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The Utility of the Unified Protocol in Treating Borderline Features

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Abstract

Borderline personality disorder (BPD) is characterized by maladaptive levels of neuroticism, agreeableness, and conscientiousness. The Unified Protocol (UP), a treatment for neuroticism, has previously demonstrated promising effects when applied to BPD; however, not all individuals with BPD respond, suggesting the UP may be incomplete for some BPD presentations. This secondary analysis explored the extent to which adapted versions of UP represent an efficacious treatment approach for BPD symptoms. Data from a subset of twelve participants with clinically-significant BPD features were included. We explored within-group changes in BPD symptoms and differences in within-person changes in BPD scores based on patients’ personality profiles. The UP resulted in improvements in BPD symptoms that were moderate in magnitude, Hedges’s g = 0.48, 95% CI [0.35, 0.62]. Individuals with personality profiles characterized by high neuroticism and low conscientiousness exhibited early gains in the UP but did not sustain them, whereas those with at least moderate levels of conscientiousness generally continued to improve across 12 weeks. Possible explanations and limitations were discussed.

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Notes

  1. All participants received treatment between baseline and second assessment (A2). After A2, participants were randomized to either discontinue after their 6th session or after their 12th session. Thus, some participants received a single additional session between A2 and A3 and some received 7 additional sessions.

References

  • Aldao, A., & Nolen-Hoeksema, S. (2010). Specificity of cognitive emotion regulation strategies: A transdiagnostic examination. Behaviour Research and Therapy, 48(10), 974–983. https://doi.org/10.1016/j.brat.2010.06.002.

    Article  PubMed  Google Scholar 

  • American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596.

  • Au, T. M., Sauer-Zavala, S., King, M. W., Petrocchi, N., Barlow, D. H., & Litz, B. T. (2017). Compassion-based therapy for trauma-related shame and posttraumatic stress: Initial evaluation using a multiple baseline design. Behavior Therapy, 48(2), 207–221. https://doi.org/10.1016/j.beth.2016.11.012.

    Article  PubMed  Google Scholar 

  • Barlow, D. H. (1991). Disorders of emotion. Psychological Inquiry, 2(1), 58–71.

    Article  ADS  Google Scholar 

  • Barlow, D. H., Farchione, T. J., Fairholme, C. P., Ellard, K. K., Boisseau, C. L., Allen, L. B., & Ehrenreich-May, J. (2011). Unified protocol for transdiagnostic treatment of emotional disorders: Therapist guide (2012-25743-000). Oxford University Press. http://offcampus.lib.washington.edu/login?url=https://search.ebscohost.com/login.aspxdirect=truedb=psyhAN=2012-25743-000site=ehost-live.

  • Carl, J. R., Gallagher, M. W., Sauer-Zavala, S. E., Bentley, K. H., & Barlow, D. H. (2014). A preliminary investigation of the effects of the unified protocol on temperament. Comprehensive Psychiatry, 9. https://doi.org/10.1016/j.comppsych.2014.04.015.

  • Cassiello-Robbins, C., Southward, M. W., Tirpak, J. W., & Sauer-Zavala, S. (2020). A systematic review of Unified Protocol applications with adult populations: Facilitating widespread dissemination via adaptability. Clinical Psychology Review, 78, 101852. https://doi.org/10.1016/j.cpr.2020.101852.

    Article  PubMed  Google Scholar 

  • Costa, P. T., & McCrae, R. R. (1992). NEO PI-R professional manual. Psychological Assessment Resources.

  • Costa, P. T., & McCrae, R. R. (1995). Domains and facets: Hierarchical personality assessment using the revised NEO personality inventory. Journal of Personality Assessment, 64(1), 21–50. https://doi.org/10.1207/s15327752jpa6401_2.

    Article  PubMed  Google Scholar 

  • Eustis, E. H., Cardona, N., Nauphal, M., Sauer-Zavala, S., Rosellini, A. J., Farchione, T. J., & Barlow, D. H. (2020). Experiential avoidance as a mechanism of change across cognitive-behavioral therapy in a sample of participants with heterogeneous anxiety disorders. Cognitive Therapy and Research, 44(2), 275–286. https://doi.org/10.1007/s10608-019-10063-6.

    Article  Google Scholar 

  • First, M. B., & Gibbon, M. (2004). The structured clinical interview for DSM-IV Axis I disorders (SCID-I) and the structured clinical interview for DSM-IV Axis II disorders (SCID-II). Comprehensive handbook of psychological assessment, Vol. 2: Personality assessment (pp. 134–143). John Wiley & Sons, Inc.

  • Harris, P. A., Taylor, R., Thielke, R., Payne, J., Gonzalez, N., & Conde, J. G. (2009). Research electronic data capture (REDCap)—A metadata-driven methodology and workflow process for providing translational research informatics support. Journal of Biomedical Informatics, 42(2), 377–381. https://doi.org/10.1016/j.jbi.2008.08.010.

    Article  PubMed  Google Scholar 

  • Harris, P. A., Taylor, R., Minor, B. L., Elliott, V., Fernandez, M., O’Neal, L., McLeod, L., Delacqua, G., Delacqua, F., Kirby, J., & Duda, S. N. (2019). The REDCap consortium: Building an international community of software platform partners. Journal of Biomedical Informatics, 95, 103208. https://doi.org/10.1016/j.jbi.2019.103208.

    Article  PubMed  PubMed Central  Google Scholar 

  • IBM Corp (2020). IBM SPSS Statistics, Version 27.

  • Jacobson, N. S., & Truax, P. (1991). Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59(1), 12–19.

    Article  PubMed  CAS  Google Scholar 

  • Kotov, R., Krueger, R. F., Watson, D., Achenbach, T. M., Althoff, R. R., Bagby, R. M., Brown, T. A., Carpenter, W. T., Caspi, A., Clark, L. A., Eaton, N. R., Forbes, M. K., Forbush, K. T., Goldberg, D., Hasin, D., Hyman, S. E., Ivanova, M. Y., Lynam, D. R., Markon, K., & Zimmerman, M. (2017). The hierarchical taxonomy of psychopathology (HiTOP): A dimensional alternative to traditional nosologies. Journal of Abnormal Psychology, 126(4), 454–477. https://doi.org/10.1037/abn0000258.

    Article  PubMed  Google Scholar 

  • Lakens, D. (2013). Calculating and reporting effect sizes to facilitate cumulative science: A practical primer for t-tests and ANOVAs. Frontiers in Psychology. https://doi.org/10.3389/fpsyg.2013.00863. 4.

    Article  PubMed  PubMed Central  Google Scholar 

  • Laporte, L., Paris, J., Bergevin, T., Fraser, R., & Cardin, J. F. (2018). Clinical outcomes of a stepped care program for borderline personality disorder. Personality and Mental Health, 12(3), 252–264. https://doi.org/10.1002/pmh.1421.

    Article  PubMed  Google Scholar 

  • Larstone, R. M., Jang, K. L., Livesley, W. J., Vernon, P. A., & Wolf, H. (2002). The relationship between Eysenck’s P-E-N model of personality, the five-factor model of personality, and traits delineating personality dysfunction. Personality and Individual Differences, 33(1), 25–37. https://doi.org/10.1016/S0191-8869(01)00132-5.

    Article  Google Scholar 

  • Linehan, M. (1993). Cognitive-behavioral treatment of borderline personality disorder. Guilford Press.

  • Lopez, M. E., Stoddard, J. A., Noorollah, A., Zerbi, G., Payne, L. A., Hitchcock, C. A., Meier, E. A., Esfahani, A. M., & Ray, D. B. (2015). Examining the efficacy of the Unified Protocol for transdiagnostic treatment of emotional disorders in the treatment of individuals with borderline personality disorder. Cognitive and Behavioral Practice, 22(4), 522–533. https://doi.org/10.1016/j.cbpra.2014.06.006.

    Article  Google Scholar 

  • Lopez, M. E., Thorp, S. R., Dekker, M., Noorollah, A., Zerbi, G., Payne, L. A., Meier, E., & Stoddard, J. A. (2019). The unified protocol for anxiety and depression with comorbid borderline personality disorder: A single case design clinical series. The Cognitive Behaviour Therapist, 12, https://doi.org/10.1017/S1754470X19000254.

  • Magidson, J. F., Roberts, B. W., Collado-Rodriguez, A., & Lejuez, C. W. (2014). Theory-driven intervention for changing personality: Expectancy value theory, behavioral activation, and conscientiousness. Developmental Psychology, 50(5), 1442–1450. https://doi.org/10.1037/a0030583.

    Article  PubMed  Google Scholar 

  • McCrae, R. R., & Costa, P. T. (2004). A contemplated revision of the NEO five-factor inventory. Personality and Individual Differences, 36(3), 587–596. https://doi.org/10.1016/S0191-8869(03)00118-1.

    Article  Google Scholar 

  • Moore, S. A., Zoellner, L. A., & Mollenholt, N. (2008). Are expressive suppression and cognitive reappraisal associated with stress-related symptoms? Behaviour Research and Therapy, 46(9), 993–1000. https://doi.org/10.1016/j.brat.2008.05.001.

    Article  PubMed  PubMed Central  Google Scholar 

  • Morey, L. C. (1991). Personality Assessment Inventory professional manual. Psychological Assessment Resources.

  • Mullins-Sweatt, S. N., Edmundson, M., Sauer-Zavala, S., Lynam, D. R., Miller, J. D., & Widiger, T. A. (2012). Five-factor measure of borderline personality traits. Journal of Personality Assessment, 94(5), 475–487. https://doi.org/10.1080/00223891.2012.672504.

    Article  PubMed  Google Scholar 

  • Roemer, L., Salters, K., Raffa, S. D., & Orsillo, S. M. (2005). Fear and avoidance of internal experiences in GAD: Preliminary tests of a conceptual model. Cognitive Therapy and Research, 29(1), 71–88. https://doi.org/10.1007/s10608-005-1650-2.

    Article  Google Scholar 

  • Sakiris, N., & Berle, D. (2019). A systematic review and meta-analysis of the Unified Protocol as a transdiagnostic emotion regulation based intervention. Clinical Psychology Review, 13.

  • Samuel, D. B., & Widiger, T. A. (2008). A meta-analytic review of the relationships between the five-factor model and DSM-IV-TR personality disorders: A facet level analysis. Clinical Psychology Review, 28(8), 1326–1342. https://doi.org/10.1016/j.cpr.2008.07.002.

    Article  PubMed  PubMed Central  Google Scholar 

  • Sauer-Zavala, S., Boswell, J. F., Gallagher, M. W., Bentley, K. H., Ametaj, A., & Barlow, D. H. (2012). The role of negative affectivity and negative reactivity to emotions in predicting outcomes in the unified protocol for the transdiagnostic treatment of emotional disorders. Behaviour Research and Therapy, 50(9), 551–557. https://doi.org/10.1016/j.brat.2012.05.005.

    Article  PubMed  PubMed Central  Google Scholar 

  • Sauer-Zavala, S., Bentley, K. H., & Wilner, J. G. (2016). Transdiagnostic treatment of borderline personality disorder and comorbid disorders: A clinical replication series. Journal of Personality Disorders, 30(1), 35–51. https://doi.org/10.1521/pedi_2015_29_179.

    Article  PubMed  Google Scholar 

  • Sauer-Zavala, S., Cassiello-Robbins, C., Woods, B. K., Curreri, A., Wilner Tirpak, J., & Rassaby, M. (2020). Countering emotional behaviors in the treatment of borderline personality disorder. Personality Disorders: Theory Research and Treatment, 11(5), 328–338. https://doi.org/10.1037/per0000379.

    Article  Google Scholar 

  • Sauer-Zavala, S., Southward, M. W., Stumpp, N. E., Semcho, S. A., Hood, C. O., Garlock, A., & Urs, A. (2022). A SMART approach to personalized care: Preliminary data on how to select and sequence skills in transdiagnostic CBT. Cognitive Behaviour Therapy, 51(6), 435–455. https://doi.org/10.1080/16506073.2022.2053571.

    Article  PubMed  PubMed Central  Google Scholar 

  • Saulsman, L. M., & Page, A. C. (2004). The five-factor model and personality disorder empirical literature: A meta-analytic review. Clinical Psychology Review, 23(8), 1055–1085. https://doi.org/10.1016/j.cpr.2002.09.001.

    Article  PubMed  Google Scholar 

  • Spong, A. J., Clare, I. C. H., Galante, J., Crawford, M. J., & Jones, P. B. (2021). Brief psychological interventions for borderline personality disorder. A systematic review and meta-analysis of randomised controlled trials. Clinical Psychology Review, 83, 101937. https://doi.org/10.1016/j.cpr.2020.101937.

    Article  PubMed  CAS  Google Scholar 

  • Stanley, B., & Singh, T. (2018). Diagnosis of borderline personality disorder. In B. Stanley & A. S. New (Eds.), Borderline personality disorder (2017-43727-002; pp. 17–34). Oxford University Press. http://offcampus.lib.washington.edu/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2017-43727-002&site=ehost-live.

  • Tolin, D. F., Gilliam, C., Wootton, B. M., Bowe, W., Bragdon, L. B., Davis, E., Hannan, S. E., Steinman, S. A., Worden, B., & Hallion, L. S. (2018). Psychometric properties of a structured diagnostic interview for DSM-5 anxiety, mood, and obsessive-compulsive and related disorders. Assessment, 25(1), 3–13. https://doi.org/10.1177/1073191116638410.

    Article  PubMed  Google Scholar 

  • Tonarely, N. A., Sherman, J. A., Grossman, R. A., & Ehrenreich-May, J. (2020). Targeting elevated borderline features in adolescents using the Unified Protocol for Transdiagnostic Treatment of Emotional disorders in adolescents (UP-A). Evidence-Based Practice in Child and Adolescent Mental Health, 6(1), 1–18. https://doi.org/10.1080/23794925.2020.1805821.

    Article  Google Scholar 

  • Tull, M. T., & Roemer, L. (2007). Emotion regulation difficulties associated with the experience of uncued panic Attacks: Evidence of experiential avoidance, emotional nonacceptance, and decreased emotional clarity. Behavior Therapy, 38(4), 378–391. https://doi.org/10.1016/j.beth.2006.10.006.

    Article  PubMed  Google Scholar 

  • Turk, C. L., Heimberg, R. G., Luterek, J. A., Mennin, D. S., & Fresco, D. M. (2005). Emotion dysregulation in generalized anxiety disorder: A comparison with social anxiety disorder. Cognitive Therapy and Research, 29(1), 89–106. https://doi.org/10.1007/s10608-005-1651-1.

    Article  Google Scholar 

  • Van Buuren, S., Brand, J. P. L., Groothuis-Oudshoorn, C. G. M., & Rubin, D. B. (2006). Fully conditional specification in multivariate imputation. Journal of Statistical Computation and Simulation, 76(12), 1049–1064. https://doi.org/10.1080/10629360600810434.

    Article  MathSciNet  Google Scholar 

  • Widiger, T. A., Livesley, W. J., & Clark, L. A. (2009). An integrative dimensional classification of personality disorder. Psychological Assessment, 21(3), 243–255. https://doi.org/10.1037/a0016606.

    Article  PubMed  Google Scholar 

  • Widiger, T. A., Costa, P. T. Jr., Gore, W. L., & Crego, C. (2013). Five-factor model personality disorder research. In T. A. Widiger & P. T. Jr. Costa (Eds.), Personality disorders and the five-factor model of personality., 3rd ed (2012-10423-006; pp. 75–100). American Psychological Association. https://doi.org/10.1037/13939-006

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Authors and Affiliations

  1. University of Kentucky, Lexington, KY, USA

    Martina Fruhbauerova, Nicole Stumpp & Shannon Sauer-Zavala

  2. Department of Psychology, University of Kentucky, 111D Kastle Hall, Lexington, KY, 40506- 0044, USA

    Martina Fruhbauerova

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  1. Martina Fruhbauerova
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  2. Nicole Stumpp
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Fruhbauerova, M., Stumpp, N. & Sauer-Zavala, S. The Utility of the Unified Protocol in Treating Borderline Features. J Psychopathol Behav Assess 46, 137–146 (2024). https://doi.org/10.1007/s10862-023-10106-z

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