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

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

3. 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

4. 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:

5. 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);

6. 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.

7. 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.

8. 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

9. 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

10. Mindfulness: let go of past & future worries

11. 4 approaches to any problem:
Change the situation.
Change how you feel about the situation.
Accept and tolerate the situation.
Stay Miserable

12. 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.

13. 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.

14. Resources in MI:
• Interact of Michigan- Kalamazoo
• DBT Institute of MI- Holt & Novi
• Kalamazoo DBT
• Nicole Kletzka, Ph.D Saline
Ann Arbor DBT Center
Bloomfield DBT of MI
Pine Rest Christian Mental Health Services- GR