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ACT+FAP TREATMENT OF BORDERLINE PERSONALITY DISORDER. Michel André Reyes Ortega PhD * ** *** Angélica Nathalia Vargas Salinas MA * ** *** Edgar Miranda Terres MA ** *** Iván Arango de Montis MD ** María de Lourdes García Anaya MD, PhD **
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ACT+FAP TREATMENT OF BORDERLINE PERSONALITY DISORDER Michel André Reyes Ortega PhD * ** *** Angélica Nathalia Vargas Salinas MA * ** *** Edgar Miranda TerresMA ** *** Iván Arango de Montis MD ** María de Lourdes García Anaya MD, PhD ** * Associationfor Contextual BehavioralScienceMexicoChapter ** Instituto Nacional de Psiquiatría Juan Ramón de la Fuente Muñiz *** Instituto de Ciencias Conductual Contextuales y Terapias Integrativas
PSYCHOTHERAPY IMPACTS ON BPD Scenario = Mental HealthHospitals FoundM=52.2% AgeM= 42.8 N= 142 m, 359 w Diagnosesystem = DSM III Still BPD = 16.5% % suicide = 7.75% Retrospectivestudies (15 years) McGlashan(1986) Plakun et al. (1985) Stone (1990) Paris et al. (1987) Paris & Zweig-Frank (2001). Improvementassociatedfactors Skillsacquisition. Absence of stablecouple. Economicindependence. Non improvementassociatedfactors. Early sexual abuse and otherforms of mistreatment. Substance abuse. Scenario = General HealthHospitals AgeM= 31 at baseline N= 63 m, 237 w Diagnose= DSM III y DSM IV Still BPD = 33.3% % suicide = 5.85% Estudios prospectivos (7, 2, 2 y 10 años) Links et al. (1998). Skodol et al. (2005). Grilo et al. (2004). Zanarini, Frankenburg et al. (2005)
BEHAVIORAL THERAPIES FOR BPD • DialecticalbehaviorTherapy (DBT)(P-B). • Reductionsonself-harmbehavior, medical emergenciesfrequencies, anger and impulsivity; improovementson social adjustment and treatmentadherence(Lieb, & Stoffers, 2012; Linehan et. al. 1999; Lieb, Zanarini, Schahl, Linehan& Bohus, 2004; Turner, 2000; Verheul et. al. 2003). • Acceptance and CommitmentTherapy (ACT)(B). • Reductionsonself-harmbehavior, emotiondysregulation, experientialavoidance, BPD symptomsseverity, anxiety and depression(Gratz & Gunderson, 2006; Morton, Snowdon, Gopold & Guymer, 2012). • DBT + ACT(B). • Betteroutcomesthan ACT or DBTalone (Shearin & Linehan, 1994). • FunctionalAnalyticPsychotherapy (FAP)(P-B). • Improvementonidentitystability and interpersonal dimensions(Callaghan, Summers & Weidman, 2003; Koerner, Kohlenberg & Parker, 1996; Kohlenberg & Tsai, 1991; Kohlenberg& Tsai, 2000). • Improvement of ACT impacts(Kohlenberg & Callaghan, 2010; Luciano, 1999) and DBT (Busch, Manos, Rusch, Bowe & Kanter, 2010).
WISE CHOICES: ACT GROUP TREATMENT FOR BPD(Morton & Shaw, 2012) • Groupsessions- 1st module. • Introduction • Avoidance and values • Willingness and acceptance • Awareness of thoughts • Mindfulness of pleasure • Awareness of emotions, sensations and urges • Responding to emotions, sensations and urges • Actingonvalues • Obstaces and choicepoints • 18 sessions (25 patients, 1 therapist, 1 cotherapist, 2 monitors)
WISE CHOICES: ACT GROUP TREATMENT FOR BPD(Morton & Shaw, 2012) • Groupsessions– 2nd module. • Values in interpersonal relationships • Listeningmindfully • Practisingcourage to share ourselves • Brainstormingalternativeperspectives • Assertivelymakingrequests • In theotherperson’sshoes • Giving and receiving positives • Negotiation • 18 sessions (25 patients, 1 therapist, 1 cotherapist, 2 monitors)
WISE CHOICES: ACT GROUP TREATMENT FOR BPD(Morton & Shaw, 2012) “ENHANGEMENT” • Individual sessions • 1st session: Assesment. • Functionalanalysis: Identifiation of experientialavoidancepatterns. • Sessions 2-9: WiseChoicesenhangement. • Review of groupweekgroupsession. • Free use of ACT strategies to solvemotivationproblems. • Assistance in use of currentweekskills to mainproblems. • Use of FEAR-DARE acronyms • Assigningweeklyhomework. • Use of SMART acronym. • 16 sessions(4 therapists)
WISE CHOICES: ACT GROUP TREATMENT FOR BPD(Morton & Shaw, 2012) “ENHANGEMENT” • Individual sessions • 10th session: Assesment. • Functionalanalysis: Identifiation of CRBs. • Sessions 11-18: WiseChoices FAP enhangement. • Review of groupweekgroupsession. • Free use of ACT strategies to solvemotivationproblems. • Assistancein use of currentweekskills to mainproblems. • Use of FEAR-DARE acronyms. • Use of 5 rules to workonCRBs and drawparallels to Os. • Assigningweeklyhomework. • Use of SMART acronym. • 16 sessions(4 therapists)
PILOT STUDY JUSTIFICATION • Contribute to psychologicalwellbeing of BPD diagnosedpatients: Diminishingentry to emergenciesservices, symptoms of emotiondysregulation, impulsivity, suicidalrisk, fear of emotions and experientialavoidance; Improvingquality of life and interpersonal adjustment. • Need to start a research line basedaboutthedevelopment and effectiveness of lowcostinterventionsfor BPD (Lieb et al., 2004; Marquis& Wilber, 2008). • INPRF BPD hadoneyear at pilotstudystart, TFP (1 year / 2 sessions per week) and DBTinformedwhere TAU (9 months / 1 group and individual session per week).
HYPOTHESIS • ACT+will show betterlobaloutcomes tan TAU on • ReductiononBPD symptomsseverity– Borderline Evaluation of Severity Over Time Scale (Pfohl et. al. 2009; Reyes & García, 2014). • ReductiononSuicide Risk– Plutchik Suicide RiskScale(Plutchik& Van Pragg, 1989). • ReductiononImpulsivity– PlutchikImpulsivityScale(Plutchik& Van Pragg, 1989; Páez et al. 1996). • ReductiononEmotionDysregulation– Difficulties in Emotion Regulation Scale (Gratz & Roemer, 2004; Marín Tejeda et al. 2012). • ReductiononExperientialAvoidance– Acceptance and Action Questionnaire-II (Ciarrochi & Bilich, 2006; Patrón 2010). • ReductiononFear of Emotions– Affective Control Scale (Williams, Chambless & Ahrens, 1997; Ramírez, Ascencio, Reyes & Vargas, 2014). • Improvement of Quality of Life– WHO Quality of LifeScale(WorldHealthOrganization, 1993). *Resultsnotshown in thispresentation
DISCUSSION AND CONCLUSION HIPOTHESIS TESTING AND IMPACT SOLUTIONS TO STUDY LIMITATIONS Need of a wider N Compare groupsbyage and diagnosis. Needof a RCT to proveeffectivenesscompared to time equivalenttreatments. Assestreatmentintegrity of alltreatments. Refinement of selectioncriteria. Need of mediationalanalysis. Assesrelationbetweenhypothesizedmediational variables and treatmentoutcomes. • ACT+ showed to be and effectivebriefintervention as neededbythe INPRF-BPD clinic. • ACT+ enhangedcouldachievebetteroutcomes, speciallyon interpersonal satisfaction and social adjustmentdomains. • Include DBT crisis survival and emotionregulationskillsonthefist module. • Use of Matrixmodel to integrate ACT and FAP elements. • DrawingparalelsbetweenCRBs and Os sincetreatmentstartincludinggroupsessions. • Formal FAP onsecond module individual sessions. • ACT+ isthe new TAU of theINPRF-BPD clinic.
CASE CONCEPTUALIZATION(Reyes, 2014; adaptedfromPolk, 2014) CRB2s G-CRB2s O2s Values I-T2s G-T2s I-T Values G-T Values FIVE SENSES EXPERIENCE • I-CRB1s • G-CRB1s • O1s I-T1s G-T1s PERSPECTIVE ------------------ CHOICE POINT AVOIDANCE ÁPROACHING I-CRB3s G-CRB3s Problematic rules T3s MENTAL EXPERIENCE
CURRENT RESEARCH • Participants: • 150 participantswith BPD diagnosis confirmedby SCID-II; 50 randomlyassigned to eachgroup. • Schizofrenia, currentpsychosis, bipolar disorder,neurologicalconditions and antisocial personalitydiagnosedparticipatswill be excluded. • Agerange: 18 – 45 years.
RCT HYPOTHESIS • H1: ACT+DBT+FAP will show betteroutcomesthan TAU in • Reductionon BPD symptomsseverity – Borderline Evaluation of Severity Over Time Scale (Pfohl et. al. 2009; Reyes & García, 2014). • ReductiononSuicide Risk– Plutchik Suicide RiskScale(Plutchik & Van Pragg, 1989). • ReductiononImpulsivity– PlutchikImpulsivityScale(Plutchik & Van Pragg, 1989; Páez et al. 1996). • ReductiononEmotionDysregulation– Difficulties in Emotion Regulation Scale (Gratz & Roemer, 2004; Marín Tejeda et al. 2012). • ReductiononExperientialAvoidance– Acceptance and Action Questionnaire-II (Ciarrochi & Bilich, 2006; Patrón 2010). • ReductiononFearof Emotions– Affective Control Scale (Williams, Chambless & Ahrens, 1997; Ramírez, Ascencio, Reyes & Vargas, 2014). • Improvement of Qualityof Life– WHO Quality of LifeScale(WorldHealthOrganization, 1993). • H2: Hypothesizedchangemechanismswillsignificantlymediateimpact of treatments. • PsychologicalFlexibility– Acceptance and Action Questionnaire-II (Ciarrochi & Bilich, 2006; Patrón 2010). • Mindfulness – Fivefacets of mindfulness questionnaire (FFMQ; Baer, Smith, Hopkins, Krietemeyer, & Toney, 2006) • EmotionRegulation– Difficulties in Emotion Regulation Scale (Gratz & Roemer, 2004; Marín Tejeda et al. 2012). • H3: Significantdifferencesonmediationalmechanismcontribution to changebetweentreatmentswill be found.