Current Clinical Challenges A Brief Overview of Borderline Personality Disorder October 21st 2016 Victoria Cane Ph.D, Licensed Psychologist, Board-certified DBT Clinician.

DSM V Criteria Topics: Evolution of the diagnosis EBTs DBT Core Elements Resources in MI DBT Conceptualization of BPD RCTs

BPD- Evolution of the diagnosis: DSM IV- *frantic efforts to avoid real or imagined abandonment. *pattern of unstable relationships. *identity disturbance. *impulsivity. *recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior. *affective instability. *chronic feelings of emptiness. *inappropriate anger. *stress-related paranoid ideation

BPD- Evolution of the diagnosis: DSM V- *SELF: Unstable identity/self-image Difficulty with self-direction. *INTERPERSONAL: Difficulty cultivating empathy/perceived threat Difficulty with intimacy-idealization & devaluation *NEGATIVE AFFECTIVITY: Emotion lability Presence of anxiety/panic Rejection insecurity Depression *DISINHIBITION: Impulsivity Risk taking *ANTAGONISM:

BPD- Evidence based Treatments: DBT is the BPD treatment model for BPD with the largest number of evidence- based published research of effectiveness (8+ RCTs vs. 2 for other treatment). The Am. Psychol. Assn. Society of Clinical Psychology (APS) considers DBT the only well-established empirically supported treatment for BPD that has strong research support (APA Division 12, 2011). DBT is currently the only therapy listed as an evidence-based practice for BPD in the U.S. Substance Abuse and Mental Health Service Administration’s (SAMHSA) National Registry of Evidence-Based Programs and Practices (SAMHSA, 2012). Growing research evidence of effectiveness for a wide range of other complex difficult to treat conditions including RCTs for substance abuse (4), eating disorder (2 RCTs), treatment resistant depression (1 RCT), elderly depressed (2 RCTs) suicidal adolescents (1 RCT), problem gambling (1 RCT);

Dialectical Behavior Therapy Based on a biosocial theory- biologically based emotion dysregulation in an invalidating environment. An invalidating environment may reinforce dysfunctional behaviors and punish more effective behaviors. Combines principles of behavior and elements of CBT with emphasis on skill acquisition and overarching dialectical stance. Individual therapy, skills training, between-session coaching, therapist consultation group.

Dialectical Behavior Therapy Enhance behavioral capability. Core Mindfulness, Emotion Regulation, Distress Tolerance, Interpersoonal Effectiveness. Improve motivation to change. Linking capabilities with demonstration in the environment. Structures the treatment environment to support behavioral change. Enhances therapist’s motivation and capability.

Dialectical Behavior Therapy Conceptualizes BPD as Characterized by 5 Areas of Dysregulation: Emotion Dysregulation Affective lability, problems w/ anger Interpersonal Dysregulation Chaotic relationships, fears of abandonment Self Dysregulation Identity disturbance Sense of emptiness Behavioral Dysregulation Self-injury Impulsive behavior Cognitive Dysregulation Dissociative behaviors Paranoid ideation/interpretation

Acceptance Skills: Mindfulness- mindfulness is awareness, without judgment, of life as it is, yourself as you are, other people as they are, in the here and now, via direct and immediate experience. when you are mindful, you are awake to life on its terms – fully alive to each moment as it arrives, as it is, and as it ends. Radical Acceptance- Deeply accepting situations that are challenging, unwanted, and exist despite what we do or don’t want. Acceptance is a first step toward moving forward away from or through a challenging situation

Mindfulness: let go of past & future worries

4 approaches to any problem: Change the situation. Change how you feel about the situation. Accept and tolerate the situation. Stay Miserable

Randomized Controlled Trials: Linehan et al 1991- DBT more effective than TAU in reducing self-harm beh., initiation and completion of treatment, less inpatient days. Linehan et al 1999- DBT more effective than TAU in reducing use of substances, overall scores of global adjustment. Linehan et al 2006- DBT more effective at reducing suicide attempts, hospitalizations for SI, self- harming beh., ER visits, treatment drop-out. Courbasson, et al 2012- DBT more effective than TAU in treatment drop-out (13% vs. 80%), incidents of binge eating, bulimic beh., eating disorder preoccupation. Mehlum et al 2014- DBT more effective at reducing self-harm, level of SI, depressive symptoms.

DBT Consultation Group • Considered, “therapy for the therapist.” • Tracks burnout levels weekly • Colleagues offer validation, tangible support, & problem solving. • Without Consultation Group, DBT therapists would not be able to cope with their emotionally dysregulated clients effectively • We all need support to cope with the stressors that arise in the helping professions.

Resources in MI: • Interact of Michigan- Kalamazoo 269-381-3700 www.interactmich.org • DBT Institute of MI- Holt & Novi 517-367-0670 www.dbtimi.com • Kalamazoo DBT- 269-350-4301 www.kalamazoodbt.com • Nicole Kletzka, Ph.D Saline 734-295-4806 Ann Arbor DBT Center 734-945-4644 www.annarbordbt.citymax.com Bloomfield DBT of MI www.bloomfielddbt.com 248-470-7967 Pine Rest Christian Mental Health Services- GR 800-678-5500 www.pinerest.org