The effectiveness and safety of dialectical behavior therapy for suicidal ideation and behavior in autistic adults: a pragmatic randomized controlled trial.

BACKGROUNDS: Many autistic people in mental health are suicidal. This study evaluated the effectiveness of dialectical behavior therapy (DBT) v. treatment as usual (TAU) in reducing suicidal ideation and suicide attempts. METHODS: At six Dutch mental health centers, 123 outpatients (18-65 years) with DSM-5 diagnosed autism spectrum disorder (ASD) and suicidal behavior were randomly assigned to the DBT intervention group (n = 63) or TAU control group (n = 60). Assessments were conducted at baseline, post-treatment at 6 months and 12-month follow-up. The primary outcomes were severity of suicidal ideation and frequency of suicide attempts. The severity of depression and social anxiety were secondary outcomes. RESULTS: At end-of-treatment, DBT significantly reduced both suicidal ideation (z = -2.24; p = 0.025; b = -4.41; s.e. = 197.0) and suicide attempts (z = -3.15; p = 0.002; IRR = 0.046; s.e. = 0.045) compared to TAU, but lost statistical significance at the 12-month follow-up. Depression severity significantly decreased with DBT (z = -1.99; p = 0.046: b = -2.74; s.e. = 1.37) remaining so at 12 months (z = -2.46; p = 0.014; b = -3.37; s.e. = 1.37). No effects were observed on social anxiety. Severe adverse events included two suicides in the TAU condition. CONCLUSIONS: DBT is an acceptable, safe, and short-term effective intervention to reduce suicidal ideation and suicide attempts in autistic adults with suicidal behavior.

The effect of dialectical behaviour therapy in autism spectrum patients with suicidality and/ or self-destructive behaviour (DIASS): study protocol for a multicentre randomised controlled trial.

BACKGROUND: Many persons with autism spectrum disorder (ASD) are treated in long-term specialised care. In this population, suicidal behaviour troubles patients, families, and specialists in the field because it is difficult to treat. At present, there is no documented effective therapy for suicidal behaviour in ASD (Autism Research 7:507-521, 2014; Crisis 35:301-309, 2014). Dialectical Behaviour Therapy (DBT) is an efficacious treatment programme for chronically suicidal and/or self-harm behaviour in patients with Borderline Personality Disorder (J Psychiatry 166:1365-1374, 2014; Linehan MM. Cognitive behavioural therapy of borderline personality disorder. 1993). This study will evaluate the efficacy of DBT in persons with ASD and suicidal/ self- destructive behaviour in a multicentre randomised controlled clinical trial. METHOD: One hundred twenty-eight persons with autism and suicidal and/or self-harming behaviour will be recruited from specialised mental healthcare services and randomised into two conditions: 1) the DBT condition in which the participants have weekly individual cognitive behavioural therapy sessions and a 2.5 h skills training group session twice per week during 6 months, and 2) the treatment as usual condition which consists of weekly individual therapy sessions of 30-45 min with a psychotherapist or social worker. Assessments will take place at baseline, at post-treatment (6 months), and after a follow-up period of 12 months. The mediators will also be assessed at 3 months. The primary outcome is the level of suicidal ideation and behaviour. The secondary outcomes are anxiety and social performance, depression, core symptoms of ASD, quality of life, and cost-utility. Emotion regulation and therapeutic alliance are hypothesised to mediate the effects on the primary outcome. DISCUSSION: The results from this study will provide an evaluation of the efficacy of DBT treatment in persons with ASD on suicidal and self-harming behaviour. The study is conducted in routine mental health services which enhances the generalisability of the study results to clinical practice. TRIAL REGISTRATION: ISRCTN96632579. Registered 1 May 2019. Retrospectively registered.

Treatment of antisocial personality disorder: Development of a practice focused framework.

There is little to no evidence of effective treatment methods for patients with an antisocial personality disorder (ASPD). One of the reasons could be the fact that they are often excluded from mental healthcare and thus from studies. A treatment framework based on 'state of the art' methods and best practices, offering guidelines on the treatment of ASP and possibilities for more systematical research, is urgently needed. This research involved a literature search and an international Delphi-study (N = 61 experts in research, management and clinical practice focused on ASPD). The results suggested important preconditions with regard to organization of care, healthcare workers and therapy. Conclusions are that there are many ways to coordinate effective treatment and management and work toward the increased availability of evidence based care for persons with ASPD.

[Dialectical behaviour theory in the Netherlands: implementation and consolidation]. / Dialectische gedragstherapie in Nederland: implementatie en consolidatie.

BACKGROUND: More and more evidence-based treatments for severe personality disorders are becoming available. Nevertheless, there are problems with the implementation of these treatments and it is proving difficult to keep the treatment programmes running. However, teams which offer dialectical behavior therapy (DBT) seem to survive. AIM: To find out which factors enable dbt teams to survive. METHOD: Twenty-five Dutch DBT teams received a questionnaire about factors that could be influencing the continuation of the DBT treatment programmes. The questionnaire consisted of 9 open questions, 2 multiple-choice questions and 26 closed questions. RESULTS: The results show that the continued existence of the treatment programmes is due largely to the commitment of both the team and its managers. They all feel embedded in the organisation as a whole, feel connected with one another and are supportive of the method. CONCLUSION: A well-functioning consultation team seems to be of crucial importance for the continued existence of the DBT programme. We believe that independent external supervision is essential to keep the dbt teams alert and aware of current trends and developments.

[Short-term dialectical behaviour therapy for borderline personality disorder]. / Kortdurende klinische dialectische gedragstherapie voor de borderlinepersoonlijkheidsstoornis: ontwerp van programma en resultaten pilotstudie.

BACKGROUND: Outpatient dialectical behaviour therapy (DBT) reduces severe suicidal and self-injurious behaviour in patients with borderline personality disorder. The Jelgersma center for personality disorders has developed an intensive inpatient dbt programme that lasts for 14 weeks and is designed to achieve a faster reduction in these borderline symptoms. AIM: To examine the effect of the Jelgersma programme by means of a pilot study in order to prepare a randomised clinical trial in which a short intensive course of DBT will be compared with standard outpatient DBT. METHOD: We compared the starting data and the final data for 39 female patients with borderline problems (DBT). We participated in 3½-month-long inpatient DBT programme. The collected data referred to (para)suicidal behaviour, drop-out, severity of borderline problems and the quality of life. RESULTS: The severity of borderline problems, particularly in the field of interpersonal problems, was significantly reduced. There was no significant reduction in (para) suicidal behaviours. The drop-out percentage was higher than in comparable studies. CONCLUSION: Short-term inpatient DBT had a positive effect on borderline problems. (Para)suicidal behaviour, however, was not reduced significantly. The randomised trial that began in 2012 should reveal whether the use of short-term inpatient DBT can lead to a faster decline of suicidal and self-injurious behaviour than does standard outpatient DBT.

DBT in an outpatient forensic setting.

Literature shows that effective treatment of borderline personality disorder (BPD) has become possible. However, borderline patients in forensic psychiatry do not seem to benefit from this development. In forensic psychiatry, prevention of criminal recidivism is the main focus of treatment, not core borderline problems like parasuicidal and self-destructive behavior. A dialectical behavioral treatment program for BPD was implemented in an outpatient forensic clinic in The Netherlands. Sociodemographic, clinical, and treatment data were collected from ten male, and nineteen female forensic BPD patients, and compared with corresponding data from fifty-eight non-forensic BPD patients. The results show that it is possible to implement dialectical behavior therapy in an outpatient forensic clinic. The data indicate that the exclusion of forensic patients, and especially female forensic patients, from evidence-based treatment is unjustified given the highly comparable clinical and etiological characteristics they share with female BPD patients from general mental health settings.

Dialectical behavior therapy: is outpatient group psychotherapy an effective alternative to individual psychotherapy?: Preliminary conclusions.

OBJECTIVES: This study evaluates a 12-month-duration adapted outpatient group dialectical behavior therapy (DBT) program for patients with a borderline personality disorder in an unselected, comorbid population. If the results of this approach are comparable with the outcome rates of a standard DBT program, the group approach can have several advantages over individual treatment. One advantage is the possibility of treating more patients per therapist. METHOD: A pre-post design was used to measure the effectiveness of an outpatient group DBT. Data from the Beck Depression Inventory II, the Symptom Checklist 90-Revised, the State-Trait Anger Inventory, the State and Trait Anxiety Inventory, of 34 female patients (mean age, 32.65 years) were collected before and after a treatment period of 1 year. RESULTS: Overall, a significant reduction (P < .05) of depressive symptoms, suicidal thoughts, anxiety, and anger was experienced by the patients. CONCLUSIONS: This study is a first attempt in showing that DBT in an outpatient group setting can be effective in reducing psychiatric complaints and therefore has several advantages, such as the opportunity to treat more patients at once.

Adverse reactions during transfusion of thawed haematopoietic progenitor cells from apheresis are closely related to the number of granulocyte cells in the leukapheresis product.

BACKGROUND AND OBJECTIVES: The infusion of thawed haematopoietic progenitor cells from apheresis (HPC-A) is associated with minor but frequent adverse reactions (ARs), which has been mainly attributed to dimethyl sulphoxide (DMSO). Nevertheless, other factors may play a role in the pathogenesis of such toxicity. MATERIALS AND METHODS: The ARs on a cohort of 423 cryopreserved HPC-A infusions for 398 patients in HPC transplantation program were analysed. RESULTS: ARs were reported in 105 graft infusions (24·8%) and most of them were graded as mild to moderate. The most frequently reported ARs were gastrointestinal and respiratory, and three patients presented epileptic seizure. The volume of DMSO/kg (P < 0·001), volume of red-blood-cells/kg (P = 0·02), number of nuclear cells (NCs)/kg (P <0·001) and number of granulocytes/kg (P<0·001) in the infused graft were significant in the univariate analysis for the occurrence of ARs. The amount of granulocytes/kg remained significant in the multivariate analysis (P<0·001). The grade of ARs also correlated with the amount of cryopreserved granulocytes. CONCLUSION: The incidence and grade of ARs during infusion of cryopreserved HPC-A are related to the amount of granulocytes in the graft.

[Dialectical behaviour therapy for adolescents; a literature review]. / Dialectische gedragstherapie bij adolescenten;een literatuuronderzoek.

BACKGROUND: According to several randomised controlled trials (rct's) dialectical behaviour therapy (dbt) is effective in treating adults diagnosed with borderline personality disorder (bpd) who present with self-injurious and suicidal behaviour. In recent years there have been several studies about dbt in adolescents with varying problems and disorders. AIM: To review the literature for evidence of the effectiveness of dbt in adolescents aged 12 to 18. METHOD: With the help of PubMed and Medline and using the search-terms 'dialectical', 'adolescent', 'suicide attempt' and 'deliberate self harm', we searched the literature for references to dbt in adolescents. RESULTS: There were no rct's involving dbt in adolescents, but we did find one quasi-experimental design and several other studies with a pre-post treatment design. However, the studies were difficult to compare. In some cases it was doubtful whether the treatment could still be called dbt. The results suggested that dbt may be just as effective with adolescents as it is with adults in reducing bpd symptoms, suicidal ideation, and comorbid depressive disorder symptoms, and in reducing the need for hospitalisation. The results also indicated that dbt might be effective in treating eating disorders, bipolar disorder, oppositionality, aggression and nonsuicidal self-injurious behaviour (nsib) in a variety of treatment settings. CONCLUSION: dbt is possibly effective for treating adolescents with nsib and/or bpd symptoms. It may also be an effective treatment for various other affective and behavioural disorders. rct's are needed.

Whole-grain consumption, dietary fibre intake and body mass index in the Netherlands cohort study.

OBJECTIVES: To assess the association of whole-grain and (cereal) fibre intake with body mass index (BMI) and with the risk of being overweight (BMI> or =25) or obese (BMI> or =30 kg m(-2)). SUBJECTS: A total of 2078 men and 2159 women, aged 55-69 years, were included in the analysis, after exclusion of subjects with diagnosed cancer or deceased within 1 year after baseline or with missing dietary information. RESULTS: We found an inverse association between whole-grain consumption and BMI and risk of overweight and obesity in men as well as women. The association in men was stronger than in women; the risk of being obese as compared to normal weight was 10% (95% CI: 2-16%) and 4% (95% CI: 1-7%) lower for each additional gram of (dry) grain consumption in men and women, respectively. Fibre and cereal fibre intake were inversely associated with BMI in men only. Associations were similar after exclusion of likely under- and overreporters of energy. A retrospective analysis of baseline fibre intake and weight gain after the age of 20 years also showed a slight inverse association. CONCLUSIONS: Whole-grain consumption may protect against becoming overweight or obese; however, the cross-sectional design of the study does not allow conclusions about the causality of the association.

Probabilistic risk assessment model for allergens in food: sensitivity analysis of the minimum eliciting dose and food consumption.

Previously, TNO developed a probabilistic model to predict the likelihood of an allergic reaction, resulting in a quantitative assessment of the risk associated with unintended exposure to food allergens. The likelihood is estimated by including in the model the proportion of the population who is allergic, the proportion consuming the food and the amount consumed, the likelihood of the food containing an adventitious allergen and its concentration, and the minimum eliciting dose (MED) distribution for the allergen. In the present work a sensitivity analysis was performed to identify which parts of the model most influence the output. A shift in the distribution of the MED reflecting a more potent allergen, and an increase in the proportion of the population consuming a food, increased the number of estimated allergic reactions considerably. In contrast, the number of estimated allergic reactions hardly changed when the MEDs were based on a more severe response, or when the amount of food consumed was increased. Development of this work will help to generate a more accurate picture of the potential public health impact of allergens. It highlights areas where research is best focused, specifically the determination of minimum eliciting doses and understanding of the food choices of allergic individuals.

Ipsilateral breast tumour recurrence in hereditary breast cancer following breast-conserving therapy.

The overall rate of an ipsilateral breast tumour recurrence (IBTR) after breast-conserving therapy (BCT) ranges from 1% to 2% per year. Risk factors include young age but data on the impact of BRCA1/2 mutations or a definite positive family history for breast cancer are scarce. We investigated IBTR after BCT in patients with hereditary breast cancer (HBC). Through our family cancer clinic we identified 87 HBC patients, including 26 BRCA1/2 carriers, who underwent BCT between 1980 and 1995 (cases). They were compared to 174 patients with sporadic breast cancer (controls) also treated with BCT, matched for age and year of diagnosis. Median follow up was 6.1 years for the cases and 6.0 years for controls. Patient and tumour characteristics were similar in both groups. An IBTR was observed in 19 (21.8%) hereditary and 21 (12.1%) sporadic patients. In the hereditary patients more recurrences occurred elsewhere in the breast (21% versus 9.5%), suggestive of new primaries. Overall, the actuarial IBTR rate was similar at 2 years, but higher in hereditary as compared to sporadic patients at 5 years (14% versus 7%) and at 10 years (30% versus 16%) (P=0.05). Post-relapse and overall survival was not different between hereditary and sporadic cases. Hereditary breast cancer was therefore associated with a higher frequency of early (2-5 years) and late (>5 years) local recurrences following BCT. These data suggest an indication for long-term follow up in HBC and should be taken into account when additional 'risk-reducing' surgery after primary BCT is eventually considered.

Substance abuse in borderline personality disorder: clinical and etiological correlates.

This work examines differences between female borderline patients with and without substance abuse problems and between borderline patients from different treatment settings. A total of 64 female borderline patients were recruited from mental health services (n = 34) and addiction treatment services (n = 20); 35 had a substance abuse problem. Patient groups were compared with regard to both clinical and etiological factors using multivariate analysis of variance for 47 continuous variables and logistic regression for 15 dichotomous variables. Borderline patients with substance abuse problems reported less hostility, suspicion, and anger but more anxiety, insufficiency, and suicide attempts. Patients from addiction treatment services reported less avoidant and more antisocial behavior. The differences between borderline patients with and without substance abuse problems are limited in number and size. Therefore, there is no empirical justification for the exclusion of borderline patients with substance abuse problems from general treatment services or clinical trials.

Predicting self-damaging and suicidal behaviors in female borderline patients: reasons for living, coping, and depressive personality disorder.

The aims of this study are to examine (1) whether reasons for living predict self-damaging and suicidal behaviors, (2) the associations of reasons for living with coping strategies and depressive personality disorder (PD), and (3) the unique predictive validity of reasons for living in a multivariate predictor model. Reasons for living (RFL), coping strategies, and depressive personality disorder were measured at baseline in 38 patients who met DSM-IV criteria for borderline personality disorder (BPD). Frequency of self-damaging and suicidal behaviors in the 6-month period following baseline was measured prospectively at 3- and 6-month follow-ups. The RFL has only one subscale that predicts parasuicidal behaviors (i.e. Survival and Coping Beliefs [SCB]). Participants who scored low on this subscale were 6.8 times more likely to exhibit self-damaging and suicidal behaviors in the follow-up period than their high-scoring counter-parts. However, SCB was substantially correlated with the coping strategies "reassuring thoughts," "active coping," and "palliative reaction pattern," as well as with depressive personality traits. In a multivariate model, the predictive power of SCB appeared to be accounted for by reassuring thoughts and depressive PD. Coping scales might be preferable over the RFL as a predictor of self-damaging and suicidal behaviors in borderline patients.

Survival and tumour characteristics of breast-cancer patients with germline mutations of BRCA1.

BACKGROUND: Hereditary breast cancer has been associated with mutations in the BRCA1 and BRCA2 genes and has a natural history different from sporadic breast cancer. We investigated disease-free and overall survival for patients with a proven BRCA1 alteration. METHODS: We estimated disease-free and overall survival for 49 Dutch patients from 19 consecutive families with a proven specific BRCA1 mutation and one family with strong evidence for linkage to the BRCA1 gene. We compared clinical outcome and data on tumour size, histology, axillary nodal status, contralateral breast cancer, and oestrogen-receptor and progesterone-receptor status with those of 196 patients with sporadic breast cancer, matched for age and year of diagnosis. FINDINGS: Disease-free survival for BRCA1 and sporadic patients at 5 years was 49% (95% CI 33-64) and 51% (43-59), respectively (p=0.98). Overall survival at 5 years was 63% (47-76) and 69% (62-76), respectively (p=0.88). Recurrence and death rates did not differ significantly between groups. Hazard ratios for recurrence and death among BRCA1 patients were 1.00 (0.65-1.55) and 1.04 (0.63-1.71) relative to sporadic patients (p=0.88), and these did not differ significantly after adjustment for prognostic factors. Patients with BRCA1-associated breast cancer had twice as many progesterone-receptor-negative tumours (p<0.005) and development of contralateral breast cancer was four to five times as frequent as in the sporadic group (p<0.001). INTERPRETATION: We showed that disease-free and overall survival were similar for sporadic and hereditary breast cancer in the presence of different tumour characteristics, which has implications for screening prophylactic therapy, and different treatments of hereditary breast cancer.