Dialectical Behavior Therapy For Borderline Personality Disorder


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Running Head: DBT treatment for borderline personality disorder                       1            
        Project Paper: Dialectical Behavior Therapy For Borderline Personality Disorder
                                                     Sarah Merve AHMAD
                                                           Koç University
  DBT treatment for borderline personality disorder                                        2
Borderline is a disorder of emotional deregulation. This instability often disrupt family and work, long-term planning and the individual’s sense of self-identity.The disorder characterized by intense emotions, self-harming acts and stormy interpersonal relationships.The essential feature of Borderline Personality Disorder is a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity that begins by early adulthood and is present in a variety of contexts. Borderline Personality Disorder. Significant impairments in personality functioning manifest by:1. Impairments in self functioning (a or b):a. Identity: Markedly impoverished, poorly developed, or unstable self-image, often associated with excessive self-criticism; chronic feelings of emptiness; dissociative states under stress.b. Self-direction: Instability in goals, aspirations, values, or career plans. 2. Impairments in interpersonal functioning (a or b): a. Empathy: Compromised ability to recognize the feelings and needs of others associated with interpersonal hypersensitivity (i.e., prone to feel slighted or insulted); perceptions of others selectively biased toward negative attributes or vulnerabilities.b. Intimacy: Intense, unstable, and conflicted close relationships, marked by mistrust, neediness, and anxious preoccupation with real or imagined abandonment; close relationships often viewed in extremes of idealization and devaluation and alternating between over involvement and withdrawal.
B. Pathological personality traits in the following domains:

  1. Negative Affectivity, characterized by: a. Emotional lability: Unstable emotional experiences and frequent mood changes; emotions that are easily aroused, intense, and/or out of proportion to events and  
  2. DBT treatment for borderline personality disorder                                      3  
  3. panic often in reaction to interpersonal stresses; worry about the negative effects of past unpleasant experiences and future negative possibilities; feeling fearful, apprehensive, or threatened by uncertainty; fears of falling apart or losing control.c. Separation insecurity: Fears of rejection by - and/or separation from - significant others, associated with fears of excessive dependency and complete loss of autonomy.d. Depressivity: Frequent feelings of being down, miserable, and/or hopeless; difficulty recovering from such moods; pessimism about the future; pervasive shame; feeling of inferior self-worth; thoughts of suicide and suicidal behavior.2. Disinhibition, characterized by: a. Impulsivity: Acting on the spur of the moment in response to immediate stimuli; acting on a momentary basis without a plan or consideration of outcomes; difficulty establishing or following plans; a sense of urgency and self-harming behavior under emotional distress.b. Risk taking: Engagement in dangerous, risky, and potentially self-damaging activities, unnecessarily and without regard to consequences; lack of concern for one's limitations and denial of the reality of personal danger.3. Antagonism, characterized by: Hostility: Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults.

Dialectical behavior therapy (DBT) treatment is a cognitive-behavioral approach that emphasizes the psychosocial aspects of treatment. The theory behind the approach is that some people are prone to react in a more intense and out-of-the-ordinary manner toward certain emotional situations, primarily those found in romantic, family and friend relationships. DBT theory suggests that some people’s arousal levels in such situations can increase far more quickly than the average person’s, attain a higher level of emotional stimulation, and take a significant amount of time to return to baseline arousal levels.People who are sometimes diagnosed with  borderline personality disorder 
DBT treatment for borderline personality disorder                                                   4
experience extreme swings in their emotions, see the world in black-and-white shades, and seem to always be jumping from one crisis to another. Because few people understand such reactions  most of all their own family and a childhood that emphasized invalidation  they don’t have any methods for coping with these sudden, intense surges of emotion.  DBT may be the first therapy that has been experimentally demonstrated to be generally effective in treating BPD. DBT is a method for teaching skills that will help individuals cope with sudden, intense surges of emotion . DBT found to be effective in borderline personality disorder and in this project paper, my main goal is to demonstrate efficacy of DBT with empirical evidences. BPD is a severe and persistent mental disorder experience of severe emotional distress and behavioral dyscontrol. DBT is a cognitive behavioral treatment program developed to treat suicidal clients meeting criteria for BPD which I have explained thoroughly above ) DBT directly targets suicidal behavior, behaviors that interfere with treatment delivery and other dangerous,severe, or destabilizing behaviors. 
According to results of empirical findings below,  dialectical behavior therapy appears to be uniquely effective in reducing suicide attempts but actually  suicidal behavior is a broad term which includes death by suicide, intentional, nonfatal, self injurious acts committed with or without intend to die. Suicidal behavior is associated with several mental disorders, including depression,substance dependence and schizophrenia. BPD is a severe and persistent mental disorder experience of severe emotional distress and behavioral dyscontrol. DBT is a cognitive behavioral treatment program developed to treat suicidal clients meeting criteria for BPD.  DBT directly targets suicidal behavior, behaviors that interfere with treatment delivery and other dangerous,severe, or destabilizing behaviors. 
The study called  Two-Year Randomized Controlled Trial and Follow-up of Dialectical Behavior Therapy vs.Therapy by Experts for Suicidal Behaviors and Borderline Personality Disorder was conducted with the aim to evaluate the hypothesis that unique aspects of DBT are more efficacious compared with treatment offered by non-behavioral psychotherapy experts( Community Treatment 
DBT treatment for borderline personality disorder                                                  5
by experts (CTBE). This study was one-year randomized controlled trial and 1 year post treatment follow-up. It was conducted at university outpatient clinic and community practice. There were one hundred one clinically referred women with recent suicidal and self-injurious behaviors behaviors which meets DSM criteria.These women participants were between the ages o 18 and 45 years and they met criteria for BPD for current and past suicidal behavior as defined by at least 2 suicide attempts or self-injuries in the last 5 years, with at least 1 in the past 8 weeks.    The intervention was one year of DBT or 1 year of community treatment by experts. 
Results shows that dialectical behavior therapy was associated with better outcomes in the intent-to-treat analysis than community treatment by experts in most target areas during the 2-year treatment and follow-up period. Subjects receiving DBT were half as likely to make a suicide attempt besides these subjects had lower medical risk and required less hospitalization also subjects who receive DBT has less drop out rate, they were less likely to drop out of treatment. 
DBT compared with non behavioral CTBE( Community Treatment By Experts) in order to determine whether effectiveness of DBT in treating suicidal patients and patients with BPD can be can be accounted for by treatment factors common to most psychotherapy by experts. According to results, DBT was superior to CTBE in preventing suicide attempts, Dialectical behavior therapy was also more effective in reducing inpatient psychiatric care for suicide ideation and emergency department visits. In addition to that DBT was more than twice as effective as non-behavioral therapy by experts(CTBE) in keeping subjects in treatment for instance; in treatment while subjects of DBT has 25 % dropout rate, subjects of CTBE has %59 dropout rate. Besides, subjects assigned to CTBE were also much more likely than those assigned to DBT hospitalized for suicide ideation. Overall, this study indicates the efficacy of DBT treatment for suicidal behavior and borderline personality disorder. 
In other study called Effectiveness of inpatient dialectical behavioral for borderline personality disorder: a controlled trial was conducted with the aim to evaluate 3 month DBT impatient 
DBT treatment for borderline personality disorder                                                       6
treatment program. Clinical outcomes, also changes on measures of psychopathology and frequency of self-mutilating acts, were estimated for 50 female patients meeting criteria for BPD. Thirty-one patients had participated in a DBT inpatient program, and 19 patients had been placed on a waiting list and received treatment as usual in the community.Pre–post-comparison showed significant changes for the DBT group on 10 of 11 psychopathological variables and significant reductions in self-injurious behavior. The waiting list group did not show any significant changes at the four-months point. The DBT group improved significantly more than participants on the waiting list on seven of the nine variables analyzed, including depression, anxiety, interpersonal functioning, social adjustment, global psychopathology and self-mutilation. 
Regarding to number of findings emerged from this study. First thing I want to point out that  when assessed one-month after discharge from a three months DBT inpatient treatment program, BPD patients showed significant reductions in the frequency of self-mutilation and significant improvement on eight of nine measures of clinical outcome, including improvements in dissociation, depression, anxiety, interpersonal functioning, social adjustment, and global psychopathology. Second thing I want to underline that when compared to individuals put on a waiting list for inpatient DBT treatment, those admitted to an inpatient DBT treatment program had significantly greater clinical improvement. Results indicated that 41.9% of those receiving DBT had clinically recovered on a general measure of psychopathology.
Also, I want to point out that as we all know, Deliberate self-harm (DSH), general hospital admission and psychiatric hospital admission are common in women meeting criteria for borderline personality disorder (BPD). Hunter DBT project: Randomized Controlled Trial of Dialectical Behavior Therapy in Women with Borderline Personality Disorder indicates that Dialectical 
DBT treatment for borderline personality disorder                                                            7
behavior therapy (DBT) has been reported to be effective in reducing DSH and hospitalization. Participants were female, aged 18-65 years, meeting criteria for BPD determined by clinical interview by a psychiatrist using DSM-IV criteria, these participants having a history of multiple episodes of deliberate self-harm, at least three episodes in the preceding 12 months. The Hunter DBT project was carried out in Newcastle, Australia at the Centre for Psychotherapy, a clinical outpatient unit of the Hunter New England Mental Health Service. The Hunter DBT project was an RCT of modified DBT. The intervention condition was based on the comprehensive DBT model, a team-based approach including individual therapy, group-based skills training, telephone access to an individual therapist and therapist supervision groups. A randomized controlled trial of 73 female subjects meeting criteria for BPD was carried out with intention-to-treat analyses and per-protocol analyses. Randomization was carried out by the research staff and participants who were allocated by selection of sealed opaque envelopes. Randomization took place after consent to participate and completion of all baseline measures and eligibility interviews. The intervention was DBT and the control condition was treatment as usual plus waiting list for DBT (TAU+WL), with outcomes measured after 6 months. Primary outcomes were about  DSH (deliberate self-harm); general hospital admission for DSH and any psychiatric admission; length of stay for any hospitalization. Secondary outcomes were about the disability and quality of life measures. According to findings of the study both groups showed a reduction in DSH and hospitalizations, but there were no significant differences in DSH, hospital admissions or length of stay in hospital between groups. Disability (days spent in bed) and quality of life (Physical, Psychological and Environmental domains) were significantly improved for the DBT group. As I mentioned above, DBT produced non-significant reductions in DSH and hospitalization when compared to the TAU+WL control, due in part to the lower than expected rates of hospitalization in the control condition. Nevertheless, DBT showed significant benefits for the secondary outcomes of improved disability and quality of life scores, a 
DBT treatment for borderline personality disorder                                                   8
clinically useful result that is also in keeping with the theoretical constructs of the benefits of DBT. Regarding to primary outcomes of the study , we see that this study failed to replicate some of the important findings from other studies such as significant reduction in DSH(deliberate self-harm) and reduction in psychiatric hospitalization. Here I want to underline that though there was improvement in both groups over time, there was no significant differential reduction in general-hospital-treated DSH, psychiatric hospitalization or self-reported DSH. When we look at secondary outcomes, secondary outcomes are disability and quality of life, we see witness improvements in disability and quality of life were found in the present study  however as I mentioned before, there was no differential improvement in DSH(deliberate self-harm) and psychiatric hospitalization. As a drawback of the study, I need to underline that these secondary outcomes, improvements in disability and quality of life, only rarely been demonstrated or evaluated in RCTs involving subjects with BPD, again making comparison with the present study difficult .
To sum up, I want to point out again , regarding to principal outcomes, the present study found no differences in self-reported DSH, general hospital-treated DSH, psychiatric hospitalization or length of stay in general hospital or psychiatric hospital, although there was a considerable improvement in both the DBT and the TAU+WL control groups from baseline .Several secondary outcomes( disability and quality of life) showed clinically significant benefits in favor of DBT.  
The fourth study that I will look sight into is called Dialectical behavior therapy for women with 
borderline personality disorder. This study is 12-month, randomized clinical trial conducted in Netherlands. This study was carried out with the aim to compare the effectiveness of DBT with treatment as usual for patients with BPD .Fifty-eight women with BPD were randomly assigned to either 12 months of DBT or usual treatment in a randomized controlled study. Women with borderline personality disorder between the ages 18-70, stay within a 40-km circle centered on 
DBT treatment for borderline personality disorder                                                                    9
Amsterdam. These women were referred by a psychologists or psychiatrist willing to sign an agreement expressing the commitment to deliver 12 months of treatment as usual, were considered for recruitment.  Participants were recruited through clinical referrals from both addiction treatment and psychiatric services. Outcome measures included treatment retention and the course of suicidal, self-mutilating and self-damaging impulsive behavior.
This randomized controlled trial of dialectical behavior therapy demonstrates significant results regarding to efficiency of DBT. Dialectical behavior therapy had a substantially lower 12-month attrition rate (37%) compared with treatment as usual (77%). Additionally, when we compare DBT with TAU, we witness that DBT demonstrates greater reductions in self-mutilating behaviors and self-damaging impulsive acts than treatment as usual. 
 Regarding to findings of the study we can comment on that Dialectical behavior therapy (DBT) is an efficacious treatment of high-risk behaviors in patients with borderline personality disorder (BPD). 
            Here I want to shift the topic a little bit, as we all know emotion regulation as a broad set of skills and abilities that help keep the emotional system healthy and functioning. Many people with borderline personality disorder struggle with basic emotion regulation skills. Individuals diagnosed with BPD consistently report having more intense emotions, having greater reactivity to emotionally evocative stimuli, and experiencing greater affective instability. An important feature of DBT is the assumption that is the emotional regulation itself that is disordered, not only specific emotions of fear, anger, or shame. Therefore, BPD individuals also experience unregulated emotions such as hate and interest. All problematic behaviors of BPD individuals are seen as due to re-regulating out of control emotions or as natural outcomes of unregulated emotions. In other words, emotion regulation deficits are at the core of the disorder. They lack of ability to enhance or reduce emotions as needed. These unregulated emotion pattern might lead them to suicidal act or 
             DBT treatment for borderline personality disorder                                                                 10
           self-injury. With DBT,  we may help these people overcome these unregulated emotion patterns. It is important to  changing the experience, expression, and acceptance of negative emotions in order to prevent them from intentionally self-harm and suicide attempts.
        The present study called Impact of dialectical behavior therapy versus community treatment by experts on emotional experience, expression, and acceptance in borderline personality disorder analyzes secondary data from a randomized controlled trial with the aim to assess the unique effectiveness of DBT when compared to Community Treatment by Experts (CTBE) in changing the experience, expression, and acceptance of negative emotions. Suicidal and/or self-injuring women with BPD were randomly assigned to DBT or CTBE for one year of treatment and one year of follow-up.  Several indices of emotional experience and expression were assessed .  Participants were 101 women between the ages of 18 and 45 who met criteria for BP.Participants were also required to have engaged in recent and recurrent intentional self-injury, which was defined as having at least two suicide attempts or self-injurious episodes in the past five years and at least one in the past eight weeks.participants were randomly assigned to DBT  or to CTBE . To summarize, research on DBT has established it as an effective treatment for high-risk behaviors related to BPD, such as suicide attempts, non-suicidal self-injury, and substance dependence. This study extends prior research by beginning to examine the effects of DBT on the experience, expression, and acceptance of negative emotions. Results indicate that both DBT and CTBE are effective at improving these outcomes over the course of treatment, and the two treatments did not differ in their ability to reduce the intensity of any specific negative emotion. However, DBT outperformed CTBE in terms of improving BPD clients' ability to approach private experiences and express anger effectively, which may account for DBT's efficacy in reducing high-risk behaviors that function to 
                DBT treatment for borderline personality disorder                                                                    
            regulate negative emotions. Further research is needed to replicate and expand on these findings.
                 To sum up based on the empirical evidence, obtained results indicate that DBT is efficacious in helping subjects with BPD to significantly decrease suicidal and self-harming acts. We witness that members of the DBT group were less likely to commit suicidal acts (self-harm with little or no intention to cause death), more likely to stay in therapy, and required fewer days of inpatient psychiatric hospitalization therefore, based on the empirical findings, we can say that DBT demonstrates great efficacy in stabilizing and controlling self-destructive behavior. In that sense, we  might assert the idea that DBT treatment has been empirically proven to be effective in many cases several studies demonstrate that DBT shows promise for clients with borderline personality disorder. 
                   Marsha M. Linehan, PhD; Katherine Anne Comtois, PhD; Angela M. Murray, MA, MSW; Milton Z. Brown, PhD; Robert J. Gallop, PhD; Heidi L. Heard, PhD; Kathryn E. Korslund, PhD; Darren A. Tutek, MS; Sarah K. Reynolds, PhD; Noam Lindenboim, MS(2008) Two-Year Randomized Controlled Trial and Follow-up of Dialectical Behavior Therapy vs.Therapy by Experts for Suicidal Behaviors and Borderline Personality Disorder.Arch Gen Psychiatry. 2006;63(7):757-766
Bohus M1, Haaf B, Simms T, Limberger MF, Schmahl C, Unckel C, Lieb K, Linehan MM. Effectiveness of inpatient dialectical behavioral therapy for borderline personality disorder: a controlled trial.Behavior Research and Therapy 2004 May;42(5):487-99.
             Carter GL1, Willcox CH, Lewin TJ, Conrad AM, Bendit N.Hunter DBT project: randomized controlled trial of dialectical behaviour therapy in women with borderline personality disorder. Aust N Z J Psychiatry. 2010 Feb;44(2):162-73.
              Verheul R1, Van Den Bosch LM, Koeter MW, De Ridder MA, Stijnen T, Van Den Brink W.Dialectical behavior therapy for women with borderline personality disorder 12-month, randomized clinical trial in The Netherlands.  Br J Psychiatry. 2003 Feb;182:135-40.
Neacsiu AD1, Lungu A2, Harned MS2, Rizvi SL3, Linehan MM2. Impact of dialectical behavior therapy versus community treatment by experts on emotional experience, expression, and acceptance in borderline personality disorder.Behavior Research and  Therapy. 2014 Feb;53:47-54.

Uzman Psikolog Sarah Merve Ahmad

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