***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Objective : The aim of this study is to compare the clinical outcome of patients with borderline personality disorder ( BPD ) who had received outpatient psychotherapy for 1 year with BPD patients who received no formal psychotherapy for the same period . Method : Thirty patients with BPD were treated by trainee psychotherapists working according to clearly described therapeutic principles . They received intensive audiotaped supervision . Patients were seen twice weekly for 1 year . They were compared with 30 patients subsequently referred to the clinic , for whom no therapist was available and who remained on a waiting list for 1 year , receiving their usual treatment . The outcome measure was a score derived from DSM criteria . It was taken at the beginning and end of the year 's treatment , in the former case , and after at least 1 year on the waiting list in the latter . ( The average waiting period was 17.1 months . ) Results and Conclusions : Patients who received psychotherapy were significantly improved in terms of the DSM score . Thirty percent of treated patients no longer fulfilled DSM-III criteria for BPD . The untreated patients were unchanged This study investigated the quality and development of the therapeutic alliance as a mediator of change in schema-focused therapy ( SFT ) and transference-focused psychotherapy ( TFP ) for borderline personality disorder . Seventy-eight patients were r and omly allocated to 3 years of biweekly SFT or TFP .  Scores of both therapists and patients for the therapeutic alliance were higher in SFT than in TFP . Negative ratings of therapists and patients at early treatment were predictive of dropout , whereas increasingly positive ratings of patients in the 1st half of treatment predicted subsequent clinical improvement . Dissimilarity between therapist and patients in pathological personality characteristics had a direct effect on growth of the therapeutic alliance but showed no relationship with clinical improvement . The authors conclude that the therapeutic alliance and specific techniques interact with and influence one another and may serve to facilitate change processes underlying clinical improvement in patients with borderline personality disorder A central component of Dialectical Behavior Therapy ( DBT ) is the teaching of specific behavioral skills with the aim of helping individuals with Borderline Personality Disorder ( BPD ) replace maladaptive behaviors with skillful behavior . Although existing evidence indirectly supports this proposed mechanism of action , no study to date has directly tested it . Therefore , we examined the skills use of 108 women with BPD participating in one of three r and omized control trials throughout one year of treatment and four months of follow-up . Using a hierarchical linear modeling approach we found that although all participants reported using some DBT skills before treatment started , participants treated with DBT reported using three times more skills at the end of treatment than participants treated with a control treatment . Significant mediation effects also indicated that  DBT skills use fully mediated the decrease in suicide attempts and depression and the increase in control of anger over time . DBT skills use also partially mediated the decrease of nonsuicidal self-injury over time . Anger suppression and expression were not mediated . This study is the first to clearly support the skills deficit model for BPD by indicating that increasing skills use is a mechanism of change for suicidal behavior , depression , and anger control The primary aim of this study was to examine the prospect i ve association of shame with self-inflicted injury ( SII ) , including suicide attempts and nonsuicidal self-injury , among women with borderline personality disorder ( BPD ) who were enrolled in a clinical trial ( N = 77 ) . A multi- method approach was used to assess self-reported shame , nonverbal shame behaviors , and assessor ratings of shame during an interview regarding antecedents for a recent episode of SII . Higher levels of nonverbal shame behaviors predicted a higher likelihood of subsequent SII , and shorter time to SII , after controlling for past SII as well as other emotions associated with SII . Self-reported state shame and assessor ratings of shame were associated with prospect i ve SII , but not after controlling for other emotions . These findings underscore the important role of shame in SII , particularly shame in the presence of context ual prompts for events that surround episodes of SII Most patients with borderline personality disorder receive no formal treatment for their personality disorder and psychotherapy is widely believed to be necessarily intensive , of long duration and of uncertain effect . This study seeks to demonstrate the scope and limits of time-limited outpatient cognitive analytic psychotherapy . Cases were identified by st and ard diagnostic procedures . Most were referred from psychiatrists and were typical of inner city patient population s. At an assessment 6 months after therapy the 27 patients completing therapy were divided into ' improved ' and ' unimproved ' groups . The patients classified as improved no longer met diagnostic criteria for borderline personality disorder . The two-thirds still traceable were re-tested at 18 months . These groups were compared in terms of a number of pre-therapy measures and features . Poorer outcome was associated with greater severity of borderline features , a history of self-cutting , alcohol abuse and unemployment Although a number of psychotherapeutic modalities for borderline personality disorder ( BPD ) have empirical support , it is unclear what aspects of treatment are responsible for improvement . The present study analyzes the relationships between different techniques and outcomes in a r and omized controlled trial of dynamic deconstructive psychotherapy ( DDP ) for comorbid BPD and alcohol-use disorders .  Video recordings of psychotherapy sessions at 3-month intervals were rated to measure therapeutic alliance and the relative frequencies of specific treatment interventions . Outcomes included measures of borderline symptoms , depression , dissociation , social support , alcohol misuse , parasuicide , and institutional care . Discrete sets of techniques were associated with reliable changes in specific outcomes , indicating that treatments for BPD should be tailored to the specific constellation of symptoms presenting in a given individual . The study findings suggest that treatments with a specified set of techniques , such as DDP , dialectical behavior therapy , mentalization-based treatment , schema therapy , supportive therapies , and transference-focused psychotherapy , may be helpful for different individuals , depending on their particular set of symptoms BACKGROUND Longer-term follow-up of patients with borderline personality disorder have found favourable clinical outcomes , with long-term reduction in symptoms and diagnosis . AIMS We examined the 6-year outcome of patients with borderline personality disorder who were r and omised to 1 year of cognitive-behavioural therapy for personality disorders ( CBT-PD ) or treatment as usual ( TAU ) in the BOSCOT trial , in three centres across the UK ( trial registration : IS RCT N86177428 ) . METHOD In total , 106 participants met criteria for borderline personality disorder in the original trial . Patients were interviewed at follow-up by research assistants masked to the patient 's original treatment group , CBT-PD or TAU , using the same measures as in the original r and omised trial . Statistical analyses of data for the group as a whole are based on generalised linear models with repeated measures analysis of variance type models to examine group differences . RESULTS Follow-up data were obtained for 82 % of patients at 6 years . Over half the patients meeting criteria for borderline personality disorder at entry into the study no longer did so 6 years later . The gains of CBT-PD over TAU in reduction of suicidal behaviour seen after 1-year follow-up were maintained . Length of hospitalisation and cost of services were lower in the CBT-PD group compared with the TAU group . CONCLUSIONS Although the use of CBT-PD did not demonstrate a statistically significant cost-effective advantage , the findings indicate the potential for continued long-term cost-offsets that accrue following the initial provision of 1 year of CBT-PD . However , the quality of life and affective disturbance remained poor Changes in attachment organization and reflective function ( RF ) were assessed as putative mechanisms of change in 1 of 3 year-long psychotherapy treatments for patients with borderline personality disorder ( BPD ) . Ninety patients reliably diagnosed with BPD were r and omized to transference-focused psychotherapy ( TFP ) , dialectical behavior therapy , or a modified psychodynamic supportive psychotherapy . Attachment organization was assessed with the  Adult Attachment Interview  and the RF coding scale . After 12 months of treatment , participants showed a significant increase in the number classified secure with respect to attachment state of mind for TFP but not for the other 2 treatments . Significant changes in narrative coherence and RF were found as a function of treatment , with TFP showing increases in both constructs during treatment . No changes in resolution of loss or trauma were observed across treatments . Findings suggest that 1 year of intensive TFP can increase patients ' narrative coherence and RF . Future research should establish the relationship between these 2 constructs and relevant psychopathology , identify treatment components responsible for effecting these changes , and examine the long-term outcome of these changes A r and omized clinical trial was conducted to evaluate whether Dialectical Behavior Therapy ( DBT ) , an effective cognitive-behavioral treatment for suicidal individuals with borderline personality disorder ( BPD ) , would also be effective for drug-dependent women with BPD when compared with treatment-as-usual ( TAU ) in the community . Subjects were r and omly assigned to either DBT or TAU for a year of treatment . Subjects were assessed at 4 , 8 , and 12 months , and at a 16-month follow-up . Subjects assigned to DBT had significantly greater reductions in drug abuse measured both by structured interviews and urinalyses throughout the treatment year and at follow-up than did subjects assigned to TAU . DBT also maintained subjects in treatment better than did TAU , and subjects assigned to DBT had significantly greater gains in global and social adjustment at follow-up than did those assigned to TAU . DBT has been shown to be more effective than treatment-as-usual in treating drug abuse in this study , providing more support for DBT as an effective treatment for severely dysfunctional BPD patients across a range of presenting problems BACKGROUND AND SIGNIFICANCE The treatment of personality disorders in older adults , particularly those co-morbid with other Axis I disorders ( e.g. , Major Depressive Disorder ) , is an understudied clinical phenomenon . It has also been demonstrated that personality disorders in older adults complicate treatment of other psychopathology , as well as result in heightened interpersonal disturbance and emotional distress . METHODS Two studies utilizing st and ard Dialectical Behavior Therapy ( DBT ) to treat depression and personality disorders in older adults are review ed . Study 1 examined 34 chronically depressed individuals aged 60 and older who were r and omly assigned to receive 28 weeks of antidepressant medication plus clinical management , either alone ( MED ) or with the addition of DBT skills-training and scheduled telephone coaching sessions ( MED + DBT ) .  Study 2 had two phases of treatment : Phase I : 8-week open-trial of antidepressant medication ( n = 65 ) ; Phase II : 24-week r and omized trial of DBT + MED versus MED alone for those who prospect ively failed to respond to the Phase I medication trial ( n = 37 ) . RESULTS Study 1 demonstrated that 71 % of MED + DBT patients were in remission at post-treatment , in contrast to 47 % of MED patients . This became a significant difference at the 6-month follow-up ; where 75 % of MED + DBT-D patients were in remission compared with only 31 % of MED patients . Study 2 showed that after 8 weeks of treatment with antidepressant medication alone ( Phase 1 ) only 14 % of the sample had at least a 50 % reduction in HAM-D scores . Phase II results showed on average , the DBT + MED group reached depression remission by the post-group assessment and maintained these gains while the MED group did not reach remission , until the follow-up assessment . Results demonstrated superiority of DBT + MED compared to MED alone on Interpersonal Sensitivity and Interpersonal Aggression at post-treatment and 6-month follow-up . CONCLUSION Results from these two treatment development studies indicate that applying st and ard DBT for the treatment of co-morbid MDD or MDD + PD in older adults is feasible , acceptable , and has clinical promise . Modifications to st and ard DBT and an overview of a new treatment manual for this population are summarized Background : A primary goal of dialectical behaviour therapy ( DBT ) is to reduce self-harm , but findings from empirical studies are inconclusive . The aim of this study was to assess the effectiveness and cost-effectiveness of  DBT  in reducing self-harm in patients with personality disorder . Methods : Participants with a personality disorder and at least 5 days of self-harm in the previous year were r and omised to receive 12 months of either  DBT or treatment as usual ( TAU ) . The primary outcome was the frequency of days with self-harm ; secondary outcomes included borderline personality disorder symptoms , general psychiatric symptoms , subjective quality of life , and costs of care . Results : Forty patients each were r and omised to DBT and TAU .  In an intention-to-treat analysis , there was a statistically significant treatment by time interaction for self-harm ( incidence rate ratio 0.91 , 95 % CI 0.89–0.92 , p < 0.001 ) . For every 2 months spent in DBT , the risk of self-harm decreased by 9 % relative to TAU . There was no evidence of differences on any secondary outcomes . The economic analysis revealed a total cost of a mean of 5,685 GBP ( 6,786 EUR ) in DBT compared to a mean of 3,754 GBP ( 4,481 EUR ) in TAU , but the difference was not significant ( 95 % CI –603 to 4,599 GBP ) . Forty-eight per cent of patients completed  DBT . They had a greater reduction in self-harm compared to dropouts ( incidence rate ratio 0.78 , 95 % CI 0.76–0.80 , p < 0.001 ) . Conclusions 
    Output:
    
RESULTS Two consistent positive predictors of symptom change were identified : pre-treatment symptom severity and patient-rated therapeutic alliance .
Contrary to theories predicting increasing immutability with age , there was no evidence that age predicted poorer outcome .
CONCLUSION More severely ill patients may have greater potential to achieve change during therapy , and should remain a focus for psychotherapy services .
The therapeutic alliance is an important common factor predicting outcome in patients with BPD , even in highly disorder-specific treatments .
Outcomes may be improved by further clinical and research focus on forming strong therapeutic alliances .