Emotion Regulation Training for Adolescents With Borderline Personality Disorder Traits: A Randomized Controlled Trial

doi:10.1016/j.jaac.2012.09.002

Journal of the American Academy of Child & Adolescent Psychiatry

Volume 51, Issue 12, December 2012, Pages 1314-1323.e2

https://doi.org/10.1016/j.jaac.2012.09.002 Get rights and content

Objective

To evaluate the effectiveness of Emotion Regulation Training (ERT), a 17-session weekly group training for adolescents with borderline personality disorder (BPD) symptoms.

Method

One hundred nine adolescents with borderline traits (73% meeting the full criteria for BPD) were randomized to treatment as usual only (TAU) or ERT + TAU. Outcome measurements included severity of BPD symptoms, general psychopathology, and quality of life. Multilevel analyses were conducted on an intent-to-treat basis. Clinical significant change was determined by normative comparisons on a primary outcome measurement.

Results

Independent of treatment condition, the two groups improved equally on the severity of BPD symptoms, general psychopathology, and quality of life. Nineteen percent of the ERT group was remitted according to the cutoff score after treatment (at 6 months) versus 12% of the control group. Follow-up assessments in the ERT group at 12 months showed some further improvement (33% remittance). With regard to predictors of outcomes, adolescents with higher levels of depression or attention-deficit/hyperactivity disorder or oppositional-defiant disorder at baseline and who reported a history of abuse had worse outcomes, regardless of treatment condition. The attrition rate for the ERT sessions was remarkably low (19%).

Conclusions

Early interventions for BPD symptoms in adolescence are feasible and necessary. No additional effect of ERT over TAU could be demonstrated in the present study. There is a clear need for developing effective interventions for adolescents with persistent BPD symptomatology. Clinical trial registration information—Evaluation of Group Training for Adolescents (Emotion Regulation Training) with Emotion Regulation Problems: A Randomized Controlled Clinical Trial; http://trailregister.nl/; ISRCTN97589104.

Section snippets

Sample

Participants were 109 adolescents 14 to 19 years old (mean = 15.98 years, SD = 1.22 years) who were referred for emotion regulation problems and/or BPD features to one of four mental health centers in the northern Netherlands. Recruitment took place from November 2007 through February 2010. The initial diagnostic procedures were completed as customary for the center concerned. In cases of emotion regulation problems or BPD symptomatology as the main problem area, the adolescents were referred

Participants

Figure 1 presents a flowchart of assessment and randomization. Initially, 133 adolescents were referred for ERT, and 109 adolescents were randomized to one of the two conditions. The mean number of DSM-IV criteria was 6.17 (range = 3–9); 73% fulfilled five or more criteria. Nine ERT groups were performed. The mean number of therapy sessions was 12.1 (SD = 4.8, range = 0–17). The attrition rate was 19% (defined as having attended less than half the training [nine sessions]).

Participants were

Discussion

To the authors’ knowledge, the present study provides an account of the largest sample in a treatment outcome study in adolescents with BPD features and is the second published RCT for this group.² This study was conducted in general mental health institutes, with few exclusion criteria, thus increasing its external validity. Most adolescents (73%) fulfilled the full BPD criteria according to the DSM-IV. In addition, 62.4% of the adolescents had a minimum score of 16 on the Children’s

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: This article is discussed in an editorial by Dr. David J. Miklowitz on page 1238.

: This research received support from the Netherlands Organization for Health Research and Development (Zon-Mw) grant 10-000-2030 (H.M.S.).

: Dr. Timmerman served as the statistical expert for this research.

: The study took place in the Netherlands in four centers: University Medical Center Groningen, Geestelijke gezondheidsinstelling (GGZ) Friesland, Jonx Groningen, and Dimence Zwolle. GGZ Groningen and Adhesie Deventer gave permission to adapt the Dutch version of the Systems Training for Emotional Predictability and Problem Solving for adolescents.

: The authors thank all participating adolescents, their parents, and all therapists. They acknowledge Jaap Ringrose of GGZ Drenthe for his contribution to develop the ERT, and thank Iris Rooke of Document-Based Care Groep BV and Annelies Wolters and Evelien Miedema of Accare, University Centre for Child and Adolescent Psychiatry, for their tremendous work in the data collection.

: Disclosure: Drs. Schuppert, van Gemert, and Wiersema are authors of the manual on Emotion Regulation Training that is commercially available in the Netherlands. Drs. Timmerman, Bloo, Minderaa, Emmelkamp, and Nauta report no biomedical financial interests or potential conflicts of interest.

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New ResearchEmotion Regulation Training for Adolescents With Borderline Personality Disorder Traits: A Randomized Controlled Trial

Objective

Method

Results

Conclusions

Section snippets

Sample

Participants

Discussion

J Am Acad Child Adolesc Psychiatry

J Am Acad Child Adolesc Psychiatry

J Adolesc

Diagnostic and Statistical Manual of Mental Disorders

Screening for borderline personality disorder in outpatient youth

J Pers Disord

Personality disorders in adolescence and risk of major mental disorders and suicidality during adulthood

Arch Gen Psychiatry

Adolescent borderline symptoms in the community: prognosis for functioning over 20 years

J Child Psychol Psychiatry

Adaptive functioning and psychiatric symptoms in adolescents with borderline personality disorder

J Clin Psychiatry

Prevalence and stability of the DSM-III-R personality disorders in a community-based survey of adolescents

Am J Psychiatry

Axis II psychopathology as a function of axis I disorders in childhood and adolescence

J Am Ac Child Adolesc Psychiatry

Factor structure of the borderline personality inventory in adolescents

Eur J Psychol Assess

The contribution of cognitive analytic therapy to the treatment of borderline personality disorder

J Pers Disord

Psychological therapies for people with borderline personality disorder (review)

Cochrane Database Syst Rev

Dialectical behavior therapy adapted for suicidal adolescents

Suicide Life Threat Behav

Mentalization based treatment for adolescents: a framework to treat adolescent breakdown and emerging personality disorders

Mentalization based treatment for borderline personality disorder

World Psychiatry

Emotieregulatie Training

Een Programma voor Adolescenten met Emotieregulatie Problemen

The Borderline Personality Disorder Skill Training

New Research
Emotion Regulation Training for Adolescents With Borderline Personality Disorder Traits: A Randomized Controlled Trial