Behaviour Therapy

In their review of the evidence base for treatment of personality disorder, Roth & Fonagy (2005) include several controlled studies that employed behavioural approaches. Most of these studies focussed on the difficulties with social interaction experienced by individuals with avoidant personality disorder. Argyle et al. (1974) found that these patients benefited from both social skills training and psychodynamic therapy; Stravynski et al. (1994) compared social skills training conducted in the clinic with training in the clinic plus in vivo and found both equally effective, although dropout rates were much higher when in vivo work was included. Alden (1989) Cappe & Alden (1986) and Marzillier et al. (1976) evaluated social skills training, exposure and systematic desensitisation and found that patients with APD made modest gains with all three relative to a waiting-list control. Alden & Capreol (1993) concluded from a trial of 76 patients with APD that individuals presenting as angry and distrustful benefited more from exposure therapy while those whose primary problem was lack of assertiveness responded better to social skills training. Results suggest that patients with APD are likely to demonstrate only modest improvements in social functioning following these interventions.

Liberman & Eckman (1981) compared brief insight-oriented therapy with a behavioural intervention that was predominantly social skills training in a group of inpatients with a history of parasuicide. At nine months post-treatment, patients who had received social skills training reported less suicidal ideation than the other cohort though the two groups did not differ significantly in number of suicide attempts.

Dialectical Behaviour Therapy

The first published study to suggest the usefulness of this approach (Linehan et al., 1991) compared weekly outpatient dialectical behavior therapy (DBT) treatment (individual plus group sessions) with treatment as usual (TAU) for female BPD patients with histories of parasuicide (N = 46). The DBT group showed significantly more improvement in para-suicidal behaviour and spent less time as inpatients than controls during the year of active treatment. The DBT group also had a lower dropout rate (17 % versus 58 %). The groups did not differ on other measures such as depression and hopelessness. A naturalistic follow-up assessed the two groups at one year post-treatment and found no significant difference between them except in terms of hospitalisation, with the DBT group requiring fewer admissions (Linehan, Heard & Armstrong, 1993).

Most recently, Linehan's group has extended its earlier findings with a two-year randomised controlled trial and follow-up of DBT versus community treatment by experts (CTBE) for 101 women with BPD and recent suicidal/self-harming behaviour (Linehan et al. 2006). This dismantling study demonstrated that, compared with the CTBE cohort, patients receiving DBT were half as likely to make a suicide attempt; required less hospitalisation for suicidal ideation; had lower medical risk following parasuicidal/self-harming behaviour and had a lower drop-out rate (19.2 % DBT versus 42.9 % CTBE).

In a study from the Netherlands (Verheul et al., 2003) describes a one-year randomised controlled trial of DBT versus TAU (treatment in the community) for 58 women with BPD who were referred from either addiction/psychiatric services. The DBT group again demonstrated a lower dropout rate (37 % versus 77 %) and a significantly greater reduction in both self-mutilating and self-damaging impulsive behaviour, particularly among participants with a history of frequent self-harm. At six month follow-up the benefits of DBT over TAU were sustained in terms of parasuicidal and impulsive behaviours, as well as alcohol use. There was no difference between the treatment conditions for drug abuse (Van den Bosch etal., 2005).

Other studies have adapted the Linehan model of DBT delivery in different ways. Evans et al. (1999) conducted an RCT (N = 34) to assess the efficacy of manualised DBT and cognitive therapy (MACT) for treatment of outpatients who met criteria for Cluster B personality disorders and had made a parasuicide attempt in the past 12 months. Individuals were assigned to MACT or TAU and assessed at six months. The rate of parasuicide was significantly lower in the MACT group, and self-ratings of depression also showed significantly more improvement in this cohort.

Inpatient Treatment

Inpatient versions of DBT have also been investigated but have not yet been adequately evaluated. Barley et al. (1993) compared inpatient DBT with standard inpatient psychiatric care for treatment of BPD and found a significant drop in parasuicide in the DBT group compared with their rate of self-harm before the intervention and compared with the TAU group. However, patients were not randomised in this study and the comparability of the groups is unclear. A group of researchers from the Netherlands (Bohus etal., 2000) assessed the benefit of inpatient DBT over a three-month period prior to long-term outpatient therapy as a means of accelerating and enhancing the course of therapy. The results of a small pilot study were encouraging but this model requires further investigation.

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