Letters to the Editor
Stage-Oriented Trauma Treatment Using Dialectical Behaviour Therapy
Dear Editor:
Chronic childhood trauma that begins at an early age is thought to be an important etiological factor in the development of borderline personality disorder (BPD). Between 60% and 90% of patients with a diagnosis of BPD have a history of developmentally adverse interpersonal traumas (1–3). Impaired capacity to self-regulate has been linked to self-mutilation and high-risk behaviours in this patient population (4). We present a preliminary case series of patients with a history of psychological trauma who met DSM-IV criteria for posttraumatic stress disorder (PTSD) and BPD. These patients were treated within a specialized traumatic stress service using stage-oriented trauma treatment (5). According to this treatment strategy, a stabilization phase is essential before trauma-focused therapy can begin. Stabilization treatment was provided using the dialectical behavioural therapy (DBT) model (4). This model effectively treats impaired emotion regulation and BPD (6) by reducing dysfunctional behaviours and hospitalization and improving treatment retention (7,8).
Data came from 18 female patients who completed 1 year of DBT within the Traumatic Stress Service, a specialized program for treating psychological trauma that is affiliated with an acute care general hospital university teaching centre. Most of the program is outpatient-based. To ensure continuity of care, the inpatient treatment is provided by the team responsible for out- patient therapy. The patient group had a mean age of 35 years (SD 9); the mean duration of psychiatric illness was 19 years (SD 12). All patients fulfilled the DSM-IV criteria for PTSD and BPD, based on clinical interview. Comorbidities included dysthymia (n = 11), major depression (n = 10), dissociative disorder not otherwise specified (NOS) (n = 9), eating disorder NOS (n = 6), substance use disorder (n = 4), panic disorder (n = 2), bipolar disorder (n = 1), and schizoaffective disorder (n = 1). We assessed clinical outcome by measuring outpatient, inpatient, and emergency health care resource use at the London Health Sciences Centre; employment and school attendance were considered to reflect successful functioning. We compared the data for 1 year immediately prior to starting the program with the data for the first year of program attendance.
The 1-year outcome data show a 65% decrease in the duration of inpatient stay (before-treatment total = 1083 inpatient days, mean 64 days per patient [SD 38]; after-treatment total = 384 inpatient days, mean 23 days per patient [SD 29]). The 1-year outcome data also show a 45% decrease in the number of emergency room visits (before-treatment total = 85 emergency room visits, mean 6 visits per patient [SD 5]; after-treatment total = 47 emergency room visits, mean 4 visits per patient [SD 4]). Lastly, these data show a 153% increase in outpatient visits (before-treatment total = 656 outpatient visits, mean 39 visits per patient [SD 28]; after-treatment total = 1661 outpatient visits, mean 98 visits per patient [SD 29]). The 700% increase in employment and school attendance was striking: 1 patient was working before treatment, compared with 8 patients working or attending school at 1-year follow-up.
By recognizing that childhood trauma is central in many cases of BPD, we have been able to incorporate DBT-based proactive outpatient management as part of a comprehensive stage-oriented trauma treatment program. This has helped to gradually shift the treatment emphasis from crisis management of the dysregulated self to functional recovery, active involvement in meaningful life activities, and successful engagement with the environment.
References
1. Herman JL, Perry JC, van der Kolk BA. Childhood trauma in borderline personality disorder. Am J Psychiatry 1989;146:490–5.
2. Paris J, Zweig F. A critical review of the role of childhood sexual abuse in the etiology of borderline personality disorder. Can J Psychiatry 1992;158:1034–9.
3. Ogata SN, Silk KR, Goodrich S, Lohr NE, Westen D, Hill EM. Childhood sexual and physical abuse in adult patients with borderline personality disorder. Am J Psychiatry 1990;147:1008–13.
4. Linehan, MM. Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press; 1993.
5. Chu JA. Rebuilding shattered lives. New York: John Wiley and Sons; 1998.
6. McMain S, Korman LM, Dimeff L. Dialectical behavior therapy and the treatment of emotion dysregulation. J Clin Psychology 2001;57:183–96.
7. Rizvi SL, Linehan MM. Dialectical behavioral therapy for borderline personality disorder. Curr Psychiatry Rep 2001;3(1):64–9.
8. Fox S. Integrating dialectical behavioral therapy into a community mental health program. Psychiatr Serv 1998;49:1338–40.
Ruth A Lanius, MD, PhD, FRCPC
Isolda Tuhan, MD, FRCPC
London, Ontario
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