incorporating the neuroscience of emotion processing, unconscious motivations for substance use, and the intersubjective relational dynamics of the denial system and of shame. Common countertransference reactions and therapeutic pitfalls are highlighted, while treatment implications are emphasized and case vignettes are provided throughout for illustration. The chapter concludes with a summary of a comprehensive and empirically supported treatment model called dynamic deconstructive psychotherapy, which creates a safe space to build emotion awareness, complex and integrated attributions of self and other, and individuated relatedness, with the goal of a lasting recovery.

Background & Aims: The characteristics of individuals with borderline personality disorder and the complex nature of this disorder suggest the need to find effective treatments. The present research has been conducted to introduce Dynamic Deconstructive Psychotherapy (DDP) and to evaluate whether it is an effective model for the treatment of borderline personality disorder in Iranian society. Materials & Methods: This research was a randomized controlled trial utilizing a pre-test and post-test design with a control group of enhanced usual care. Among the patients with borderline personality disorder referred by psychologic and psychiatric clinics in Gonbad-e-Kavoos city, 30 consecutive participants with borderline personality disorder were selected and randomly assigned to the two treatment groups. Participants completed the Borderline Evaluation of Severity over Time (BEST) and the Patient Health Questionnaire Mood Scale (PHQ-9) at the time of entering the research (baseline), and also in the 3th month, the 6th month and the 9th month of the treatment. Repeated Measures ANOVA and SPSS19 software were used for statistical analysis. Results: The results obtained from the analysis of variance indicated that the DDP was effective in reducing the core symptoms of borderline personality disorder and depression. Conclusion : According to the findings of this research, DDP appears to be an efficient and cost-effective therapeutic treatment. These findings have theoretical and practical implications.

Dialectical behavior therapy (DBT) and dynamic deconstructive psychotherapy (DDP) are listed in the National Registry of Evidence-Based Programs and Practices based on their performances in randomized controlled trials. However, little is known about their effectiveness in real-world settings. In the present study, the authors observed the naturalistic outcomes of 68 clients with borderline personality disorder (BPD) who were treated at a medical university clinic by experienced therapists using either comprehensive DBT (n = 25) or DDP (n = 27), with 16 clients treated with unstructured psychotherapy serving as a control. We found both DBT and DDP achieved significant reductions in symptoms of BPD, depression, and disability by 12 months of treatment, and showed effect sizes consistent with controlled trials. However, attrition from DBT was high and DDP obtained better outcomes than DBT (d = .53). Larger effectiveness studies are needed to replicate these findings, delineate common and unique treatment processes, and determine therapist and patient characteristics predicting positive outcomes.

Borderline personality disorder is common across mental health settings and associated with substantial suffering, disability, and mortality risk. However, it is often underdiagnosed and no prevalence data are available for state hospital settings. This study aims to provide a preliminary assessment of the prevalence and characteristics of borderline personality disorder (BPD) within an inpatient unit of a state psychiatric hospital. In order to improve the quality of care at a state psychiatric hospital, all patients admitted to a 40-bed unit from April 2008 to June 2009 were routinely administered a structured diagnostic interview for BPD. A total of 65 patients were screened and their charts were reviewed. Twenty patients (31%) met criteria for BPD, but only eight of them (40%) had a chart diagnosis of BPD. Compared to patients without BPD, patients with BPD were significantly more likely to be female (75%), to carry a diagnosis of major depressive disorder, and to have been admitted within the past year. Twenty-four percent of patients with a primary psychotic disorder also met criteria for BPD. BPD patients tended to have shorter lengths of stay, but they had significantly more management problems, including incidents of self-harm, episodes of restraint, and stat administrations of medications. The authors conclude that BPD can be a common but underappreciated co-occurring condition in a state psychiatric hospital. In this setting, BPD is associated with more frequent admissions and numerous management challenges, suggesting the need for comprehensive screening, coordination of care, and specialized treatment programming.

Adolescents sometimes cut themselves to relieve distress; however, the mechanism is unknown. Previous studies have linked self-injury to deficits in processing emotions symbolically through language. To investigate expressive language of adolescent cutters, the authors analyzed 100 narratives posted on the Internet. Most narratives (n = 66) displayed idiosyncratic use of language indicating poor differentiation between the real and the symbolic, such as blood substituting for negative emotions, which can then be released from the self; or emotional pain magically transforming into physical pain, which can then be managed. This kind of magical thinking correlated with cutting to relieve distress, to see blood, and to feel pain, but negatively correlated with complex representation of people, understanding social causality, and self-esteem. The results suggest that magical thinking represents a pre-symbolic mental state that processes and organizes distressing emotions through body schema. Magical thinking thus provides a plausible mechanism for why cutting works.

Dissociative Identity Disorder (DID) is an under-researched entity and there are no clinical trials employing manual-based therapies and validated outcome measures. There is evidence that borderline personality disorder (BPD) commonly co-occurs with DID and can worsen its course. The authors report three cases of DID with co-occurring BPD that we successfully treated with a manual-based treatment, Dynamic Deconstructive Psychotherapy (DDP). Each of the three clients achieved a 34% to 79% reduction in their Dissociative Experiences Scale scores within 12 months of initiating therapy. Dynamic Deconstructive Psychotherapy was developed for treatment refractory BPD and differs in some respects from expert consensus treatment of DID. It may be a promising modality for DID complicated by co-occurring BPD.

There is substantial literature documenting the process factors that lead to effective psychotherapy. Similarly, there is now a wealth of data attesting to the effectiveness of several psychotherapy brands. Little is known about the elements that facilitate learning how to be an effective clinician. One important step, after reading about a treatment model and seeing techniques demonstrated, is having the chance to practice the approach and receiving feedback and coaching from an experienced, knowledgeable supervisor. To accomplish this efficiently, most programs rely not only on trainee accounts of what went on in their therapy sessions, but also on recordings and videos of therapeutic encounters. This article describes our experience over a 5-year period in developing the use of Webcams for training psychology interns and psychiatric residents in the delivery of psychotherapy services. Pragmatic and technical details are given about how we went about establishing a recording system that is easy to use and provides secure, confidential storage of information at a reasonable cost. Discussion addresses both the weighing of choices that need to be made and overcoming the hesitation of trainees to reveal their work during treatment sessions.

Patients having co-occurring borderline personality disorder and alcohol use disorders represent a common, but particularly severe and refractory subgroup. An individual, time-limited treatment, dynamic deconstructive psychotherapy (DDP), has been shown to be effective for this subgroup, but long-term outcomes are not known. Participants were recruited from a sample of 30 patients enrolled in a 12-month randomized controlled trial of DDP versus optimized community care (OCC). Outcomes were assessed after an additional 18 months of naturalistic follow-up. DDP participants received an equivalent amount of individual treatment and less group therapy than those receiving OCC, but demonstrated large, sustained treatment effects over a broad range of outcomes and achieved significantly greater improvement in core BPD symptoms, depression, parasuicide, and recreational drug use over the 30-month study. These results suggest that DDP is a cost-effective treatment that can lead to broad and sustained improvement for the dually diagnosed subgroup.