User:Victoria Mealor/sandbox

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Dialectical Behaviour Therapy as treatment in Borderline Personality Disorder[edit]

Borderline Personality Disorder[edit]

Borderline Personality Disorder (BPD) was first described by American psychoanalyst Adolph Stern in 1938 [1]. Adolph Stern described the symptoms, suggested possible causes, and suggested possible treatment for Borderline Personality Disorder. BPD effects around 1.4% of the population, and occurs three times more often in women than in men [2]. BPD is recognised in the Diagnostic and Statistical Manual of Mental Disorders (DSM- all revised issues)[3], it is also recognised in the International Statistical Classification of Diseases and Related Health Problems (ICD-10)[4]. BPD is a chronic psychological disorder characterised by marked impulsivity, instability of mood and interpersonal relationships, and suicidal behaviour. Symptoms of BPD would include the following:

  • Wide mood swings
  • Fear of being alone
  • Suicidal behaviour
  • Feelings of self-hate and/ or self loathing
  • Impulsivity and risky behaviour
  • Awareness of destructive behaviour
  • Short but intense episode of anxiety or depression
  • Inappropriate anger and antagonistic behaviour
  • Feeling misunderstood, neglected, alone, empty or hopeless
  • Difficulty controlling emotions or impulses[3][4][5]

The cause of BPD is not fully known but evidence suggests that there is a link with genetics [6]

Dialectical Behavior Therapy[edit]

Dialectical Behavior Therapy was originally developed by Marsha Linehan. It was developed as a treatment for BPD in particular. It was designed in order to help individuals change their pattern of behaviour, and also increase their emotional and cognitive regulation [7]. DBT is used to treat a variety of psychological disorders, for example;

It combines techniques for emotion regulation and reality testing. The different concepts used are that of distress tolerance, acceptance and mindful awareness. Research involving DBT suggests that it is effective in treating BPD and other disorders [8][9] There are 4 components to DBT treatment, they are the following;

  • Individual
    • Issues that have arisen during the week are discussed.
    • Suicidal and life threatening behaviours dealt with first.
    • Behaviours that are not directly harmful to self and others but affect treatment course are discussed secondly.
    • Thirdly, quality of life issues and improving life generally.
  • Group
    • Meet once a week.
    • Learn to use specific skills that are broken down into four skill modules: Core mindfulness, Interpersonal Effectiveness, Emotion Regulation, and Distress Tolerance.
  • Therapist Consultation Team
    • Includes therapists providing DBT.
    • Occurs weekly.
    • Supports therapist in providing treatment.
  • Phone Coaching
    • Helps generalise skills.
    • Brief and focused on skills.
    • Neither of the components are used alone[7]

DBT as treatment in BPD[edit]

DBT is the treatment that has been studied the most and recorded as the most effective form of psychotherapy for treatment in BPD. Any long term therapy is effective for the treatment of BPD. The first studies of DBT in the treatment of BPD, all displayed rates of reduced suicide attempts, hospitalisations, and treatment drop-outs when they have been compared to usual psychotherapy treatments [10]. It is extremely challenging to treat individuals' with BPD due to the nature of the disorder. It is difficult for therapists to maintain treatment as individuals' fail to attend sessions. It is also evident that individuals' make emotional demands on therapists with the suicidal behaviours. The success of the treatment depends on the patient- therapist relationship, as it is a very humanistic approach to therapy. It will be important during the treatment that whilst the therapist is practicing DBT, that they also are in receipt of DBT from colleagues to prevent burnout [11]. When a therapist begins consultations, they will need to have a set of assumptions beforehand. These assumptions would be the following;

  • The individual should want to change their behaviour and circumstances. They must be showing that they are trying their best to make these improvements.
  • Although the individuals' life or circumstances may seem extremely distressing, it is important that they are reassured suicide is not the answer.
  • The individual must keep trying harder no matter how they feel.
  • If things are not improving and do not seem to be working, it does not mean that they are failing DBT, it just means that the treatment is not suitable for them.[11]

When dealing with the individual there is a system that is adhered to. There is an order of targets that are dealt with in hierarchy form. They are as follows;

  • Decreasing suicidal behaviors.
  • Decreasing therapy interfering behaviors.
  • Decreasing behaviors that interfere with the quality of life.
  • Increasing behavioral skills.
  • Decreasing behaviors related to post-traumatic stress.
  • Improving self -esteem.
  • Individual targets negotiated with the patient

It is important that in the individual sessions the targets are dealt with in this order.[11]

Below are just some of the ways that DBT is effective in treatment of BPD, and which areas can assist with particular characteristics.

  • Mindfulness is a core concept in DBT, it enables individuals to accept and tolerate the powerful emotions that they feel from BPD. It challenges the habits that they have when confronting situations that make them feel uncomfortable. Mindfulness uses meditation techniques [12].
  • Little attention has been paid to accepting or finding meaning for, and tolerating distress. DBT allows individuals to bear pain skillfully.
  • Emotional regulation is important because individuals suffering BPD are emotionally intense. DBT can help individuals to regulate these emotions and behave appropriately. Interpersonal skills are taught through DBT in order for individuals to manage any problem solving rather than allowing it to cause frustration and consume their emotions [13]

Studies involving the use of DBT as treatment do suggest due to the nature of characteristics of individuals suffering with BPD, it is the most successful treatment used. Most studies are conducted over a period of time anywhere up to a 1-2 year mark. A study involving individuals with suicidal behaviours and also BPD, were recruited to take part in a randomised controlled trial using DBT over a two year period. DBT was given to all individuals, the aim was to see if it was more effective than other experts that offer a non behavioural psychotherapy treatment [14] The treatment was administered over a one year period and it then included a one year post treatment follow up. The results show that DBT was effective and gave better outcomes with less patients attempting suicide, or self-harm. It was also documented that individuals were less likely to give up on the treatment programme, than with other psychotherapy'.

A study conducted over a three month period using DBT as treatment, aimed to provide evidence that the therapy is responsible for a reduction in self-harm and also suicide rates of individuals with BPD. Even after a short period of time, the treatment was recorded as having major benefits for individuals. The individuals that were selected for the study were significantly improved by the treatment in seven out of the nine factors being assessed [15]

Other characteristics of BDP that have been successfully treated using DBT, are impulsivity. A study conducted over twelve months, assessed patients with BPD having treatment using DBT to find effective results on parasuicidal behaviours, and also impulsivity. The group of women were also a mixed group of individuals with and without substance abuse. Six months after the treatment was discontinued, the assessments gave evidence that individuals with parasuicidal behaviours, impulsivity, and substance abuse had sustained efficacy. The treatment had sustained its effect on most of the core symptoms [16]







References[edit]

  1. ^ Bateman, A. W. (2011). Borderline Personality Disorder. In J. C. Norcross, G. R. VandenBos, D. K. Freedheim (2nd Eds.), History of Psychotherapy: Continuity and Change (pp.588-600). Washington DC: American Psychological Association.
  2. ^ Salters-Pedreault, K. (2014). Borderline Personality Disorder Statistics. Retrieved From http://bpd.about.com/od/understanding bpd/a/bpdstats.htm
  3. ^ a b American Psychiatric Association. "Diagnostic and Statistical Manual of Mental Disorders 5th Edition". psychiatry.org. American Psychiatric Association. Retrieved 2013. {{cite web}}: Check date values in: |accessdate= (help)
  4. ^ a b World Health Organisation. "International Classification of Diseases and Related Health Problems". who.int. World Health Organisation. Retrieved 2015. {{cite web}}: Check date values in: |accessdate= (help)
  5. ^ Paris, J. (2005). Borderline Personality Disorder. Canadian Medical Association Journal, 172, 1579-1583
  6. ^ Livesley, W. J., Jang, K. L., & Vernon, P. A. (1998). Phenotypic and Genetic Structure of Traits Delineating Personality Disorder. Journal of the American Medical Association, 55, 941-948.
  7. ^ a b Read, K (2013). Instructors Manual of Dialectical Behaviour Therapy with Marsha Linehan. Mill Valley, CA: Psychotherapy.net. {{cite book}}: |access-date= requires |url= (help); Check date values in: |accessdate= (help)
  8. ^ Wagner, A. W., Rizvi, S. L., & Harned, M. S. (2007) Applications of Dialectical Behaviour Therapy to the Treatment of Complex trauma-related problems: When one case formulation does not fit all. Journal of Traumatic Stress, 20, 391-400.
  9. ^ Linehan, M. M., Schmidt, H., Dimeff, L. A., Craft, J. C., Kanter, J., & Comtois, K. A. (1999). Dialectical Behaviour Therapy for Patients with Borderline Personality Disorder and Drug-Dependence. The American Journal on Addiction Psychiatry, 8, 279-292.
  10. ^ Bohus, M., Haaf, B., Stiglmayr, C., Pohl, U., Bohme, R., & Linehan, M. (2000). Evaluation of Inpatient Dialectical Behaviour Therapy for Borderline Personality Disorder- A Prospective Study. Behaviour Research and Therapy, 38, 875-887.
  11. ^ a b c Psych Central Staff. "Dialectical Behaviour Therapy in the Treatment of Borderline Personality Disorder". psychcentral.com. Psychcentral. Retrieved 2015. {{cite web}}: Check date values in: |accessdate= (help)
  12. ^ Brown, K. W., & Ryan, R. M. (2003). The Benefits of Being Present: Mindfulness and its Role in Psychological Well- Being. Journal of Personality and Social Psychology, 54, 822-848
  13. ^ Verheul, R., Van Den Bosch, L. M. C., Koeter, M. W. J., De Ridder, M. A. J., Stijnen, T., & Van Den Brink, W. (2003). Dialectical Behaviour Therapy for Women with Borderline Personality Disorder: 12 Month, Randomised Clinical Trial in the Netherlands. British Journal of Psychiatry, 182, 135-148.
  14. ^ 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. (2006). Two-Year Randomized Controlled Trial and Follow-Up of Dialectical Behaviour Therapy vs Therapy by Experts for Suicidal behaviours and Borderline Personality Disorder. Archives of General Psychiatry, 63, 757-766.
  15. ^ Bohus, M., Haaf, B., Simms, T., Limberger, M. L., Schmal, C., Unckel, C., Lieb, K., & Linehan, M. M. (2004). Effectiveness of Inpatient Dialectical Behaviour Therapy for Borderline Personality Disorder: A Controlled Trial. Behaviour Research and Therapy, 42, 487-499.
  16. ^ Van Den Bosch, L. M. C., Koeter,,M. W. J., Stijnen, T., Verheul, R., & Van Den Brink, W. (2005). Sustained Efficacy of Dialectical Behaviour Therapy for Borderline Personality Disorder. Behaviour Research and Therapy, 43, 1231-1241.
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