Yangsan Hospital Mingeol Kim, M.D., ACT. Dialectical Behavior Therapy for Individuals with Borderline Personality Disorder and Substance Dependence Yangsan Hospital Mingeol Kim, M.D., ACT.

Modification of CBT for BPD

Comparing DBT to CBT Acceptance and Validation – Eastern Zen Practice Treating Therapy interfering behaviors both client and therapist – Psychodynamic concept of Tr., CTr. Therapeutic Relationship – Attachment Theory Dialectic Process – Dialectic Philosophy

Difficulties to Treat Rate of suicide and suicide attempts already high among the individuals with… Borderline Personality Disorder (BPD) Substance Use Disorder (SUD) BPD + SUD

Comorbidity Prevalence Substance Use Disorders(SUDs) commonly co-occurred with…. SUD & Mood Disorder - ICBT SUD & Borderline Personality Disorder(BPD) - DBT Modifications for SUD Mood Disorder & Antisocial Personality Disorder – most high comorbidity prevalence - Anger Management Porgram

Borderline PD A pervasive pattern of instability of interpersonal relationships, self-image and affects, as well as marked impulsivity, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following: Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-injuring behavior covered in Criterion 5 A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. Identity disturbance: markedly and persistently unstable self-image or sense of self. Impulsivity in at least two areas that are potentially self-damaging (e.g., promiscuous sex, eating disorders, binge eating, substance abuse, reckless driving). Note: Do not include suicidal or self-injuring behavior covered in Criterion 5 Recurrent suicidal behavior, gestures, threats or self-injuring behavior such as cutting, interfering with the healing of scars (excoriation) or picking at oneself. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability or anxiety usually lasting a few hours and only rarely more than a few days). Chronic feelings of emptiness Inappropriate anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights). Transient, stress-related paranoid ideation, delusions or severe dissociative symptoms

Anti-Social PD A) There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by three or more of the following: failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest; deception, as indicated by repeatedly lying, use of aliases, or conning others for personal profit or pleasure; impulsiveness or failure to plan ahead; irritability and aggressiveness, as indicated by repeated physical fights or assaults; reckless disregard for safety of self or others; consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations; lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another; B) The individual is at least age 18 years. C) There is evidence of conduct disorder with onset before age 15 years. D) The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or a manic episode.

Structure of DBT DBT Skill Training Group DBT Individual Therapy DBT Team Meeting (Therapist Consultation Team) Telephone Coaching ( 24 hours – Office hour) Homework – Diary Card

DBT Skill Training Group - 3 Modules 1. Interpersonal Effectiveness 2. Emotion Regulation 3. Distress Tolerance 4. Clean Mind (for BPD + SUD)

DBT Skill Training Group - Hierachy Mindfulness Life Threatening Behavior Therapy Interfering Behavior Quality of Life Behavior New Agenda Skill Class

Diary Card I

Diary Card II

Dialectical Abstinence Synthesis of Unrelenting insistence on total Abstinence before any illicit drug use. Radical acceptance, nonjudgmental problem solving, and effective relapse prevention after use. Balanced position

Path to Clear Mind Decrease substance abuse Decrease physical discomfort Decrease urges, cravings, and temptations to use drugs Decrease options to use drugs Decrease contact with cues for drug use Increase reinforcement of “Clear Mind” behaviors