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ACT+FAP TREATMENT OF BORDERLINE PERSONALITY DISORDER

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

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  1. 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

  2. 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)

  3. 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).

  4. 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)

  5. 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)

  6. 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)

  7. 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)

  8. 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).

  9. 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

  10. STUDY PARTICIPANTSSOCIODEMOGRAPHIC CHARACTERISTISCS

  11. STUDY PARTICIPANTS COMORBIDITIES

  12. PILOT STUDY RESULTS

  13. PILOT STUDY RESULTS

  14. PILOT STUDY RESULTS

  15. PILOT STUDY RESULTS

  16. 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.

  17. 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

  18. 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.

  19. 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.

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