الفهرس 
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Abstract
Borderline personality disorder is commonly associated with other axis I disorders and comorbidity with SUD is one of the very common comorbidities. Co-morbidity between BPD and SUDS is associated with greater severity than is found in either diagnostic group alone. Individuals with SUD and BPD are among the most difficult patients to treat for either condition, and they have more problems than those with only one or the other.
Dialectical behavior therapy (DBT) is a well-established treatment for individuals with multiple and severe psychosocial disorders, including those who are chronically suicidal. Because many such patients have substance use disorders (SUDs), DBT was adapted for treatment of substance abusers. DBT-S incorporates concepts and modalities designed to promote abstinence and to reduce the length and adverse impact of relapses. Among these are dialectical abstinence, “clear mind,” and attachment strategies that include off-site counseling as well as active attempts to find patients who miss sessions. Several randomized clinical trials have found that DBT for Substance Abusers decreased substance abuse in patients with borderline personality disorder.
The aim of the present work was:
- To evaluate the effectiveness of dialectical behavior therapy ”DBT” in outpatients with comorbid borderline personality disorder and substance use disorder recruited from substance use treatment centers in Alexandria.
- To evaluate impact of DBT on emotional regulation in outpatients with comorbid borderline personality disorder and substance use disorder.
The study was conducted in three private practice outpatient clinics Alexandria and Cairo including 40 outpatients visiting the above mentioned settings during the period from 1st of January 2014 till 30th of March 2016. Forty patients of both genders aging between 18 and 40 years with comorbid BPD and SUD assigned at their convenience or according to immediate availability of treatment slot either to Group-I receiving comprehensive DBT (n=20) or Group-II receiving treatment as usual “TAU” (n=20).
All patients were diagnosed with comorbid substance use disorder and borderline personality according to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria. All patients signed a written consent to participate in the study. Patients with other psychiatric illnesses that may interfere with judgment (schizophrenia, any other psychotic disorder, bipolar disorder or intellectual disability) were excluded.
Structured Clinical Interview (SCID-II) and International Personality Disorder Examination (IPDE): were used as a screening for borderline personality disorder followed by clinical psychiatric examination using DSM-5 criteria for confirming diagnosis of borderline personality disorder and substance use disorder. The Arabic version of The Mini-International Neuropsychiatric Interview (M.I.N.I.) was for assessment of comorbid psychiatric disorders at baseline. Arabic translation of timeline followback assessment of alcohol and drugs of abuse was utilized for quantitative assessment of alcohol and drug use at baseline, 4, 8, 12 and 16 months. Arabic translation of Difficulties in Emotion Regulation Scale (DERS) was used for assessment of emotional dysregulation at baseline, 4, 8, 12 and 16 months.
The collected data were analysed using Chi-square test (X2), Monte carlo test (MCp), Fisher Exact test (FEp), Mann Whitney test (Z) and liner mixed model to compare between different periods in each group.
Results of this study revealed that:
- Both groups were mixed gender with no significant difference in between groups regarding male/female ratio with mean age of 24.20 ± 4.19 for DBT group and 26.25 ± 6.29 for TAU group.
- The sample was balanced with no significant difference between DBT group and TAU group regarding age, sex, marital status, work, education or past history of chronic medical conditions (e.g. Diabetes Mellitus, hypertension, cardiac problems).
- Psychiatric comorbidities included mood disorders (major depressive disorder and bipolar affective disorder), anxiety disorders (generalized anxiety disorder, social anxiety disorder and panic disorder), post-traumatic stress disorder (PTSD), obsessive compulsive disorder (OCD), adult attention deficit hyperactive disorder (ADHD) and eating disorders (one case suffering from bulimia nervosa in the DBT group and one case suffering from anorexia nervosa in the TAU group) with no significant difference between the two groups regarding each axis I disorder or total number of comorbid disorders.
- Four patients from the DBT group had comorbid personality disorder other than BPD (2 cases with histrionic personality disorder, one with narcissistic personality disorder and one with antisocial personality disorder), while six patients of the TAU group had another personality disorder (4 suffering from histrionic personality disorder, one with comorbid and obsessive personality disorder and one with antisocial personality disorder) with no significant difference in between the two groups.
- The sample was balanced regarding the past history of psychiatric hospital admission and there was no significant difference between DBT group and TAU group regarding the mean number of hospital admissions.
- Nearly half of the patients in each group was receiving current psychotropic medications including antidepressants (AD), antipsychotics (AP), mood stabilizers (MS), benzodiazepines and one patient in DBT group was receiving stimulant medication (long-acting methylphenidate) and another one from the same group was on non-stimulant medication for adult ADHD (Atomoxetine). There was no significant difference between the two groups regarding use of psychotropic medications in general nor in each drug class separately.
- DBT patients were generally suffering from a more severe form of BPD with significantly more mean number of BPD symptoms in comparison to the TAU group (8.10 ± 0.79 vs. 7.35 ± 0.93). Also 18 patients out of the DBT group had past history of suicidal attempts in comparison to 12 patients only of the TAU group (90% vs. 60%) and the difference was statistically significant in favor of the DBT group. The same applies to past history of non-suicidal self-injury (NSSI) where DBT patients were significantly more cutting in comparison to TAU group (80% vs. 40%).
- There was no significant difference between the two studied groups regarding the mean total number of years using substances. Almost all of the patients in study sample were using Cannabis. Other drugs included heroin, cocaine, alcohol, sedative hypnotics, tramadol and other prescription medications that they couldn’t specify (described by patients as pills).
- Patients in the DBT group had significantly more severe SUD in comparison with patients in the TAU group regarding the mean of the total number of substances being used (2.65 ± 1.14 vs. 1.85 ± 1.04). Also, DBT patients were suffering from comorbid alcohol use disorder two times more than the TAU patients (80% vs. 40%) and the difference was statistically significant.
- Family history of psychiatric illnesses was assessed as a part of history taking during the intake. There was no significant difference between the two studied groups regarding family history of psychiatric illness other than BPD and SUD nor in family history of BPD or SUD. Nearly one third of patients in both groups had family history of BPD in one of their parents or first degree relatives.
- Patients in DBT group had significantly lower drop-out rates with only 5 out of 20 patients that did not complete treatment year, in comparison to 12 patients who dropped out of 20 in the TAU group (25% vs. 60%).
- Patients in the DBT group had less mean number of suicidal attempts by the end of treatment year and no suicidal attempts at all during the four months follow up period and the difference was statistically significant in comparison to TAU group at follow up.
- There was no significant difference between the DBT and TAU patients regarding the mean of number of NSSI and number of hospital admissions by the end of treatment year and at follow up although there was a significant difference between the two groups at baseline.
- DBT patients visited ER less than TAU patients by the end of treatment year and had no visits at all during the four months follow up and the difference between the two groups was statistically significant during follow up period.
- In comparison to TAU patients, patients in the DBT group had significantly longer mean of durations since last substance use and longer mean of longest period of abstinence of all drugs and the difference was maintained to be statistically significance at 4 months follow up after completion of treatment year.
- Also, DBT patients had significantly lower mean of both maximum and least amount of substance used during the treatment year in comparison to the TAU group, and again the difference continued to be statistically significance at the 4 months follow up after completion of treatment year.
- DBT patients showed better improvement of emotion regulation in comparison to TAU as shown in the statistically significant lower mean of total score of DERS (93.20 ± 9.76 vs. 130.17 ± 10.34) that retained its statistically significant lower values at the 4 month follow up following treatment year.
- The decrease in mean of DERS scores in the DBT group in comparison to TAU was also statistically significant for the mean value of all DERS subscales except for lack of emotional awareness (AWARENESS) which was lower in the DBT group too but the difference was not statistically significant. Again, the outcomes obtained at the end of treatment year were all maintained at 4 months follow up with statistically significant differences between DBT and TAU patients among all DERS subscales except for lack of emotional awareness.
- Patients in both groups showed decreases number of suicidal attempts at different assessment points over treatment year but the difference was statistically significant in favor of DBT patients only at the last four months of treatment and at follow up.
- The same pattern was shown in terms of decrease in number of ER visits and again the DBT patients had a statistically significant difference in comparison to TAU group at the last four months of treatment that remained significant at follow up.
- Whereas patients in both groups showed a pattern of decreasing number of NSSI and hospital admissions throughout treatment year and at follow up but the difference between the two groups was not statistically significant.
- Although patients in the DBT groups had significantly higher values for all of the above mentioned parameters at baseline, it is clear that DBT patients showed a steady decrease in numbers of suicide attempts, NSSI, hospital admissions and ER visits that started as early as the first four months of treatment and continued to decrease steadily even at 4 months follow up.
- Although patients in both groups showed a gradual increase in durations since their last substance use and achieved longer periods of abstinence at different assessment points during the treatment year, the difference between the two groups was statistically significant in favor of patients receiving DBT and the difference was obvious starting from the first 4 months
- On the other hand, statistically significate difference between DBT and TAU groups regarding the maximum and least amount of substances used at 8, 12 and 16 months showing that DBT patients used decreasing amounts of substances in comparison to TAU patients and the DROP in amounts was steady even at follow up.
- DBT patients had statistically significant lower mean total score of DERS in comparison to patients receiving TAU at 4, 8, 12 and 16 months although the two groups were not significantly different at baseline.
- The difference between the two groups favoring patients receiving DBT was not only regarding the total DERS score, but also the same difference and steady decrease across treatment year and at follow up was statistically significant for all the six subscales of DERS with clear bifurcation of the two groups starting from the first assessment point at 4 months.