Mentalization-based treatment for female patients with comorbid personality disorder and substance use disorder: A pilot study

Mentalization-based treatment for female patients with comorbid personality disorder and substance use disorder: A pilot study
Our pilot study indicates that mentalization-based treatment may be a promising treatment modality for female patients with comorbid substance use disorder and borderline personality disorder, write Katharina T. E. Morken and colleagues.
IMPROVEMENTS: We found that for the majority of the 18 female patients who received mentalization-based treatment in our pilot study, their drug and alcohol consumption and personality problems improved considerably over time, write Katharina T. E. Morken and colleagues. Illustration: Aurora Nordnes. Mentalization-based treatment for female patients with comorbid personality disorder and substance use disorder: A pilot study

One possible way of understanding substance use is by seeing it as one of several self-soothing strategies utilized by patients who struggle with personality problems (e.g. emotional dysregulation and social deficiencies Substance use disorder (SUD) and personality disorder (PD) are frequently co-occurring but clinically their comorbidity is often ignored or treated separately; in some institutions, SUD is even considered an exclusion criterion in treatment programs for PD.

There is no doubt that the comorbidity between personality disorder and substance use disorder overall is high. Numerous studies have demonstrated the frequent covariance between these two disorders . It has been debated whether it is PD in general or Cluster B specifically that drives the covariation. It has also been discussed if the covariance can be explained by overlapping criteria (e.g. impulsivity in borderline personality disorder (BPD) and antisocial PD).

For example, in one study of opiate use disorders in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), 50% of respondents had a PD. When controlling for the general criteria for PD, borderline personality disorder became a clear predictor for SUD (). It has been suggested that the covariation between BPD and SUD are linked via impulsivity Among SUD patients, a median of 57% (range 35%-73%) had concurrent PD (), and among PD in the general population, the prevalence of comorbid SUD was 42% for alcohol and 19% for substance use ().

In Scandinavian samples, the co-occurrence of SUD in PD in a population-based study was 46 For female patients with SUD, BPD is the most common personality disorder (). Cluster B personality traits have been found to be independent risk factors for developing SUD BPD has been found as a significant risk factor for the persistence of SUD (), but remission of SUD in BPD in a 10-year study was also common (). Treatment of patients with BPD/SUD has been described as difficult due to high dropout rates and to relational problems that make the process of establishing a therapeutic alliance challenging ().

For instance, Cluster B traits present a barrier in forming a therapeutic alliance with SUD patients and Cluster B traits have been found to provoke distanced and overwhelmed/disorganized countertransference in helpers Concurrent PD/SUD results in a more serious substance use disorder and more substance use-related problems (). Risk for suicide attempts is higher for BPD patients with comorbid SUD compared to BPD or SUD patients alone although one study found no correlation between suicide attempts and baseline PD (). Risk for treatment attrition is higher for PD/SUD compared to SUD alone In addition, Cluster B traits and a PD diagnosis have been found to influence outcome negatively for SUD patients although in one study PD had no influence on the outcome of SUD at a six-year follow-up ().

Thus, when BPD and SUD co-occur, the patients seem to be struggling even more than when each of these serious disorders occurs alone, and therapeutically there are many pitfalls. Patients with dual diagnoses are marginalized, often excluded from psychiatric treatments, and most likely need additional support (T). Many have voiced the need for targeted treatments for this group of patients

Concerning evidence for efficacy of psychotherapy for BPD/SUD, the latest review found 10 controlled studies on BPD/SUD patients (). The studies included four studies with dialectical behavioral therapy (DBT), three with dual focused schema therapy (DFST), and three with dynamic deconstructive psychotherapy (DDP). DBT and DDP showed some reduction in symptoms and substance use while DFST had minimal effect on outcome. The authors conclude that the evidence base for treatment of co-occurring BPD/SUD needs more research and that some preliminary evidence exists to date in benefit of DBT and DDP.

Mentalization-based treatment has shown great promise with BPD patients in various RCTs and naturalistic cohort studies, both within the original environment and from other independent institutions (; B In some studies the difference between the control condition (structured clinical management, supportive group psychotherapy) and MBT has not been that large regarding outcome. However, the superiority of MBT has been demonstrated when the severity of PD is taken into consideration ().

To date, there is only one unpublished study from Stockholm on MBT for BPD/SUD. In this RCT, patients received 18 months of MBT or treatment as usual (TAU) within an outpatient addiction treatment clinic. Surprisingly, the MBT patients (N=24) did not differ from the control group (N = 22) with respect to outcome. There was one near significant finding (Mann-Whitney p = 0.06) that demonstrated the MBT group had no suicide attempts during treatment, versus four in the control group (). However, we cannot know for sure that treatment in this study was MBT proper since adherence was low Another study on MBT with severely impaired young BPD patients involved 79% with comorbid SUD. In this study, MBT showed improvement on several outcome measures, and effect sizes were large ().

Thus, to date, we still do not know whether MBT is an efficient approach for BPD/SUD patients. It could be that the presence of SUD has some consequences for treatment that we still do not fully understand. We have tentative knowledge that BPD/SUD patients seem to improve after MBT, but we also have knowledge of the opposite: no improvement at all. Many have advocated the importance of tailoring treatments to these patients who are so severely disordered. Still, we have only preliminary evidence that specialized treatment (e.g. DBT) for this patient group is beneficial (). Against this backdrop, we aimed to investigate in a pilot project if MBT, a specialized tailored treatment for BPD, is promising in the treatment of a group of severely disordered dual diagnosis patients with BPD/SUD. Furthermore, we strove to investigate the feasibility aspects of implementation, delivery by clinicians, and acceptability for patients in order to clarify whether a larger study could be recommended on this population and within this context.

Research questions

Does mentalization-based treatment have any positive effect on BPD/SUD patients' substance use and personality disorder (primary outcome)? Does mentalization-based treatment have any positive effect on symptom distress and/or interpersonal and social functioning (secondary outcome)? Is MBT feasible as a treatment and for investigation in a larger study format in a general drug clinic on female patients with dual PD/SUD?

Material and Methods


Patients were recruited from the inpatient and outpatient facilities of the Bergen Clinic Foundation (BCF). Patients in the BCF consist of both inpatients and outpatients with SUD, the majority with alcohol use disorder (40%-45%) and then equally distributed SUD diagnosis among cannabis, benzodiazepines and amphetamine dependency as most frequent. Multiple substance use is common; most patients have more than one SUD diagnosis. Most patients are without occupation (78%) and supported by different economic welfare benefits (75%-80%). A minority of the patients are female (27 Because the BCF has an explicit focus on gender-specific treatment where males and females are given separate treatments, this pilot was performed with female patients alone. We went out broadly in the clinic asking for participants who were "difficult to treat," female, and with a tentative diagnosis of BPD. Eighteen patients were included in the project. Inclusion criteria included being female and having a diagnosis of SUD together with a personality disorder with clinically significant borderline traits according to the SCID-II (). The full diagnosis of BPD was not necessary to enter the pilot. Exclusion criteria were diagnosis of schizophrenia and substitute opiate medication. See Table 2 for diagnostic profiles.

The patients were severely impaired, and all had histories of trauma. Seven of 18 had histories with rape, eight had been victims of violence in childhood, 10 had a history of neglect in childhood, and seven had experienced sexual trauma in childhood. Most patients had problems with violence and aggression. Ten of 18 had been violent toward people, 14 of 18 had been violent to material objects, and seven of 18 had been reported to the police for violent offences. Six patients had a prior history of psychotic episodes but not a diagnosis of schizophrenia. Their history of prior treatment was quite substantial, with a mean of four (range 1-15) prior admissions to inpatient treatment and a mean of three (range 1-7) periods of outpatient treatment.

They had a mean of two (range 1-4) SUD diagnoses and a mean of four (range 1-7) Axis I diagnoses at baseline. (See Table 2 for diagnostic characteristics.) All patients had maladaptive traits within the BPD category (range 3-9 traits). As for PD traits according to SCID-II, they had a mean of 18 (range 9-42) PD traits. The distribution of PDs can be seen in Table 3. Nine patients had more than one PD (range 2-5 PDs).

Clinical vignettes on one patient are hereby included to demonstrate a typical patient in this project:

Patient 1 Female patient, 28 years old, antisocial PD/BPD, polysubstance use disorder, and ADHD. History of neglect and conduct disorder in childhood. Before treatment, she uses amphetamine daily intravenously and in addition opiates and benzodiazepines. During assessment, she gets an ADHD diagnosis and starts on appropriate medication. Her level of functioning is very low, with a GAF score of 37. She has frequent impulsive, aggressive outbursts with people around her, both strangers and close relations. She gets easily agitated and sometimes uses violence or threats of violence. She is unemployed and receives welfare benefits. She finished two years of MBT. At follow-up she describes being abstinent from all drugs for the last four years. She has much fewer conflicts with others because she is able to see situations from the other's perspective. She has started a part-time job and deals with the relational aspect of working by thinking things through instead of acting out on colleagues. She is very grateful for the treatment that helped her.

Patients were assessed prior to treatment, every six months during treatment, and at follow-up. The number of measurement points per patient varied with a mean of four (range 2-6). All patients were invited via post to participate in a follow-up assessment. They received a gift certificate of 500 NOK (60 Euro / 60 U.S. dollars) for participation. Thirteen patients participated. Five patients did not participate in the follow-up. Some descriptive data and length of treatment are included below. Their reasons for not participating in t

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