Acta Medica Mediterranea, 2017, 33: 1025

COMPARING OF THE EFFECT OF DIALECTICAL BEHAVIOR THERAPY (DBT) AND THERAPY (ST) ON REDUCING MOOD ACTIVITY AND SUICIDAL THOUGHTS IN PATIENTS WITH BORDERLINE

LADAN MOHAMADIZADEH1, BEHNAM MAKVANDI2*, REZA PASHA2, SAEID BAKHTIARPOUR2, FARIBA HAFEZI2 1Psychology PhD Candidate, Department of Psychology, Khuzestan Science and Research Branch, Islamic Azad University, Ahvaz, Iran - 2Assistant Professor, Department of Psychology, Ahvaz Branch, Islamic Azad University, Ahvaz, Iran

ABSTRACT

Introduction: Borderline personality disorder is known as the most common personality disorder in the field of psychiatry. The aim of this study was to compare the effect of dialectical behavior therapy and schema therapy on mood activity and suicidal thou- ghts in patients with borderline personality disorder in the city of Qazvin. Materials and methods: This study in terms of purpose is an applied one and in terms of the method of data collection, can be regarded as pre-experimental and post-experimental semi-experimental study with the control group. The study population included all patients with borderline personality disorder and mood activity and suicidal thoughts who referred to Bou-Ali Hospital in the city of Ghazvin. The sample consisted of 36 students, who were selected by convenience sampling. Of these, 24 patients were randomly divided into two groups, two experimental group including12 people, and a control group consisting 12 patients. In this study, The Millon Clinical Multiaxial Inventory, The beck Depression Inventory and Scale suicide imagination Mach (SSIM) were used. Patients with the borderline personality disorder who belonged to the experimental group were under intervention for 16 section which takes long 90 minutes sessions in eight consecutive weeks under the controls. Research data was analyzed using multivariate and single factor analysis of covariance, and T-experimental was analyzed for the independent groups. Results: The results showed that there was a significant difference between dialectical behavior therapy and schema therapy with regard to their effect on mood activity and suicidal thoughts at (0.05> P). The results of the Independent t-experimental also showed that there was no significant difference between dialectical behavior therapy and schema therapy in patients with the border- line personality disorder in terms of the Suicidal thoughts variable at (0.05> P), but there was a significant difference between sche- ma therapy and dialectical behavior therapy in patients with the borderline personality disorder in terms of the mood activity varia- ble at (0.01> P). Discussion and conclusion: So, we could conclude that dialectical behavior therapy and schema therapy should be effective in reducing mood activity and suicidal thoughts in patients with borderline personality disorder.

Keywords: dialectical behavior therapy, schema therapy, mood activity, suicidal thoughts, borderline personality disorder.

DOI: 10.19193/0393-6384_2017_6_162 Received December 30, 2016; Accepted June 20, 2017

Introduction der in this way; it is a pervasive pattern in relation with instability in interpersonal relationships, self- Borderline personality disorder which is image, and mood. It starts in the early known as one of the personality disorders, is the adulthood and emerges in different situations. most common one in psychiatric settings. The term According to the previous studies, the prevalence of border is a psychoanalytic term first used for a borderline personality disorder has been growing in group of patients who were on the border of neurot- the population from1 to 2%, and the rate of suicide ic and discrete mental groups(1). The psychiatric in people suffering from it is about 10%. The num- Association of America(2) has described this disor- ber of women with borderline personality disorder 1026 Ladan Mohamadizadeh, Behnam Makvandi et Al is two times more than that of men with this disor- reducing anger before it happens, as well as ders(3). reduced self-harm(9). The main characteristic of borderline personal- Schema therapy is another psychological treat- ity is emotional instability. Some important features ment that can have a positive effect on the symp- of patients with this disorder are mood activity and toms of borderline personality disorder. Schema suicidal thoughts. These patients are known with therapy has been developed for the treatment of downward and upward emotions, instability and patients with chronic cognitive behavior problems; anger; they need to communicate and have variable these patients have not got enough help from the comments in relation to others. Patients with bor- classical cognitive-behavioral therapy. The treat- derline personality disorder even for a brief ment is a good choice for many patients with disor- moment when they are alone, experience empti- ders of Axis 1 and 2 who have long-term cognitive ness. Despite having romantic and strong relation- behavior problems related to the cognitive charac- ships, they are heartbroken most of the time. They ter. According to this model, the schemas are at the make efforts without reason, such as committing core of personality disorders, and behavioral pat- suicide to avoid losing. Suicidal behaviors are relat- terns in DSM are mainly responses to the central ed to a situation in which a person puts himself at scheme. The main goal of treatment in patients with the risk, but his suicide attempt is not complete cognitive behavior problems is to improve the (Like dropping over the bridge and putting the schema(10). tablets in the mouth but not swallowing them)(4). Taking into account the effectiveness of They suffer from the problems like mood schema therapy and dialectical behavior therapy in activity, unsatisfactory relationships with others, reducing the symptoms of borderline personality impulsive behavior and ambiguous identity. Despite disorder, the present research aimed to study and the fact that most patients with borderline personal- compart the effect of these treatments on people ity disorder are intelligent and creative, they rarely, who commit suicide. Physical therapists and crisis show progress in the development of their talents. intervention experts can make benefit from the The risk of self-injury in people is due to the high findings of the study. Therefore, the present study self-mutilation or drug abuse. 69 to 75% of people was set out to find out how and to what extent each with borderline personality disorder suffer from the of these schema therapy treatments and dialectical self-harm behaviors as well. 69% of them are at a behavior therapy could improve the mood activity high risk for suicide, and approximately 10% of and suicidal thoughts in borderline personality dis- deaths in this population are as a result of a suicide order. attempt(5). To reduce the borderline personality dis- order in patients with depression, various treat- Materials and methods ments have been suggested among which dialecti- cal behavior therapy (DBT) and Schema Therapy The research method was a quasi-experimental (ST) can be named(6). one. The experimental group was trained in two DBT is more complex than some other meth- groups in the field of dialectical behavior therapy ods, and its success in the treatment of personality and Schema Therapy, while the control group disorders, especially BPD(7) and its related traits(8), received no intervention. The population in this has been well proved. This method was invented in group included all patients with borderline person- 1993 by Marshall Linehan. The model was pro- ality disorder who lived in the city of Qazvin in posed by dialectical behavior therapy for borderline 2015. The sample included 36 cases of female personality disorder because people with borderline patients with borderline personality disorder who personality disorder suffered from poor emotional referred to Bou-Ali Hospital in Qazvin they were regulation in their interpersonal relationships. selected using the convenience sampling method. There are many maladaptive behaviors The patients were randomly divided into three (including many symptoms of borderline personali- 12-person groups; the first group received dialecti- ty disorder diagnosis), such as impulsive behavior, cal behavior therapy intervention, the second group that have been reinforced in these people. got schema therapy received Dialectical behavior According to the research, dialectical behavior ther- therapy intervention, and the control group received apy plays an important role in reducing suicide no intervention. Exclusion criteria in the samples attempts and depression, increasing control and were related to the patients who had committed sui- Comparing of the effect of dialectical Behavior therapy (DBT) and schema therapy (ST) on reducing mood activity ... 1027 cide, and re-suicide; people with perturbations such symptoms. The standardized cutoffs used differed as bipolar disorder, , and personali- from the original: 0-13: minimal depression, 14-19: ty disorder treated with the drug, were initially mild depression, 20-28: moderate depression, 29- excluded. The use of any psychiatric medication 63: severe depression. during training, from the very first session of treat- The BDI-II is positively correlated with the ment, and the use of any type of psychological ser- Hamilton Depression Rating Scale with a Pearson r vices were abandoned. Also, variables such as age of 0.71, showing a good agreement. The test was and gender were controlled. also shown to have a high one-week test–retest reli- Tools: 1. Clinical Interview, 2. The Millon ability (Pearson r =0.93), suggesting that it was not Clinical Multiaxial Inventory, 3. The beck overly sensitive to the daily variations in mood Depression Inventory, and 4. Scale suicide imagina- (16). The test also had high internal consistency tion Mach. (α=0.91)(15). 1) Clinical interview based on the Diagnostic 4) The Scale for Suicide Ideation (SSI) of and Statistical Manual of Mental Disorders: Mach: Structured and semi-structured diagnostic interview This scale was designed by Beck et al., (1979). consisted of a systematic set of specific questions A tester has a questionnaire with 19 items. Each meant is to evaluate those behavior patterns, question has three choices with zero, one and; two thoughts and emotions of readers that were some- scores. Totally, scores range from zero to 38 (based how associated with their disorder(11). on the presence or absence and different stages of 2) Millon Clinical Multi-axial scale: This ideation to the suicide act). The scores in the range scale, which was built in 1977 by Million, was of 0-3 show no suicide ideation, the 4-11 range rep- revised in 1990. It measures thirteen personality resent the low risk suicide ideation and scores 12- disorder in terms of Article 175, by answering two 38 stand for the risky suicide ideation. Translations, “yes” or “no” items. Psychometric characteristics of adaption and initial study on Mach are performed in the Millon Clinical Multiaxial -2 included experi- recognition and behavior studies of Rusbeh mental-reexperimental reliability, internal consis- Hospital. The studies verified the content validity tency and reliability in the preceding foreign studies and the relative reliability of the Persian version of that had been reviewed and approved(12, 13). this questionnaire in the Iranian population. The It could measures thirteen personality disorder studies of Kaviani et al., (2001) verified the content in terms of Article 175 by answering with a yes or validity and the relative reliability of the Persian no. Millon Clinical features of The Million Clinical version of this questionnaire in the Iranian popula- Multiaxial Inventory (MCMI) including experimen- tion. tal-re experimental reliability, internal consistency Methods of study: After selecting, the subjects and reliability in the studies had been reviewed and were randomly divided into three12-people groups: approved(12, 13). According to the Preliminary two experimental groups and one control group; the Validation results of The Million Clinical Beck Depression Inventory and Scale suicide imag- Multiaxial Inventory-2 in Iran, reliability was mea- ination Mach (SSIM) were used as the pre-experi- sured using kuder-richardson which had been mental. Then, two experimental groups were reported to be equal to 0.85, and the reliability coef- trained by a psychologist under dialectical behavior ficient of re experimental was estimated to be to therapy and schema therapy in 16 sessions for 90 0.86(14). minutes, while the control group received no inter- 3) The Beck Depression Inventory (BDI, BDI- vention. After the intervention, the post- experi- 1A, BDI-II), created by Aaron T. Beck, is a 21- mental was collected from three groups. question multiple-choice self-report inventory(15). Topics of the dialectical behavior therapy ses- The BDI-II was a 1996 revision of the BDI which sions included: the first and fifth session: was, developed in response to the American Mindfulness based on the symptoms control, sec- Psychiatric Association’s publication of the ond and sixth meetings: expression and emotion Diagnostic and Statistical Manual of Mental regulation, third and seventh sessions: Stress Disorders, Fourth Edition. Like the BDI, the BDI-II Tolerance, and the fourth and eighth sessions: train- also contained 21 questions, with each answer ing Interpersonal skills. Also, the topics of the being scored on a scale value of 0 to 3. Higher total Schema therapy sessions were as follows: scores would indicate more severe depressive 1028 Ladan Mohamadizadeh, Behnam Makvandi et Al

First session: introduction took place and the variance showed that all three groups (experimental subjects were interviewed. and control) were homogeneous in terms of vari- The second and third sessions: the pre-experi- ance, thereby revealing that our next results would mental was taken, and cognitive techniques with be sustainable. The results also showed significant homework were on the agenda. homogeneity using MANCOVA tests, which Fourth and fifth sessions: Mental imagery, the included Pillai’s Trace, Wilks’ Lambda, Hotelling's conversation, limited parental relations, depending Trace and Roy’s Largest Root. The tests presented on the type of scheme, were used. indicated that; there was a significant difference Sixth and seventh sessions: the between the three groups at least in one of the of the problematic position, Relationship Therapy, dependent variables (0.05 = P). relationships with important people in life and role- Variables F Df1 Df2 P playing were employed. mood activity 2.418 2 33 0.144 Eighth Session: Analysis and implementation of the post-experimental were performed. Because suicidal thoughts 1.456 2 33 0.248 of moral considerations, the consent of participants in the research was got from their families. Also, Table 2: The results of the analysis of the homogeneity of variances (Levene experimental). they were assured that their information would remain confidential. Tests of Between-Subjects Effects Dependent Type III Sum Source Df Mean Square F Sig Variable of Squares Results Post-test of Group 25.007 2 12.504 4.318 0.034 mood activity

In total, 36 patients with borderline personality Post-test of sui- 5.124 2 2.562 4.246 0.041 disorder and mood activity and suicidal thoughts cidal thoughts were studied; the mean and standard deviation of Table 3: MANCOVA results related to the variables of the variables in groups 1, 2 and the control group mood activity and suicidal thoughts in three control are presented in Table 1. groups and 1 and 2 experimental groups after controlling the pre-test.

Group DBT group ST group Control group According to the results in Table 3, the Variables Standard Standard Standard Mean Mean Mean effect of group according to the amount of F deviation deviation deviation reported at 0.05, was significant. Table 4 Pre-test 55 3.93 57 4.44 54.91 3.08 summarizes the results of the independent t- mood activity Post-test 24.16 2.7 19.83 1.53 53.75 2.13 test to examine the significance of differ-

Pre-test 33.41 1.5 31.83 1.52 31.58 1.24 ence between the means for the dependent suicidal thoughts variable. Post-test 15.25 1.65 14.33 1.55 31 0.96 According to the data from Table 4, the Table 1: The mean and standard deviation of the variables of research effect of group was significant for the mood in groups 1, 2 and the control group. activity variable at 0.05 levels; and for the suicidal thoughts variable at the 0.05 level, Multivariate analysis of variance was used to it was not found to be significant according to the investigate the differences between the dependent T-reported values. variables. Before applying this analysis, the Therapy Standard assumptions underlying its use , including normal Variables Mean t P Type deviation distribution of variables, the same slope of the regression line, and the homogeneity of variances, DBT 19.83 1.528 mood activity 3.034 0.006 were investigated; all of them were met. Table 2 ST 24.17 4.707 shows the results of the analysis of the homogene- DBT 15.25 1.658 ity of variances (Levene experimental). suicidal thoughts 1.396 0.663 As can be seen in Table 2, the significance ST 14.33 1.557 level indicated that the data did not question the Table 4: summary of the results of the independent t-test assumption of the equality of the variances error. In to examine the significance of difference between the fact, the Levene experimental results for the exami- means for the dependent variables. nation of the assumption of the homogeneity of Comparing of the effect of dialectical Behavior therapy (DBT) and schema therapy (ST) on reducing mood activity ... 1029

Thus, there was a significant difference symptom that are associated with a lack of emo- between schema therapy and dialectical behavior tional control. For example, previous studies have therapy in patients with borderline personality dis- shown that those with dissociative tendencies in order in terms of the mood activity variable at the their behavioral repertoire may respond to traumat- level 0.01. But the results showed that there were ic events with automatic dissociative patterns, even no significant differences between schema therapy in response to milder stressors or reminders of the and dialectical behavior therapy in patients with original trauma(24).Therapist teaches the patient that borderline personality disorder in terms of the suici- these behaviors are harmful, and makes clear, why dal thoughts variable (P<0.001). the behaviors that are detrimental to treatment; should be stopped. Thus, the first strategy in deal- Discussion ing with such a behavior is commitment to change. These behaviors are disturbing the patient’s The results showed that dialectical behavior quality of life, an issue discussed between patient therapy and schema therapy could have a signifi- and therapist(25). Therapist teaches the patient that cant effect on reducing mood activity and suicidal Mood activity can be harmful, and makes clear, thoughts in patients with the borderline personality why the behaviors caused by it are detrimental to disorder. Also, in terms of the above variable, there the treatment and should be, therefore stopped… was no significant difference between schema ther- Thus, the first strategy in dealing with such behav- apy and dialectical behavior therapy in terms of ior is commitment to change. This issue that which their effectiveness. The findings of this research are of behaviors are disturbing the patient quality of consistent with the studies conducted by Zamani, life is an issue that is discussed between patient and Ataei and Mirshekari(17), Lynch, Shionz, Kokroviz, therapist Interpersonal skills including training, dis- Trop, Brunner and Bear(18), Mohammadi, Dadkhah, tress to lerance skills (discomfort), emotion regula- Mozafari and Molaei(19), Alizadeh et al(9), tion skills, and Central mindfulness skills are con- Abolghasem and Jafari(20), Aghayousefi, Tarkhān sidered as behavioral skills that are taught in this and Ghorbani(21), and Dykhavt and Arnetz(22). treatment of the patient. Emotional irritability is the In explaining the results obtained in the pre- main characteristic of BPD. Therefore, emotion sent study, we can say that, people with borderline regulation skill training has a key role in the treat- personality disorder have hard experiences in emo- ment of this disorder. tion regulation, interpersonal relationships and Another important issue is training distress stress tolerance. Most of these people have faced tolerance, which can prepares the patient to accept the suicidal behavior to reduce negative emotions. and deal with painful emotions at the same time(25, Intense negative emotions and the inability to modi- 17). Therefore, a dialectical action takes place fy are very important for their self-harm behavior between two groups of skills. Training skills and and very few of them respond to the psychiatric accreditation by the therapist can increases the drug treatments(3). Suicidal behaviors are considered patient's sense of self-confidence due to the feeling as symptoms for solving maladaptive problems and that he understands surroundings exactly. the result of the lack of alternative behaviors(23). Moreover, achieving individual goals, resolving Thus, dialectical behavior therapy is related to feelings of inadequacy and coming to a feeling of training behavioral skills and replacing adaptive relief and happiness are other objectives of dialecti- behaviors rather than the maladaptive behaviors. cal behavior therapy. Mood activity in patients with borderline per- From the perspective of Yang’s schema thera- sonality disorder have characteristics such as py, any individual forms some schemes during his extreme impulsivity behaviors, driving in a forth- childhood. Schema is an organized notice structure right way, sexual promiscuity, destructive and dys- formed in childhood and reflected in behaviors, functional interpersonal relationships (for example, feelings and thoughts. A patient with borderline doing sexual abuse within the family, or acceding to personality disorder may make change in his abuse and emotional exploitation by an sexual or intense emotional mood in a very short time. Based emotional partner), risky behaviors, substance on the schema mentality model, this is due to the abuse, eating disorders, depression and thoughts of positional and uncontrollable changes of the patient suicide, homelessness, long-term unemployment which occur sequentially from one mentality to courses, interpersonal problems, and dissociative another(26). 1030 Ladan Mohamadizadeh, Behnam Makvandi et Al

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