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Themenschwerpunkt

Veränderung von Bindungsmerkmalen im Verlauf einer Dialektisch Behavioralen Therapie für Borderline-Patientinnen

Published Online:March 21, 2018https://doi.org/10.1024/1661-4747/a000347

Abstract

Zusammenfassung.Hintergrund: Die Bindungsorganisation ist ein zentrales Merkmal, um die Psychopathologie der Borderline-Persönlichkeitsstörung (BPS) im Kontext affektiver und interpersonaler Probleme zu verstehen. In dieser Pilotstudie wurden anhand verschiedener Methoden bindungsbezogene Merkmale von 26 BPS-Patientinnen und 26 alters- und bildungsgleich gemachten gesunden Kontrollprobandinnen vor, während und nach einer einjährigen ambulanten DBT-Intervention erhoben. Methode: Die Bindungsrepräsentationen wurden mittels Adult Attachment Projective Picture System (AAP) erfasst. Mittels parametrischer- und non-parametrischer Tests wurden Veränderungen des Bindungsstils (ASQ) und subjektive Einschätzungen zu Affektivität, autobiografischer Relevanz und emotionaler Valenz personalisierter Sätze aus den eigenen AAP-Interviews vor, während und nach der einjährigen DBT-Intervention erhoben. Ergebnis: Wie erwartet wiesen die BPS-Patientinnen im AAP signifikant häufiger unverarbeitete Traumata (desorganisierte Bindungsrepräsentation), einen höheren Anteil an traumatisch-dysregulierenden Markern in Narrativen zu AAP Bildern, die potentiell Alleinsein und Verlassenwerden induzieren (monadische Bilder), eine stärkere Bindungsangst und -vermeidung (ASQ) sowie mehr BPS-assoziierte Emotionen bei stärkerer autobiografischer Relevanz und emotionaler Valenz in der Konfrontation mit personalisierten Sätzen des eigenen AAP-Interviews auf. Nach einjähriger DBT wurden Bindungsangst und -vermeidung in der BPS-Gruppe signifikant reduziert, Bindungssicherheit wurde signifikant gestärkt (ASQ). Bei erhalten gebliebener autobiografischer Relevanz gaben die Patientinnen nach DBT in der Konfrontation mit personalisierten Sätzen des eigenen AAP-Interviews weniger BPS-assoziierte Emotionen, sowie mehr Akzeptanz und eine reduzierte emotionale Valenz an und glichen sich damit den Kontrollprobanden an. Schlussfolgerung: Es ergaben sich Hinweise, dass Veränderungen in Richtung einer stärkeren Bindungssicherheit und intrapsychischen Integration bindungsbezogener autobiografischer Aspekte im Rahmen der ambulanten DBT für BPS-Patienten zu erzielen sind. Zum Aufbau einer sicheren therapeutischen Allianz mit positiven Bindungserfahrungen ist ein ausreichender, hier einjähriger, Interventionszeitraum vorauszusetzen.


Change of attachment characteristics during dialectic behavioral therapy for borderline patients

Abstract.Background: Attachment organization is considered as one major constituting factor in the development of a Borderline-Personality Disorder, especially in the context of the patients' affective and interpersonal problems. In this pilot study several attachment related measures were administered to 26 patients with Borderline Personality Disorder (BPD) and 26 matched healthy controls. Assessment were before, during and after one year of outpatient treatment with Dialectic Behavior Therapy (DBT). Measures: Attachment representations were assessed with the Adult Attachment Projective Picture System (AAP). We examined changes of attachment styles and subjective evaluations of affective, emotional and autobiographic valence of personalized sentences from the participants' own AAP interviews by using parametric and non-parametric tests before, during and after one year of DBT treatment. Results: As expected BPD patients showed a significant higher proportion of unresolved trauma (disorganized attachment representation) in the AAP, a higher amount of traumatic-dysregulating makers in AAP narratives in response to AAP pictures inducing potential emotional states like abandonment or loneliness (monadic pictures), a higher score on attachment anxiety and avoidance (ASQ) and a higher amount of BPD relevant affects related to enhanced autobiographic and emotional valence when confronted with their personalized sentences from their own AAP narratives. After one year of DBT treatment the patients' high scores on attachment anxiety and avoidance were substantially decreased, and attachment security was increased significantly. Patients still evaluated the personalized sentences as autobiographically relevant, however after DBT treatment they showed less BPD-specific emotions, a higher acceptance and reduced emotional valence, comparable to the evaluations of healthy controls. Conclusion: The pilot study confirmed changes of attachment features towards attachment security and an improved capacity to emotionally integrate attachment related autobiographical features in the course of DBT treatment. To ensure a secure therapeutic alliance with positive attachment experiences in the therapeutic relationship we suggest that one year of treatment is an appropriate time frame.

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