Transcript Presentación de PowerPoint - Association for Contextual Behavioral

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 **
* Association for Contextual Behavioral Science Mexico Chapter
** Instituto Nacional de Psiquiatría Juan Ramón de la Fuente Muñiz
*** Instituto de Ciencias Conductual Contextuales y Terapias Integrativas
PSYCHOTHERAPY IMPACTS ON BPD
Retrospective studies
(15 years)
McGlashan (1986)
Plakun et al. (1985)
Stone (1990)
Paris et al. (1987)
Paris & Zweig-Frank (2001).
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)
Scenario = Mental Health
Hospitals
Found M=52.2%
Age M= 42.8
N= 142 m, 359 w
Diagnose system = DSM III
Still BPD = 16.5%
% suicide = 7.75%
Scenario = General Health
Hospitals
Age M= 31 at baseline
N= 63 m, 237 w
Diagnose = DSM III y DSM IV
Still BPD = 33.3%
% suicide = 5.85%
Improvement associated
factors
Skills acquisition.
Absence of stable couple.
Economic independence.
Non improvement associated
factors.
Early sexual abuse and other
forms of mistreatment.
Substance abuse.
BEHAVIORAL THERAPIES FOR BPD
• Dialectical behavior Therapy (DBT)(P-B).
• Reductions on self-harm behavior, medical emergencies frequencies, anger and impulsivity;
improovements on social adjustment and treatment adherence (Lieb, & Stoffers, 2012; Linehan et.
al. 1999; Lieb, Zanarini, Schahl, Linehan & Bohus, 2004; Turner, 2000; Verheul et. al. 2003).
• Acceptance and Commitment Therapy (ACT)(B).
• Reductions on self-harm behavior, emotion dysregulation, experiential avoidance, BPD symptoms
severity, anxiety and depression (Gratz & Gunderson, 2006; Morton, Snowdon, Gopold & Guymer,
2012).
• DBT + ACT(B).
• Better outcomes than ACT or DBT alone (Shearin & Linehan, 1994).
• Functional Analytic Psychotherapy (FAP) (P-B).
• Improvement on identity stability 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)
• Group sessions - 1st module.
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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
• Acting on values
• Obstaces and choice points
 18 sessions (25 patients,
1 therapist, 1 cotherapist, 2 monitors)
WISE CHOICES: ACT GROUP TREATMENT FOR BPD
(Morton & Shaw, 2012)
• Group sessions – 2nd module.
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Values in interpersonal relationships
Listening mindfully
Practising courage to share ourselves
Brainstorming alternative
perspectives
Assertively making requests
In the other person’s shoes
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.
• Functional analysis: Identifiation
experiential avoidance patterns.
• Sessions
2-9:
enhangement.
Wise
of
Choices
• Review of group week group session.
• Free use of ACT strategies to solve
motivation problems.
• Assistance in use of current week skills to
main problems.
• Use of FEAR-DARE acronyms
• Assigning weekly homework.
• Use of SMART acronym.
 16 sessions (4 therapists)
WISE CHOICES: ACT GROUP TREATMENT FOR BPD
(Morton & Shaw, 2012)
“ENHANGEMENT”
• Individual sessions
• 10th session: Assesment.
• Functional analysis: Identifiation of CRBs.
• Sessions 11-18:
enhangement.
Wise
Choices
FAP
• Review of group week group session.
• Free use of ACT strategies to solve
motivation problems.
• Assistance in use of current week skills to
main problems.
• Use of FEAR-DARE acronyms.
• Use of 5 rules to work on CRBs and draw
parallels to Os.
• Assigning weekly homework.
• Use of SMART acronym.
 16 sessions (4 therapists)
PILOT STUDY JUSTIFICATION
• Contribute to psychological well being of BPD diagnosed patients:
Diminishing entry to emergencies services, symptoms of emotion
dysregulation, impulsivity, suicidal risk, fear of emotions and
experiential avoidance; Improving quality of life and interpersonal
adjustment.
• Need to start a research line based about the development and
effectiveness of low cost interventions for BPD (Lieb et al., 2004; Marquis &
Wilber, 2008).
• INPRF BPD had one year at pilot study start, TFP (1 year / 2 sessions per week) and
DBTinformed where TAU (9 months / 1 group and individual session per week).
HYPOTHESIS
• ACT+ will show better lobal outcomes tan TAU on
• Reduction on BPD symptoms severity – Borderline Evaluation of Severity Over Time
Scale (Pfohl et. al. 2009; Reyes & García, 2014).
• Reduction on Suicide Risk – Plutchik Suicide Risk Scale (Plutchik & Van Pragg, 1989).
• Reduction on Impulsivity – Plutchik Impulsivity Scale (Plutchik & Van Pragg, 1989;
Páez et al. 1996).
• Reduction on Emotion Dysregulation – Difficulties in Emotion Regulation Scale
(Gratz & Roemer, 2004; Marín Tejeda et al. 2012).
• Reduction on Experiential Avoidance – Acceptance and Action Questionnaire-II
(Ciarrochi & Bilich, 2006; Patrón 2010).
• Reduction on Fear of Emotions – Affective Control Scale (Williams, Chambless &
Ahrens, 1997; Ramírez, Ascencio, Reyes & Vargas, 2014).
• Improvement of Quality of Life – WHO Quality of Life Scale (World Health
Organization, 1993).
*Results not shown in this presentation
STUDY PARTICIPANTS
SOCIODEMOGRAPHIC
CHARACTERISTISCS
STUDY PARTICIPANTS COMORBIDITIES
PILOT STUDY RESULTS
PILOT STUDY RESULTS
PILOT STUDY RESULTS
PILOT STUDY RESULTS
DISCUSSION AND CONCLUSION
HIPOTHESIS TESTING AND IMPACT
SOLUTIONS TO STUDY LIMITATIONS
• ACT+ showed to be and effective brief intervention
as needed by the INPRF-BPD clinic.
• Need of a wider N
• ACT+ enhanged could achieve better outcomes,
specially on interpersonal satisfaction and social
adjustment domains.
• Include DBT crisis survival and emotion regulation skills
on the fist module.
• Use of Matrix model to integrate ACT and FAP
elements.
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Drawing paralels between CRBs and Os since treatment
start including group sessions.
Formal FAP on second module individual sessions.
• ACT+ is the new TAU of the INPRF-BPD clinic.
• Compare groups by age and diagnosis.
• Need of a RCT to prove effectiveness
compared to time equivalent treatments.
• Asses treatment integrity of all treatments.
• Refinement of selection criteria.
• Need of mediational analysis.
• Asses relation between hypothesized
mediational variables and treatment
outcomes.
CASE CONCEPTUALIZATION
(Reyes, 2014; adapted from Polk, 2014)
FIVE SENSES EXPERIENCE
I-T1s
G-T1s
AVOIDANCE
T3s
I-CRB1s
G-CRB1s
O1s
PERSPECTIVE
-----------------CHOICE
POINT
I-CRB3s
G-CRB3s
Problematic rules
CRB2s
G-CRB2s
O2s
I-T2s
G-T2s
ÁPROACHING
Values
MENTAL EXPERIENCE
I-T Values
G-T Values
CURRENT RESEARCH
RG1
01
RG2
04
RG3
O7
ACT+FAP+DBT
(18 G+I sessions)
02
(6 months)
03
(12 months)
ACT+
(18 G+I sessions)
DBTi
(18 G+I sessions)
05
(6 months)
08
(6 months)
06
(12 months)
09
(12 months)
• Participants:
• 150 participants with BPD diagnosis confirmed by SCID-II; 50 randomly assigned to each group.
• Schizofrenia, current psychosis, bipolar disorder, neurological conditions and antisocial
personality diagnosed participats will be excluded.
• Age range: 18 – 45 years.
RCT HYPOTHESIS
• H1: ACT+DBT+FAP will show better outcomes than TAU in
• Reduction on BPD symptoms severity – Borderline Evaluation of Severity Over Time Scale
(Pfohl et. al. 2009; Reyes & García, 2014).
• Reduction on Suicide Risk – Plutchik Suicide Risk Scale (Plutchik & Van Pragg, 1989).
• Reduction on Impulsivity – Plutchik Impulsivity Scale (Plutchik & Van Pragg, 1989; Páez et al.
1996).
• Reduction on Emotion Dysregulation – Difficulties in Emotion Regulation Scale (Gratz &
Roemer, 2004; Marín Tejeda et al. 2012).
• Reduction on Experiential Avoidance – Acceptance and Action Questionnaire-II (Ciarrochi &
Bilich, 2006; Patrón 2010).
• Reduction on Fear of Emotions – Affective Control Scale (Williams, Chambless & Ahrens,
1997; Ramírez, Ascencio, Reyes & Vargas, 2014).
• Improvement of Quality of Life – WHO Quality of Life Scale (World Health Organization,
1993).
• H2: Hypothesized change mechanisms will significantly mediate impact of
treatments.
• Psychological Flexibility – Acceptance and Action Questionnaire-II (Ciarrochi & Bilich, 2006;
Patrón 2010).
• Mindfulness – Five facets of mindfulness questionnaire (FFMQ; Baer, Smith, Hopkins,
Krietemeyer, & Toney, 2006)
• Emotion Regulation – Difficulties in Emotion Regulation Scale (Gratz & Roemer, 2004; Marín
Tejeda et al. 2012).
• H3: Significant differences on mediational mechanism contribution to change
between treatments will be found.