Dialectical Behaviour Therapy and Borderline Personality Disorder.

Presentation Outline Psychoanalysis and BPD. Dialectical Behavior Therapy Studies Positive and Negative aspects of DBT Evaluation

Borderline Personality Disorder Five or more of the following to be present for a significant period of time: Frantic efforts to avoid real or imagined abandonment. [Not including suicidal or self-mutilating 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., spending, promiscuous sex, eating disorders, substance abuse, reckless driving, binge eating). [Again, not including suicidal or self-mutilating behavior covered in Criterion 5] Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior. 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, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights). Transient, stress-related paranoid ideation or severe dissociative symptoms.

Psychoanalysis and BPD Traditional psychoanalytic treatments of BPD required longer hospitalization periods. They relayed on patients being in a controlled environment. Long hospitalization periods are rarer nowadays. Psychoanalysis requires longer periods of commitment to treatment, which is incompatible with Borderline Personality Disorder.

Dialectical Behaviour Therapy Dialectical Behaviour Therapy(DBT) is a form of cognitive behavioural therapy for borderline personality disorder patients developed by Marsha Linehan. It was developed in the 1990´s. DBT was first developed for “chronically suicidal individuals”. This form of therapy is called “Dialectical” because it deals with emotional and rational aspects, and with acceptance and change. DBT mixes cognitive behavior therapy with mindfulness techniques. Individual Therapy and Group Therapy.

Reasoning behind DBT - BPD has a biological basis, which affects emotional regulation. Social environments may reinforce their dysfunctional behaviour (Biosocial theory). DBT encourages clients to be aware of the current moment and accept reality. DBT tries to replace rigid/dichotomous worldviews. It emphasizes the importance of a more holistic approach to life. DBT also stresses that balance is important in life. Clients should achieve a middle ground between reason and emotion.

Four Modules Mindfulness Interpersonal effectiveness Distress endurance Emotion regulation

Pre- treatment stage Agreeing on goals Individualized treatment lists :decrease behaviours which prolong hospitalization (parasuicidal, therapy interfering behaviour), decrease behaviours that affect quality of life, increase life skills, decrease stress, increase self-esteem. 2)Committing to treatment plans - Most patients enter the hospital involuntarily.

Stages Stage one Decrease behaviour which prolong hospitalization Increase skills for getting out and staying out of the hospital. - Crisis survival skills : distress tolerance module Stage 2 Deal with stress related problems Stage 3 Increase self- esteem Treatment goals Stage 4

Diary Cards

Effectiveness of dialectical behavior therapy for Borderline personality disorder in an inpatient setting Fifty inpatients diagnosed with BPD were evaluated at three different points in time. The patients were screened for substance abuse, bipolar I, dementia and schizophrenia. - Each patient went to individual therapy sessions once a week and group sessions three times a week Sixty-two percent of patients also received anti-depression medication. Benzodiapines were also used. Symptoms were reduced, but not eliminated. Findings confirmed the effectiveness of DBT. It was also proved that DBT can be used in an inpatient setting.

Positive aspects of DBT Reduced suicidal behaviour Hospitalizations Length of hospitalization treatment dropout Depression scores Anger Dissociation Substance use Increased interpersonal functioning Global functioning

Negative aspects of DBT The first stage alone takes one year at least. Expensive Long- waiting lists

Evaluation There are few studies about DBT. Most studies use small samples. There were no follow-up studies of the original research. Personality disorders are difficult to treat. Parasuicidal behaviours are hard to control. However, DBT seems to help most patients. It is possible to adapt DBT to other situations and settings.