تاثیر اجتناب تجربی بر کاهش افسردگی در درمان اختلال شخصیت مرزی

Background Reducing symptoms of depression is an important target in the treatment of borderline personality disorder (BPD). Although current treatments for BPD are effective in reducing depression, the average post-treatment level of depression remains high. Aim To test whether experiential avoidance (EA) impedes the reduction of depression during treatment for BPD. Method EA and depression were assessed in 81 clients at baseline and 4-month intervals during 1 year of therapy. Simple correlations, hierarchical linear modeling, and latent difference score models were used to investigate the association between self-reports of EA and both self-reports and observer-based ratings of depression. Results EA was positively associated with greater severity of depression at all points of assessment, and changes in EA were positively associated with changes in depression. Moreover, EA significantly predicted less subsequent reduction in depression whereas no such effect was found for depression on subsequent EA. Conclusion The findings are consistent with the hypothesis that EA impedes the reduction of depression in the treatment of BPD and should thus be considered an important treatment target.

Strong evidence suggests that depression is a common experience among individuals meeting criteria for borderline personality disorder (BPD). For example, in carefully controlled studies, comorbidity rates between BPD and current mood disorder range between 31 and 61% for major depressive disorder (MDD) and between 12 and 24% for dysthymia (Comtois et al., 1999, Skodol et al., 1999 and Zimmerman and Mattia, 1999). Moreover, up to 83% of individuals suffering from BPD report a history of MDD, up to 39% report a history of dysthymia (Zanarini et al., 1998), and 37% meet criteria for depressive personality disorder (Grilo, Sanislow, & McGlashan, 2002). Additionally, individuals meeting criteria for both BPD and MDD exhibit greater severity of depression in self-reports than individuals with MDD but without BPD (e.g., Abela et al., 2006 and Stanley and Wilson, 2006). Finally, individuals with BPD often suffer from depressive symptoms even when they do not meet full criteria for any affective disorder. For example, chronic dysphoric mood states, negative self-evaluations, and feelings of hopelessness and helplessness are commonly found in individuals suffering from BPD (Gunderson and Phillips, 1991, Hooley, 2007, Trull, 2001 and Zittel-Conklin and Westen, 2005). These findings imply that reducing the suffering associated with depressive symptoms is an important way of reducing the suffering of BPD individuals. Fortunately, the results of major outcome-studies of the past decade indicate that today's treatments for BPD are effective in reducing depression (Bateman and Fonagy, 1999, Bohus et al., 2004, Bohus et al., 2000, Brown et al., 2004, Koons et al., 2001, Kröger et al., 2006, Linehan et al., 2006 and Turner, 2000). Pre-post effect sizes (Cohen's d) in these studies range from 0.54 to 2.1 (Mdn = 1.1) for the Beck Depression Inventory (BDI), and from 0.17 to 2.55 (Mdn = 0.93) for the Hamilton Rating Scale for Depression (HRSD). However, these studies also demonstrate a significant post-treatment level of depression, with mean values ranging between M = 13.4–25.1 for the BDI (Mdn = 20.9) and M = 7.5–19.1 for the HRSD (Mdn = 14.0). In fact, most of these studies report post-treatment mean depression scores corresponding to moderate or even severe levels of depression. Thus, even after carefully conducted state-of-the-art BPD-treatments, a great amount of depression-related suffering remains in these patients. Considering that residual symptoms of depression are known to be important predictors of relapse after treatment for unipolar depression ( Judd et al., 1998) and that residual depressive symptoms are likely to trigger more typical symptoms of BPD (which have been conceptualized as dysfunctional attempts to avoid aversive inner experiences; Linehan, 1993a), it can be concluded that there is a considerable need to identify factors impeding the reduction of depression during treatment for BPD. Evidence-based maintaining factors for depression include: a depressogenic attributional style (Abramson, Metalsky, & Alloy, 1989), hopelessness (Beck, Weissman, Lester, & Trexler, 1974), low self-esteem (Brown & Harris, 1978), dysfunctional attitudes (Beck, 1967) and rumination (Nolen-Hoeksema, 1991). All these factors are significantly associated with BPD (Abela et al., 2006). Another concept that is currently discussed as a putative risk-factor for the development and maintenance of depression is the general tendency to react towards aversive experiences with avoidance-oriented response patterns (e.g., Hayes et al., 2005 and Ottenbreit and Dobson, 2004). These response tendencies are thought to lead to: loss of reinforcement (Ferster, 1973 and Jacobson et al., 2001), rumination (Cribb, Moulds, & Carter, 2006), impaired emotional processing (Borkovec, Ray, & Stoeber, 1998), increased negative cognitions (Abramowitz et al., 2001, Wegner and Zanakos, 1994 and Wenzlaff and Bates, 1998) and emotions (Campbell-Sills et al., 2006, Eifert and Heffner, 2003, Feldner et al., 2003, Feldner et al., 2006 and Levitt et al., 2004), and consequently to depression. Hayes, Wilson, Gifford, Follette, and Strosahl (1996) have proposed the term of experiential avoidance (EA) to summarize a broad range of potentially problematic behaviors that individuals apply in order to avoid aversive experiences. According to Hayes et al. (2004, p. 554), EA is “a phenomenon that occurs when a person is unwilling to remain in contact with particular private experiences (e.g., bodily sensations, emotions, thoughts, memories, images, behavioral predispositions) and takes steps to alter the form or frequency of these experiences or the contexts that occasion them, even when these forms of avoidance cause behavioral harm.” In order to measure EA, Hayes et al. (2004) developed the Acceptance and Actions Questionnaire (AAQ), a self-report measure that assesses constructs considered as important indicators of EA. The total score of the AAQ has been demonstrated to be strongly associated with self-report measures of depression (for a review see Hayes, Luoma, Bond, Masuda, & Lillis, 2006). Moreover, two longitudinal studies in non-clinical samples provide further preliminary support for the assumed causal effect of EA on depression ( Bond and Bunce, 2003 and Kashdan et al., 2006). However, due to the striking lack of more rigorous tests of causal effects in clinical populations, it is unclear whether EA is a cause or merely a consequence of depression. Several findings suggest that EA might be particularly important for the maintenance of depression in BPD: first, BPD individuals report more frequently avoidance-oriented response patterns in coping inventories (Bijttebier and Vertommen, 1999, Kruedelbach et al., 1993 and Vollrath et al., 1998) and in the AAQ (Rüsch et al., 2006) than do normal controls or patients suffering from social phobia, respectively. Second, both symptoms of BPD and symptoms of other mental disorders often co-occurring with BPD (such as posttraumatic stress disorder; Zanarini et al., 1998) are associated with EA (Chapman et al., 2006, Chapman et al., 2005 and Marx and Sloan, 2005). Third, the tendency to suppress negative thoughts was shown to moderate the effect of negative affect on borderline characteristics (Rosenthal, Cheavens, Lejuez, & Lynch, 2005). However, at this point no study has explicitly investigated the association between EA and depression in individuals treated for BPD.