Clinical Psychology and PsychotherapyClin. Psychol. Psychother. 18, 148–158 (2011)Published online 25 February 2010 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/cpp.684

Copyright © 2010 John Wiley & Sons, Ltd.

Dialectic Behavioural Therapy Has an Impact on Self-Concept Clarity and Facets of Self-Esteem in Women with Borderline Personality Disorder

Stefan Roepke,1* Michela Schröder-Abé,2 Astrid Schütz,2 Gitta Jacob,3 Andreas Dams,1 Aline Vater,1 Anke Rüter,1 Angela Merkl,1 Isabella Heuser1 and Claas-Hinrich Lammers1

1 Department of Psychiatry, Charité-University Medicine Berlin, Campus Benjamin Franklin, Berlin, Germany2 Department of Psychology, Personality Psychology and Assessment, Chemnitz University of Technology, Chemnitz, Germany3 Department of Psychiatry and Psychotherapy, University of Freiburg Medical Centre, Hauptstrasse, Freiburg, Germany

Identity disturbance and an unstable sense of self are core criteria of borderline personality disorder (BPD) and signifi cantly contribute to the suffering of the patient. These impairments are hypothesized to be refl ected in low self-esteem and low self-concept clarity. The objective of this study was to evaluate the impact of an inpatient dia-lectic behavioral therapy (DBT) programme on self-esteem and self-concept clarity. Forty women with BPD were included in the study. Twenty patients were treated with DBT for 12 weeks in an inpa-tient setting and 20 patients from the waiting list served as controls. Psychometric scales were used to measure different aspects of self-esteem, self-concept clarity and general psychopathology. Patients in the treatment group showed signifi cant enhancement in self-concept clarity compared with those on the waiting list. Further, the scales of global self-esteem and, more specifi cally, the facets of self-esteem self-regard, social skills and social confi dence were enhanced signifi -cantly in the intervention group. Additionally, the treatment had a signifi cant impact on basic self-esteem in this group. On the other hand, the scale of earning self-esteem was not signifi cantly abased in patients with BPD and did not show signifi cant changes in the intervention group. Our data provide preliminary evidence that DBT has an impact on several facets of self-esteem and self-concept clarity, and thus on identity disturbance, in women with BPD. Copyright © 2010 John Wiley & Sons, Ltd.

* Correspondence to: Dr Stefan Roepke, Department of Psychiatry, Charité-University Medicine Berlin, Campus Benjamin Franklin, Berlin, Germany.E-mail: stefan.roepke@charite.de

Impact of DBT on identity disturbance in BPD 149

Copyright © 2010 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 18, 148–158 (2011)DOI: 10.1002/cpp

Key Practitioner Message:• Self-concept clarity, which refers to the BPD criterion identity dis-

turbance, and facets of self-esteem, are impaired in patients with BPD compared with reference data from healthy controls.

• Our study replicates that depressive symptoms and general psycho-pathology are improved after a 12-week DBT programme in BPD patients compared with a waiting list.

• The 12-week inpatient DBT treatment programme shows signifi cant enhancement in self-concept clarity and facets of self-esteem com-pared with the waiting list.

• Thus, in BPD patients, self-esteem and the diagnostic criteria iden-tity disturbance, captured by self-concept clarity, can be infl uenced with short-term psychotherapy.

Keywords: Self-Esteem, Self-Concept Clarity, Borderline Personality Disorder, Dialectic Behavioural Therapy, Identity Disturbance

INTRODUCTION

Borderline personality disorder (BPD) is character-ized by a pervasive pattern of instability in inter-personal relationships, self-image and affect as well as by marked impulsivity (APA, 1994). Iden-tity disturbance and an unstable sense of self con-stitute one of the nine criteria for BPD in DSM-IV (APA, 1994). The criterion of identity disturbance is based on the psychoanalytic theory of identity diffusion in borderline personality organization (Kernberg, 1975). There is little empirical research on the criterion of identity disturbance in BPD. The few existing studies focus on whether this crite-rion is specifi c to BPD (for a review see Jørgensen, 2006). In our study, we empirically measured aspects of identity and related constructs of the ‘self’ in BPD patients (see also Schröder-Abé et al., under submission), and empirically assessed the impact of an evaluated psychotherapeutic treat-ment programme for BPD on these measures.

As existing theories vary in describing the term ‘self’, we followed the concept as defi ned by Baumeister (1999; see Schütz, 2005, for a review) describing the self-concept as ‘your ideas about yourself’, identity as ‘who you are’, and self-esteem (SE) as ‘how you evaluate yourself’. More specifi -cally, self-concept is defi ned as a cognitive schema, an organized knowledge structure that contains traits, values and episodic and semantic memories about the self, and that controls the processing of self-relevant information (e.g., Greenwald & Prat-kanis, 1984). Self-concept clarity (SCC) overlaps with the construct of identity and refers to the structural aspect of the self-concept: the extent to which the contents of an individual’s self-concept are clearly and confi dentially defi ned, internally

consistent and temporally stable (Campbell et al., 1996). However, identity comprises more complex sets of elements than SCC. They are rather dif-fi cult to assess empirically (Campbell et al., 1996). Thus, SCC is characteristic of people’s beliefs about themselves and may be considered an empirically assessable aspect of identity (Campbell et al., 1996).

Self-esteem is the evaluative dimension of the self-concept, the ‘positivity of a person’s evaluation of self’ (Baumeister, 1998). Various constructs are used to describe different aspects of SE. In terms of ana-lytical theories, basic self-esteem can be compared with an individual’s ego-integrated libidinous and aggressive drives as well as their derivates (Forsman & Johnson, 1996). The concept is free of references to perceived skills, competencies, family relations or others’ appraisal. Instead, it refers to attitudes that are regarded as the end result of the success-ful merging of libidinous and aggressive emotions into the ego, for example, warm and gratifying rela-tions with others, the freedom to experience and express emotions, including sexual impulses and a sense of security and integrity (Forsman & Johnson, 1996). By contrast, earning self-esteem is defi ned as the need to earn SE by competences and others’ appraisals (Forsman & Johnson, 1996), which means that earning SE represents a less-adaptive aspect of SE. Individuals high in earning self-esteem experi-ence their sense of self-esteem as being conditional, especially upon competence and success, and upon the praise and approval of others. They strive hard to do well and to be perfect (Forsman & Johnson, 1996). The hierarchical facet model of SE devel-oped by Shavelson, Hubner and Stanton (1976) and advanced by Fleming and Courtney (1984) states that SE is a multidimensional construct. With an additional subdivision of social SE into social con-

150 S. Roepke et al.

Copyright © 2010 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 18, 148–158 (2011)DOI: 10.1002/cpp

fi dence and social skills, Schütz and Sellin (2006) presented a modifi ed version of the Fleming and Courtney (1984) model and differentiated six factors: self-regard, social skills, social confi dence, performance SE, physical appearance and physi-cal abilities. Measures of SE have several clinical implications. SE is positively related to indicators of subjective well-being and psychological health (see Baumeister, Campbell, Krueger, & Vohs, 2003, for a review). High SE is associated with various posi-tive outcomes such as optimism (Taylor & Brown, 1988), life satisfaction (e.g., Diener & Diener, 1995) and low levels of depression (e.g., Tennen & Herz-berger, 1987; Watson, Suls, & Haig, 2002). Further-more, emotional instability, which is characteristic of BPD (Ebner-Priemer et al., 2007), is negatively related to SE (Judge, Erez, Bono, & Thoresen, 2002; Robins, Hendin, & Trzesniewski, 2001). In addi-tion, individuals with high SE are less prone than others to experience stress and negative affect when confronted with negative events (Brown & Dutton, 1995; DiPaula & Campbell, 2002). Interestingly, BPD patients show more emotional reactivity to daily life stress (Glaser, Mengelers, & Myin-Germeys, 2007).

Only a few studies have examined SCC and SE in relation to features of personality disorders. However, in normal samples, low SCC has been shown to be related to dysfunctional personal-ity characteristics, such as high neuroticism, low agreeableness and low SE (Baumeister, 1998; Campbell, 1990). Very little empirical research has been done on the self and identity in BPD. Wilkinson-Ryan and Westen (2000) have found a pattern of identity disturbance that distinguishes BPD patients from other patients and normal con-trols. In another study, BPD patients’ mood has been correlated with a negative view of themselves (De Bonis, De Boeck, & Lida-Pulik, 1998). Only one study so far has examined SCC in BPD patients. The authors reported lower SCC in BPD patients as compared with the general population (Pollock, Broadbent, Clarke, Dorrian, & Ryle, 2001). In one of our own studies, we have found the same result of lower SCC and lower SE in women with BPD (Schröder-Abé et al., under submission).

The present study was aimed at investigating effects of dialectic behavioral therapy (DBT) on SE and SCC in women with BPD. Studies investigat-ing psychotherapeutic interventions to improve SE in various mental disorders have yielded con-tradictory results. Two studies (Chen, Lu, Chang, Chu, & Chou, 2006; Knapen et al., 2005) found cog-nitive behavioural therapy (CBT) to improve SE in depressed patients, whereas two other studies

(Hyun, Chung, & Lee, 2005; Reynolds & Coats, 1986) found no signifi cant improvement of SE in depressed patients. To our knowledge, however, the possible improvement of SE and SCC through psychotherapeutic intervention in patients with BPD has not been studied yet. DBT was specifi cally developed as an outpatient treatment programme for chronically suicidal individuals meeting the cri-teria for BPD (Linehan, Armstrong, Suarez, Allmon, & Heard, 1991; Linehan, Heard, & Armstrong, 1993). To date, DBT has demonstrated effi cacy in a number of randomized controlled trials for BPD in inpatient and outpatient settings (Lynch et al., 2007). DBT treatment strategies aim to enhance emotion regulation by increasing awareness and acceptance of the emotional experience, and by changing negative affect through new learning experiences (Linehan et al., 1993). The treatment aims at reducing dysfunctional behaviour in four high-priority target areas: suicidal behaviours, intentional self-injuries, behaviours that interfere with treatment and behaviours that prolong hospi-talization. Randomized clinical trials revealed that DBT reduces incidences of parasuicide and medi-cally severe parasuicides, improves adherence to individual therapy, and diminishes inpatients’ psychiatric days (Linehan et al., 1993).

Based on theoretical considerations and previous empirical data, we hypothesize that DBT utilizes different techniques that improve SE, clarify the self-concept and thus improve identity disturbance in BPD. Accordingly, we expected improved SCC and SE and an overall reduction of symptoms after 12 weeks of inpatient DBT treatment in patients with BPD.

METHODParticipants

Forty-fi ve women with BPD were consecutively enrolled and participated in the study. Five patients dropped out of the study and were excluded from analysis, two from the DBT group and three from the waiting list group. Data from 20 patients who completed a 12-week inpatient DBT programme were compared with data from 20 patients from a waiting list. All BPD patients from the interven-tion group (DBT) were on a waiting list before participating in the DBT programme. Patients from the control group (waiting list) were not included in the DBT-treatment arm of the study, but com-pleted the DBT programme after study participa-tion. Also, patients from the control group (waiting

Impact of DBT on identity disturbance in BPD 151

Copyright © 2010 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 18, 148–158 (2011)DOI: 10.1002/cpp

list) continued treatment as usual in an outpatient setting while waiting for the DBT programme. Treatment as usual was not assessed more specifi -cally. Sociodemographic characteristics, psycho-tropic medication and comorbidity on axis I and II of the sample are presented in Table 1.

All participants met the DSM-IV (APA, 1994) criteria for BPD on the Structured Clinical Inter-view for DSM-IV Personality Disorders (SCID-II; First, Spitzer, Gibbon, Williams, & Benjamin, 1997; Fydrich, Renneberg, Schmitz, & Witchen, 1997). Axis I comorbidity was assessed with the Mini International Neuropsychiatric Interview (MINI.; Ackenheil, Stotz-Ingenlath, Dietz-Bauer, & Vossen, 1999; Sheehan et al., 1998). Lifetime diagnosis of schizophrenia, bipolar I or II disorder, substance abuse within the last 6 months or mental retardation were exclusion criteria. Prior psychiatric or psycho-therapeutic treatment was not assessed systemati-cally and thus not included in further analyses.

Measures

Questionnaires

Psychometric Scales Assessing Self-Esteem and the Self-Concept. Facets of self-esteem were measured using the 32-item Multidimensional Self-Esteem

Scale (MSES; Schütz & Sellin, 2006), the modifi ed German version of the scale by Fleming and Court-ney (Fleming & Courtney, 1984). The question-naire comprises six subscales: self-regard, social skills, social confi dence, performance SE, physical appearance and physical abilities. Two of the sub-scales capture different aspects of SE in social con-texts: The social skills scale captures the perception of a person’s own capacity to interact with others, whereas the social confi dence scale captures the ability to handle criticism from others. The sub-scale self-regard captures the emotional compo-nent of SE, the emotional evaluation of the self. The performance scale captures the perception of technical and professional abilities. All subscales consist of fi ve items, except for self-regard, which consists of seven items. Additionally, the subscales are combined to form a Global SE index, which comprises all subscales. Responses were made on 7-point scales with endpoints labelled not at all (1) and very much (7) or never (1) and always (7), respec-tively. Previous research indicated internal con-sistency reliabilities in a healthy sample between 0.75 and 0.87 (Cronbach’s alpha; Schütz & Sellin, 2006). Values for internal consistency in the present sample are presented in Table 2. Test–retest reli-abilities of MSES sum and subscales were between 0.46 and 0.86 (Schütz & Sellin, 2006).

Table 1. Socioedemographic data, psychotropic medication and comorbidity of patients in the intervention group (DBT) and control group

DBT CG t testM (SD) M (SD)

Age 27.7 (6.7) 32.5 (7.5) t = −2.1, df = 38, p = 0.04*frequency (%) frequency (%) χ2-tests

Psychotropic med. 16 (80) 14 (70) χ2 = 0.53, df = 1, p = 0.47 SSRI 16 (80) 11 (55) χ2 = 2.85, df = 1, p = 0.09 aNL 6 (30) 7 (35) χ2 = 0.11, df = 1, p = 0.74

Axis I Depression, lifetime 8 (40) 8 (40) χ2 = 0.00, df = 1, p = 1 Dysthymia 9 (45) 8 (40) χ2 = 0.10, df = 1, p = 0.75 PTSD 6 (30) 5 (25) χ2 = 0.13, df = 1, p = 0.72 Substance abuse 6 (30) 5 (25) χ2 = 0.13, df = 1, p = 0.72 Eating disorder 10 (50) 5 (25) χ2 = 2.67, df = 1, p = 0.10

Axis II Avoidant PD 5 (25) 8 (40) χ2 = 1.03, df = 1, p = 0.31 Dependent PD 3 (15) 1 (5) χ2 = 1.11, df = 1, p = 0.29 Paranoid PD 1 (5) 3 (15) χ2 = 1.11, df = 1, p = 0.29 Histrionic PD 1 (5) 0 (0) χ2 = 1.03, df = 1, p = 0.31

* p < 0.05.M = mean. SD = standard deviation. PTSD = Posttraumatic Stress Disorder. PD = Personality Disorder. SSRI = selective serotonin reuptake inhibitor. aNL = atypical neuroleptic. DBT = DBT intervention group (n = 20). CG = control group (n = 20).

152 S. Roepke et al.

Copyright © 2010 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 18, 148–158 (2011)DOI: 10.1002/cpp

Basic self-esteem was assessed by the 38-item Basic Self-Esteem Scale (BSE; Forsman & Johnson, 1996; e.g., ‘I can freely express what I feel’). Responses were made on a 5-point scale, ranging from strongly disagree (1) to strongly agree (5). Cron-bach’s alpha internal consistency reliability was reported as 0.92 in the validation study of the scale (Forsman & Johnson, 1996). Internal consistency of the scale in the present study is reported in Table 2.

Earning self-esteem was measured by the 28-item Earning Self-Esteem (ESE) Scale (Forsman & Johnson, 1996; e.g., ‘If people say that they like me, my self-esteem is strengthened quite a lot’). Responses were made on a 5-point scale, ranging from 1 (strongly disagree) to 5 (strongly agree). Inter-nal consistency reliability was reported as 0.76 (Cronbach’s alpha) in the validation study of the scale (Forsman & Johnson, 1996). Values for the reliability of the present sample are reported in Table 2. The test–retest reliabilities of ESE (0.723) and BSE (0.735) were calculated from the control group of the present study as data were not pro-vided in the validation study of the scales (Forsman & Johnson, 1996).

Self-concept clarity (SCC) was measured using the German version of the 12-item Self-Concept Clarity Scale (Campbell et al., 1996; Stucke, 2002). Participants responded to each item using a 5-point scale with endpoints 1 (strongly disagree) and 5 (strongly agree). Internal consistency reliability was reported as 0.86 (Cronbach’s alpha) on average in

the validation study of the scale (Campbell et al., 1996). Reliability of the scale in the present sample is reported in Table 2. Test–retest reliability of the scale was reported as 0.79 in the validation study of the scale (Campbell et al., 1996).

Psychometric Scales Assessing Severity of Psycho-pathological Symptoms. The German version of the 21-item Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961; Hautz-inger, Bailer, Worall, & Keller, 1994) was employed to assess severity of depression. Test–retest reli-ability of the BDI was reported as 0.93 (Beck, Steer, Ball, & Ranieri, 1996).

The SCL-90-R was used to assess current subjec-tive experience of symptoms (Franke, 1995). The Global Severity Index (GSI), which comprises all subscales of the SCL-90-R, was used to measure global psychopathological impairment. Responses were made on 5-point scales with end points labelled not at all (0) and very much (4). Test–retest reliability of the GSI of the SCL-90-R was reported as 0.92 (Franke, 1995).

ProcedureThe study was conducted at the Borderline

Research Unit of the Department of Psychiatry and Psychotherapy, Charité, University Medicine Berlin, Campus Benjamin Franklin. The interven-tion group was treated with a 12-week DBT pro-gramme following Linehan’s DBT manual adapted

Table 2. Self-esteem and self-concept clarity in the total group of patients with BPD prior to intervention and comparison with reference data from healthy samples

Chronbach’s alpha

Study group, n = 40

M (SD)

Reference data d-value

n M (SD)

SCC 0.76 1.98 (0.62) 126† 3.74 (0.94) −2.21*BSE 0.72 2.21 (0.34) 26‡ 3.59 (0.39) −3.77*ESE 0.81 3.64 (0.44) 26‡ 3.51 (0.36) 0.32, n.s.††

MSES global SE 0.88 2.54 (0.72) 214§ 4.74 (0.95) −2.61*MSES self-regard 0.79 2.53 (0.84) 231§ 5.21 (1.11) −2.72*MSES social skills 0.78 2.52 (1.08) 234§ 5.01 (1.30) −2.08*MSES social confi dence 0.84 2.31 (1.07) 227§ 5.65 (1.42) −2.66*MSES performance SE 0.72 3.02 (1.18) 225§ 5.08 (1.02) −1,87*MSES physical appearance 0.88 2.24 (1.16) 231§ 4.51 (1.34) −1.81*MSES physical abilities 0.73 2.64 (1.16) 228§ 3.97 (1.36) −1.05*

* = p < 0.05.† Data from the total sample in Stucke (2002).‡ Data from the healthy control group in Schröder-Abé et al. (unpublished data).§ Data from the female healthy norm sample in Schütz and Sellin (2006).†† Higher ESE values indicate a less stable self-esteem, Cronbach’s alpha: data from both groups before treatment/waiting list.M = mean. SD = standard deviation. SCC = Self-concept clarity. BSE = Basic Self-Esteem Scale. ESE = Earning Self-Esteem Scale. MSES = Multidimensional Self-Esteem Scale.

Impact of DBT on identity disturbance in BPD 153

Copyright © 2010 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 18, 148–158 (2011)DOI: 10.1002/cpp

for inpatient treatment (Bohus et al., 2004). The inpatient DBT programme included the following components: individual therapy (1 hour/week), group skills training (3 hours/week), mindfulness groups (2 hours/week), group psychoeducation (1 hour/week), peer group meetings (2 hours/week), individual body-oriented therapy (1.5 hours/week) and therapist team consultation meetings (2 hours/week). The individual therapy, skills train-ing, and therapist team consultation meetings fol-lowed Linehan’s DBT manual (Linehan et al., 1993). The psychoeducation group included instructions in Linehan’s bio-behavioural theory of BPD com-bined with information on theory and research on BPD. The mindfulness group was an extended version of the mindfulness segment of DBT skills training. The body-oriented therapy included education classes about psychomotor interaction and individually tailored exercises focusing on improvement of the body concepts. The therapists and the staff were trained and supervised regu-larly by a senior DBT trainer (Christian Stiglmayr). All DBT therapists were certifi ed psychologists or psychiatrists. All completed or were in the fi nal course of DBT certifi cation. DBT certifi cation addi-tionally included 96 hours of theory training in DBT, at least one supervised therapy case (for at least 1 year), leading a supervised skills group for at least 6 months and a fi nal oral examination by a senior DBT therapist.

Structured interviews (SCID II and MINI) were administered by trained, master-level psy-chologists, and confi rmed by a clinical inter-view performed by the last author (CHL, senior psychiatrist).

Patients from the intervention group adminis-tered all self-report scales at two different times: at admission for the 12-week DBT programme and after 10 weeks of DBT, to avoid effects due to hospital discharge. Patients in the control group were also assessed twice with approximately 10 weeks in between (M = 9.7, SD = 3.6) while they were waiting for DBT. The study was approved by the Ethical Committee of the Faculty of Medicine of the Charité-University Medicine Berlin. Written informed consent was obtained from all patients before they entered the study.

Statistical AnalysesAll analyses were conducted with the Statistical

Package for the Social Sciences SPSS, version 14.0 (SPSS, Chicago, USA). Baseline differences between patients and the control group were analyzed with independent t tests or chi-square tests when appro-

priate. Time and group effects were calculated with ANCOVAs. The signifi cance level in all of the tests was set at 0.05 (two-tailed). Effect size d for baseline variables and references for healthy subjects from the literature were calculated according to Cohen (1977). Effect sizes of main effects and interactions for ANCOVAs were reported as eta-squared. Clini-cal signifi cance was calculated with the reliable change index (RCI; Jacobson & Truax, 1991). RCI > 1.96 was considered improvement.

RESULTSSelf-Concept Clarity

Women with BPD showed signifi cantly impaired SCC compared with reference data from healthy subjects (Table 2). The ANCOVA model for SCC with age as a covariate revealed a signifi cant inter-action effect between time and group, indicating signifi cant improvement of SCC in the interven-tion group (Table 3), but no signifi cant changes in the waitlisted control group. The effect size for SCC was the largest of all variables measured in the present study. Fifteen out of 20 patients (75%) improved as calculated by the RCI.

Self-Esteem

Measures of basic self-esteem and all six facets of self-esteem from the MSES scale were signifi cantly lower in the BPD sample than in healthy controls (Table 2). The ANCOVA model for BSE revealed a signifi cant interaction effect between group and time, indicating signifi cant improvement in the intervention group (Table 3), but no signifi cant changes in the waitlisted control group. Seven out of 20 patients (35%) improved in BSE (according to the RCI). The ANCOVA model for the MSES global score and the six subscales showed signifi -cant interactions of group and time for the global score and the subscales of self-regard, social skills and social confi dence, indicating signifi cant improvement in the global score and the men-tioned subscales in BPD patients who had been treated with DBT. As calculated by the RCI: Eight (40%) patients improved on the global score, six (30%) on the self-regard scale, seven (35%) on the social skills scale, nine (45%) on the social confi -dence scale, two (10%) on the performance scale, two (10%) on the physical appearance scale, three (15%) on the physical abilities scale of the MSES out of the 20 subjects in the intervention group.

154 S. Roepke et al.

Copyright © 2010 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 18, 148–158 (2011)DOI: 10.1002/cpp

Tabl

e 3.

M

eans

and

sta

ndar

d d

evia

tion

s of

all

outc

ome

vari

able

s an

d A

NC

OV

A r

esul

ts w

ith

all

outc

ome

mea

sure

s as

dep

end

ent

vari

able

s an

d a

ge a

s co

vari

ate

Pre

M (

SD)

Post

M (

SD)

AN

CO

VA

IGC

GIG

CG

Mai

n ef

fect

gro

upM

ain

effe

ct t

ime

Inte

ract

ion

grou

p*ti

me

SCC

1.95

(0.

64)

2.02

(0.

60)

3.35

(1.

92)

1.92

(0.

67)

F =

18.0

; df =

1, 3

6;

p <

0.00

1**,

ηp2 =

0.3

3F

= 0.

02; d

f = 1

, 36;

p

= 0.

89, η

p2 = 0

.001

F =

30.4

; df =

1, 3

6;

p <

0.00

1**,

ηp2 =

0.4

6B

SE2.

21 (

0.34

)2.

20 (

0.36

)2.

60 (

0.49

)2.

18 (

0.40

)F

= 2.

44; d

f = 1

, 36;

p

= 1.

22, η

p2 = 0

.06

F =

0.16

; df =

1, 3

6;

p =

0.69

, ηp2 =

0.0

1F

= 14

.0; d

f = 1

, 36;

p

= 0.

001*

, ηp2 =

0.2

8E

SE3.

71 (

0.41

)3.

57 (

0.47

)3.

60 (

0.26

)3.

56 (

0.50

)F

= 0.

67; d

f = 1

, 35;

p

= 0.

42, η

p2 = 0

.02

F =

0.63

; df =

1, 3

5;

p =

0.43

, ηp2 =

0.0

2F

= 2.

5; d

f = 1

, 35;

p

= 0.

12, η

p2 = 0

.07

MSE

S gl

obal

SE

2.46

(0.

45)

2.62

(0.

92)

2.90

(0.

80)

2.45

(0.

94)

F =

0.09

, df =

1, 3

7;

p =

0.77

, ηp2 =

0.0

02F

= 0.

01; d

f = 1

, 37;

p

= 0.

93, η

p2 = 0

.00

F =

9.6;

df =

1, 3

7;

p =

0.00

4*, η

p2 = 0

.21

MSE

S se

lf-r

egar

d2.

62 (

0.51

)2.

44 (

1.08

)2.

96 (

0.77

)2.

24 (

1.03

)F

= 1.

2; d

f = 1

, 37;

p

= 0.

28, η

p2 = 0

.03

F =

0.19

; df =

1, 3

7;

p =

0.67

, ηp2 =

0.0

05F

= 4.

9; d

f = 1

, 37;

p

= 0.

033*

, ηp2 =

0.1

2M

SES

soci

al s

kills

2.49

(1.

09)

2.54

(1.

09)

3.16

(1.

22)

2.51

(1.

10)

F =

0.94

; df =

1, 3

7;

p =

0.34

, ηp2 =

0.0

3F

= 0.

29; d

f = 1

, 37;

p

= 0.

59, η

p2 = 0

.008

F =

4.9;

df =

1, 3

7;

p =

0.03

4*, η

p2 = 0

.12

MSE

S so

cial

con

fi den

ce1.

99 (

0.80

)2.

64 (

1.23

)2.

93 (

1.16

)2.

57 (

1.61

)F

= 0.

11; d

f = 1

, 35;

p

= 0.

75, η

p2 = 0

.003

F =

0.9;

df =

1, 3

5;

p =

0.77

, ηp2 =

0.0

02F

= 10

.0; d

f = 1

, 35;

p

= 0.

003*

, ηp2 =

0.2

2M

SES

perf

orm

ance

SE

2.86

(0.

92)

3.17

(1.

40)

2.93

(1.

10)

2.75

(1.

51)

F =

0.01

; df =

1, 3

7;

p =

0.92

, ηp2 =

0.0

00F

= 0.

07; d

f = 1

, 37;

p

= 0.

79, η

p2 = 0

.002

F =

1.8;

df =

1, 3

7;

p =

0.19

, ηp2 =

0.0

45M

SES

phys

ical

app

erar

ence

2.22

(0.

96)

2.25

(1.

37)

2.59

(1.

34)

2.19

(1.

16)

F =

0.02

; df =

1, 3

6;

p =

0.89

, ηp2 =

0.0

01F

= 0.

92; d

f = 1

, 36;

p

= 0.

34, η

p2 = 0

.025

F =

3.3;

df =

1, 3

6;

p =

0.07

6, η

p2 = 0

.085

MSE

S ph

ysic

al a

bilit

ies

2.52

(0.

95)

2.75

(1.

34)

2.82

(1.

38)

2.44

(1.

11)

F =

0.00

2; d

f = 1

, 36;

p

= 0.

97, η

p2 = 0

.000

F =

0.6;

df =

1, 3

6;

p =

0.45

, ηp2 =

0.0

2F

= 1.

6; d

f = 1

, 36;

p

= 0.

22, η

p2 = 0

.04

BD

I32

.2 (

9.23

)33

.6 (

11.5

)20

.9 (

12.0

)32

.7 (

11.5

)F

= 2.

1; d

f = 1

, 35;

p

= 0.

16, η

p2 = 0

.06

F =

6.2;

df =

1, 3

5;

p =

0.02

*, η

p2 = 0

.15

F =

7.3;

df =

1, 3

5;

p =

0.01

*, η

p2 = 0

.17

SCL

-90-

R G

SI1.

79 (

0.52

)1.

99 (

0.60

)1.

29 (

0.72

)1.

87 (

0.76

)F

= 2.

5; d

f = 1

, 35;

p

= 0.

13, η

p2 = 0

.07

F =

0.92

; df =

1, 3

5;

p =

0.34

, ηp2 =

0.0

3F

= 7.

1; d

f = 1

, 35;

p

= 0.

01*,

ηp2 =

0.1

7

* p <

0.0

5, *

* p <

0.0

01.

IG =

Int

erve

ntio

n gr

oup

(n =

20)

. C

G =

Con

trol

gro

up (

n =

20).

M =

mea

n. S

D =

sta

ndar

d d

evia

tion

. SC

C =

Sel

f-co

ncep

t cl

arit

y. B

SE =

Bas

ic s

elf-

este

em s

cale

. E

SE =

Ear

ning

se

lf-e

stee

m s

cale

. MSE

S =

Mul

tid

imen

sion

al s

elf-

este

em s

cale

. BD

I =

Bec

k d

epre

ssio

n in

vent

ory.

SC

L-9

0-R

= S

ympt

om c

heck

list

90 r

evis

ed. G

SI =

Glo

bal s

ever

ity

ind

ex.

Impact of DBT on identity disturbance in BPD 155

Copyright © 2010 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 18, 148–158 (2011)DOI: 10.1002/cpp

Scores of ESE for BPD patients were not signifi -cantly different from those of the healthy controls (Table 2). The ANCOVA model for ESE did not show signifi cant main effects and no interaction effect between time and group (Table 3), indicating no signifi cant modifi cation of ESE in either group. Also, no patient improved as calculated by the RCI in the intervention group.

Changes in Psychopathology and Depression

Depressive symptoms measured by the BDI and general psychopathology measured by the GSI of the SCL-90-R were not signifi cantly different between the two groups at baseline (Table 3). The BDI and the GSI of the SCL-90-R showed a signifi cant interaction effect of time and group in the ANCOVA model, indicating a signifi cant improvement after a 10-week DBT programme on both scales (Table 3), but no signifi cant changes in the waitlisted control group. Thirteen out of 19 patients (68%) improved as calculated by the RCI on the BDI scale. On general psychopathol-ogy measures (GSI), 11 out of 19 patients (58%) improved as calculated by the RCI.

DISCUSSIONWe tested the impact of a 12-week inpatient DBT programme on SE and SCC of BPD patients. We had hypothesized that participants treated with the DBT programme would show (a) an enhan-cement in SCC, and thus an improvement of identity disturbance; (b) an enhancement in SE; and (c) an overall reduction of psychopathological symptoms.

Within the limitations that are discussed later, all of our hypotheses were confi rmed. We found that SCC was signifi cantly enhanced after 10 weeks of DBT, 75% of patients fulfi lled criteria of clinical improvement as calculated by the RCI. This result is of special interest as SCC overlaps with the con-struct of identity (Campbell et al., 1996), which indicates that DBT directly improves the degree of the criterion ‘identity disturbance’, in DSM-IV (APA, 1994). To our knowledge, the present study is the fi rst to empirically demonstrate that short-term psychotherapy is able to improve identity disturbance in BPD patients.

DBT comprises different strategies that are can-didates for improving identity disturbance. Thus, validation strategies can be conceptually under-stood to enhance the stability of the patient’s

sense of self (Lynch et al., 2006). Validation can be considered to be steady, self-verifying feedback from the therapist, thus leading to a perception of coherence (Lynch et al., 2006, Swann et al., 2003). Further, analysis and modifi cation of dysfunctional behaviour (e.g., by chain analysis) and cognitions (e.g., by dialectic strategies to reduce polarization) are hypothesized to reduce BPD symptomatology (Lynch et al., 2006) and probably improve the sense of self, and thus SCC and identity disturbance. Fur-thermore, mindfulness, a technique related to the quality of awareness within a present experience aims to improve participating and ‘becoming one’ with experience (Chapman & Linehan, 2005) could be a candidate to improve the experience of coher-ence and thus identity.

DBT treatment furthermore resulted in a sig-nifi cant increase in global and basic SE of BPD patients. Nevertheless, only 35% of patients ful-fi lled criteria of clinical improvement on the BSE and 45% of patients on the MSES sum score, as calculated by the RCI. Differentiating the facets of SE using the MSES (Schütz & Sellin, 2006), revealed that only self-regard and the two facets of social SE, social skills and social confi dence, improved sig-nifi cantly after 10 weeks of DBT. Clinical improve-ment of these facets (RCI) was found in 30–45% of patients in the intervention group. This result sug-gests that the improvement of global and basic SE can be mainly attributed to pronounced changes within the emotional and social domains of SE. The improvement in social SE can be explained as an effect of the intensive training of social skills that BPD patients receive during DBT. Social dys-function is characteristic of BPD (Hill et al., 2008), and without social skills it is impossible to main-tain stable interpersonal relationships, pursue long term goals or gain self-respect in social situations. Therefore, an increase of social skills and compe-tence is an important source of improved SE for patients with BPD.

Changes in the emotional domain of SE could be attributed to specifi c techniques used in DBT as emotion regulation is one central focus in that therapy and is directly linked to the bioso-cial theory of BPD (Linehan, 1993). DBT aims to enhance emotion regulation, and thus, the teaching of emotion regulation skills is a core intervention (Linehan, 1993). Further, mindfulness, conceptu-alized as an internal state for the acquisition of various emotional and behavioural responses (Lynch et al., 2006), could infl uence emotional experience. Findings of activation of brain areas related to positive affect after mindfulness train-

156 S. Roepke et al.

Copyright © 2010 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 18, 148–158 (2011)DOI: 10.1002/cpp

ing point in that direction (Davidson et al., 2003). Also, validation strategies, as core acceptance strategies in DBT (Linehan, 1993), possibly reduce emotional arousal (Lynch et al., 2006). Thus, self-regard, which is the basic emotional dimension of SE, may have been improved through the applica-tion of these techniques in DBT.

The lack of improvement in performance and physical ability self-esteem may be due to the fact that DBT does not emphasize aspects related to performance or physical ability self-concept. As demonstrated in previous studies (Schröder-Abé et al., under submission) earning self-esteem was not signifi cantly impaired in BPD patients com-pared with healthy controls. Thus, in contrast to the improvement of global and basic SE, earning self-esteem was not signifi cantly modifi ed after DBT. General psychopathology and depressive symptoms had also improved signifi cantly after 10 weeks of inpatient DBT, which dovetails with results from previous studies (Bohus et al., 2004; Linehan et al., 1991). Also, the percentage of patients that clinically improved due to RCI cri-teria were comparable to previous results, which revealed clinical improvement in 45% of patients after 3 months of inpatient DBT (Kleindienst et al., 2009).

Besides specifi c DBT techniques as emotion regulation and mindfulness, one also has to con-sider the impact of cognitive interventions, which are part of DBT, on SCC and SE. Self-devaluating and self-denigrating ideas, which are expressions of low SE, can be considered the most frequent cognitions underlying behaviour typical of BPD. The therapeutic correction of these dysfunctional cognitions is also part of the DBT programme. On the one hand, these interventions may clarify the self-concept of BPD patients; on the other hand, they may increase SE by reducing self-devaluat-ing cognitions. The data showing improved SE in depressed patients after CBT (Chen et al., 2006; Knapen et al., 2005) argue for a positive impact of these more general techniques on self-esteem. Also, the successful completion of DBT therapy and reduction of BPD symptoms may be consid-ered general factors that lead to modifi ed SCC and SE.

Limitations of the Study

One limitation of our study is the lack of random-ization between the two groups. Further, the inter-vention group was treated as inpatients, while the

control group spent that time period at home. Thus we cannot exclude possible effects of hospitaliza-tion and ‘unspecifi c’ intervention. In both groups, most patients were on psychotropic medication, thus we did not include this factor in the statistical analysis. The effect of concomitant psychotropic medication has to be assessed in further research. Also, follow-up data need to be obtained in future research to prove stability of the improvement in SE and SCC. Depressive symptoms after DBT (measured by the BDI) were still higher than in other comparable studies (Linehan et al., 1993). This could refl ect general impairment in the study population, as inpatient programmes are especially designed for severely disturbed patients. Neverthe-less, depressive symptoms improved signifi cantly in the intervention group, and previous studies have shown that depressive symptoms are related to low SE (Chen et al., 2006; Knapen et al., 2005), thus improvements in SE can be directly related to the reduction of depressive symptoms. Further research should now provide a more fi ne-grained analysis of the effect of CBT and specifi c therapies such as DBT on SCC and SE in patients with BPD and patients with major depression. Future studies should also identify specifi c effi ciency factors of DBT that help to improve SE and SCC in BPD patients. Also, the impact of other specifi c proto-coled psychotherapeutic treatments of BPD, e.g., transference-focused psychotherapy (Kernberg, Yeomans, Clarkin, & Levy, 2008), mentalization-based treatment (Bateman & Fonagy, 2009) and the systems training for emotional predictability and problem solving (Blum et al., 2008), on self-concept clarity and facets of self-esteem needs to be assessed. Finally, further studies are needed to replicate our preliminary fi ndings and, even more importantly, follow-up examinations are needed to prove stability of the described impact of DBT on self-concept clarity and facets of self-esteem.

In summary, within the described limitations, our results indicate that a 12-week inpatient DBT programme for women with BPD provides clini-cally signifi cant improvement in SE and SCC. Thus, the results of the present study argue that in BPD patients, self-esteem and the diagnostic cri-teria identity disturbance can be infl uenced with short-term psychotherapy.

ACKNOWLEDGEMENTSWe thank Birgit Baumkötter, Sandra Schauen, Alisa Zukanovic and Martina Schickart for their

Impact of DBT on identity disturbance in BPD 157

Copyright © 2010 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 18, 148–158 (2011)DOI: 10.1002/cpp

help with data collection. We thank Mirja Petri for her comments on an earlier version of the manuscript.

REFERENCESAckenheil, M., Stotz-Ingenlath, G., Dietz-Bauer, A., &

Vossen, A. (1999). Mini International Neuropsychiatric Interview (MINI), German Version 5.0.0. The develop-ment and validation of a structured diagnostic psychi-atric interview for DSM-IV and ICD-10. Psychiatrische Universitätsklinik, München, Germany.

American Psychiatric Association (APA) (1994). Diagnos-tic and statistical manual of mental disorders DSM-IV. Washington, DC: Author.

Bateman, A., & Fonagy, P. (2009). Randomized controlled trial of outpatient mentalization-based treatment versus structured clinical management for borderline personality disorder. American Journal of Psychiatry, 166, 1355–1364.

Baumeister, R. (1999). Self in social psychology: Essential readings (Key readings in social psychology). Hove: Psychology Press.

Baumeister, R.F. (1998). The self. In D.T. Gilbert, S.T. Fiske, & G. Lindzey (Eds), The Handbook of social psy-chology (pp. 339–374). New York: McGraw-Hill.

Baumeister, R.F., Campbell, J.D., Krueger, J.I., & Vohs, K.D. (2003). Does high self-esteem cause better perfor-mance, interpersonal success, happiness, or healthier lifestyles? Psychological Science in the Public Interest, 4, 1–44.

Beck, A.T., Steer, R.A., Ball, R., & Ranieri, W. (1996). Comparison of Beck Depression Inventories -IA and -II in psychiatric outpatients. Journal of Personality Assess-ment, 67, 588–597.

Beck, A.T., Ward, C.H., Mendelson, M., Mock, J., & Erbaugh, J. (1961). An inventory of measuring depres-sion. Archives of General Psychiatry, 4, 561–571.

Blum, N., St John, D., Pfohl, B., Stuart, S., McCormick, B., Allen, J., Arndt, S., & Black, D.W. (2008). Systems train-ing for emotional predictability and problem solving (STEPPS) for outpatients with borderline personality disorder: A randomized controlled trial and 1-year follow-up. American Journal of Psychiatry, 165, 468–478.

Bohus, M., Haaf, B., Simms, T., Limberger, M.F., Schmahl, C., Unckel, C., Lieb, K., & Linehan, M.M. (2004). Effec-tiveness of inpatient dialectical behavioral therapy for borderline personality disorder: A controlled trial. Behavior, Research and Therapy, 42, 487–499.

Brown, J.D., & Dutton, K.A. (1995). The thrill of victory, the complexity of defeat: Self-esteem and people’s emotional reactions to success and failure. Journal of Personality and Social Psychology, 68, 712–722.

Campbell, J.D. (1990). Self-esteem and clarity of the self-concept. Journal of Personality and Social Psychology, 59, 538–549.

Campbell, J.D., Trapnell, P.D., Heine, S.H., Katz, I.M., Lavallee, L.F., & Lehman, D.R. (1996). Self-concept clarity: Measurement, personality correlates, and cul-tural boundaries. Journal of Personality and Social Psy-chology, 70, 141–156.

Chapman, A.L., & Linehan, M.M. (2005). Dialectical behavior therapy for borderline personality disorder. In M. Zanarini (Ed.), Borderline personality disorder (pp. 211–242). Florida: Taylor & Francis.

Chen, T.H., Lu, R.B., Chang, A.J., Chu, D.M., & Chou, K.R. (2006). The evaluation of cognitive-behavioral group therapy on patient depression and self-esteem. Archives of Psychiatric Nursing, 20, 3–11.

Cohen, J. (1977). Statistical power for the behavioral sciences. New York: Academic Press.

Davidson, R., Kabat-Zinn, J., Schumacher, J., Rosen-kranz, M., Muller, D., Santorelli, S.F., et al. (2003). Alternations in brain and immune function produced by mindfulness meditation. Psychosomatic Medicine, 65, 564–570.

De Bonis, M., De Boeck, P., & Lida-Pulik, H. (1998). Self-concept and mood: A comparative study between depressed patients with and without borderline per-sonality disorder. Journal of Affective Disorders, 48, 191–197.

Diener, E., & Diener, M. (1995). Cross-cultural correlates of life satisfaction and self-esteem. Journal of Personality and Social Psychology, 68, 653–663.

DiPaula, A., Campbell, J.D. (2002). Self-esteem and per-sistence in the face of failure. Journal of Personality and Social Psychology, 83, 711–724.

Ebner-Priemer, U.W., Kuo, J., Kleindienst, N., Welch, S.S., Reisch, T., Reinhard, I., Lieb, K., Linehan, M.M., & Bohus, M. (2007). State affective instability in bor-derline personality disorder assessed by ambulatory monitoring. Psychological Medicine, 37, 961–970.

First, M.B., Spitzer, R.L., Gibbon, M., Williams, J.B.W., & Benjamin, L.S. (1997). Structured clinical interview for DSM-IV personality disorders (SCID-II). Washington DC: American Psychiatric Press.

Fleming, J.S., & Courtney, B.E. (1984). The dimension-ality of self-esteem: II. Hierarchical facet model for revised measurement scales. Journal of Personality and Social Psychology, 46, 404–421.

Forsman, L., & Johnson, M. (1996). Dimensionality and validity of two scales measuring different aspects of self-esteem. Scandinavian Journal of Psycholology, 37, 1–15.

Franke, G.H. (1995). Die Symptom-Checkliste von Derogatis (SCL-90-R). Göttingen: Beltz.

Fydrich, T., Renneberg, B., Schmitz, B., & Wittchen, H.U. (1997). Strukturiertes Klinisches Interview für DSM-IV. Achse II. Persönlichkeitsstörungen (SKID-II). Göttingen: Hogrefe.

Glaser, J.P., Os, J.V., Mengelers, R., & Myin-Germeys, I. (2007). A momentary assessment study of the reputed emotional phenotype associated with borderline per-sonality disorder. Psychological Medicine, 30, 1–9.

Greenwald, A.G., & Pratkanis, A.R. (1984). The self. In R.S. Wyer, & T.K. Srull (Eds), Handbook of social cognition (pp 129–178). Hillsdale: Erlbaum.

Hautzinger, M., Bailer, M., Worall, H., & Keller, F. (1994). Das Beck Depressionsinventar (BDI): Testhandbuch. Bern: Huber.

Hill, J., Pilkonis, P., Morse, J., Feske, U., Reynolds, S., Hope, H., Charest, C., & Broyden, N. (2008). Social domain dysfunction and disorganization in border-

158 S. Roepke et al.

Copyright © 2010 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 18, 148–158 (2011)DOI: 10.1002/cpp

line personality disorder. Psychological Medicine, 38, 135–146.

Hyun, M.S., Chung, H.I., & Lee, Y.J. (2005). The effect of cognitive-behavioral group therapy on the self-esteem, depression, and self-effi cacy of runaway adolescents in a shelter in South Korea. Applied Nursing Research, 18, 160–166.

Jacobson, N.S., & Truax, P. (1991). Clinical signifi cance: A statistical approach to defi ning meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology, 59, 12–19.

Jørgensen, C.R. (2006). Disturbed sense of identity in borderline personality disorder. Journal of Personality Disorders, 20, 618–644.

Judge, T.A., Erez, A., Bono, J.E., & Thoresen, C.J. (2002). Are measures of self-esteem, neuroticism, locus of control, and generalized self-effi cacy indicators of a common core construct? Journal of Personality and Social Psychology, 83, 693–710.

Kernberg, O.F. (1975). Borderline conditions and pathologi-cal narcissism. Lanham: Jason Aronson.

Kernberg, O.F., Yeomans, F.E., Clarkin, J.F., & Levy, K.N. (2008). Transference focused psychotherapy: Over-view and update. The International Journal of Psycho-analysis, 89, 601–620.

Kleindienst, N., Limberger, M.F., Schmahl, C., Steil, R., Ebner-Priemer, U.W., & Bohus, M. (2008). Do improve-ments after inpatient dialectial behavioral therapy persist in the long term? A naturalistic follow-up in patients with borderline personality disorder. The Journal of Nervous and Mental Disease, 196, 847–851.

Knapen, J., Van de Vliet, P., Van Coppenolle, H., David, A., Peuskens, J., Pieters, G., & Knapen, K. (2005). Comparison of changes in physical self-concept, global self-esteem, depression and anxiety following two different psychomotor therapy programs in nonpsy-chotic psychiatric inpatients. Psychotherapy and Psycho-somatics, 74, 353–361.

Linehan, M.M., Armstrong, H.E., Suarez, A., Allmon, D., & Heard, H.L. (1991). Cognitive-behavioral treat-ment of chronically parasuicidal borderline patients. Archives of General Psychiatry, 48, 1060–1064.

Linehan, M.M., Comtois, K.A., Murray, A.M., Brown, M.Z., Gallop, R.J., Heard, H.L., Korslund, K.E., Tutek, D.A., Reynolds, S.K., & Lindenboim, N. (2006). Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disor-der. Archives of General Psychiatry, 63, 757–766.

Linehan, M.M., Heard, H.L., & Armstrong, H.E. (1993). Naturalistic follow-up of a behavioral treatment for chronically parasuicidal borderline patients. Archives of General Psychiatry, 50, 971–974.

Lynch, T.R., Trost, W.T., Salsman, N., & Linehan, M.M. (2007). Dialectical behavior therapy for borderline

personality disorder. Annual Review of Clinical Psychol-ogy, 3, 181–205.

Pollock, P.H., Broadbent, M., Clarke, S., Dorrian, A., & Ryle, A. (2001). The Personality Structure Question-naire (PSQ): A measure of the multiple self-states model of identity disturbance in cognitive analytic therapy. Clinical Psychology and Psychotherapy, 8, 59–872.

Reynolds, W.M., & Coats, K.I. (1986). A comparison of cognitive-behavioral therapy and relaxation training for the treatment of depression in adolescents. Journal of Consulting and Clinical Psychology, 54, 653–660.

Robins, R.W., Hendin, H.M., & Trzesniewski, K.H. (2001). Measuring global self-esteem: Construct vali-dation of a single item measure and the Rosenberg Self-Esteem Scale. Personality and Social Psychology Bulletin, 27, 151–161.

Schütz, A. (2005). Je selbstsicherer desto besser? Licht und Schatten positiver Selbstbewertung. [Self-esteem—The more the better? Positive and negative aspects of high self-esteem]. Weinheim: Beltz.

Schütz, A., & Sellin, I. (2006). Die multidimensionale Selbst-wertskala (MSWS) [The Multidimensional Self-Esteem Scale, MSES]. Göttingen: Hogrefe.

Shavelson, R.J., Hubner, J.J., & Stanton, G.C. (1976). Self-concept: Validation of construct interpretations. Review of Educational Research, 46, 407–441.

Sheehan, D.V., Lecrubier, Y., Sheehan, K.H., Amorim, P., Janavs, J., Weiller, E., Hergueta, T., Baker, R., & Dunbar, G.C. (1998). The Mini-International Neu-ropsychiatric Interview (MINI): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry, 59, 22–33.

Stucke, T.S. (2002). Investigation of a German version of Campbell’s self-concept clarity scale. Zeitschrift für Differentielle und Diagnostische Psychologie, 23, 475–484.

Swann, W., Rentfrow, P., & Guinn, J. (2003) Self-verifi cation: The search for coherence. Handbook of self and identity. New York: Guilford Press.

Taylor, S.E., & Brown, J. (1988). Illusion and well-being: A social psychological perspective on mental health. Psychological Bulletin, 103, 193–210.

Tennen, H.J., & Herzberger, S. (1987). Depression, self-esteem, and the absence of self protective attributional biases. Journal of Personality and Social Psychology, 52, 72–80.

Watson, D., Suls, J., & Haig, J. (2002). Global self-esteem in relation to structural models of personality and affectivity. Journal of Personality and Social Psychology, 83, 185–197.

Wilkinson-Ryan, T., & Westen, D. (2000). Identity distur-bance in borderline personality disorder: An empiri-cal investigation. American Journal of Psychiatry, 157, 528–541.

Copyright of Clinical Psychology & Psychotherapy is the property of John Wiley & Sons, Inc. and its content

may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express

written permission. However, users may print, download, or email articles for individual use.