Treatment for Borderline personality disorder: Dialectical Behavior Therapy- DBT and Medication
Dialectical Behavior Therapy (DBT) is a skill-building therapeutic approach developed in the 1970s by Marsha Linehan, PhD. Although DBT was originally developed for the treatment of women with Borderline Personality Disorder (BPD), it has proven effective for a wide range of psychiatric disorders, including depression, anxiety disorders, substance abuse, and eating disorders. "This type of therapy focuses on the concept of mindfulness, or being aware of and attentive to the current situation. DBT teaches skills to control intense emotions, reduces self-destructive behaviors, and improves relationships. It seeks to achieve a balance between changing and accepting beliefs and behaviors." (NIH)
http://www.nytimes.com/2011/06/23/health/23lives.html?_r=0
DBT assumes the problems of BPD individuals are twofold:
1. Individuals with Borderline personality disorder do not have many very important capabilities, including sufficient interpersonal skills, emotional and self regulation capacities (including the ability to self regulate biological systems) and the ability to tolerate distress.
2. Personal and environmental factors block coping skills and interfere with self regulation abilities the individual does have, often reinforce maladaptive behavioral patterns, and punish improved adaptive behaviors.
In DBT, treatment requires confrontation, commitment and patient responsibility, on the one hand, and on the other, focuses considerable therapeutic energy on accepting and validating the patient's current condition while simultaneously teaching a broad range of behavioral skills. Confrontation is balanced by support. The therapeutic task, over time, is to balance this focus on acceptance with a corresponding focus on change.
• Treatment:
•
• Capability Enhancement focuses on increasing behavioral and self regulation. All patients in DBT receive psycho-educational skills training in five areas: mindfulness (to improve control of attention and the mind), interpersonal skills and conflict management, emotional regulation, distress tolerance, and self management.
• Motivational Enhancement focuses on making sure that clinical progress is reinforced (rather than punished), that maladaptive behavior is not reinforced, and on reducing other factors (such as emotions or beliefs) that inhibit or interfere with clinical progress. Generally, this requires intensive (at least weekly sessions of one to one and a half hours) individual therapy. The full range of effective cognitive and behavioral therapies are integrated into the treatment targeting in order of importance: reducing suicidal and other life threatening behaviors; reducing therapy-interfering behaviors (including noncompliance and dropping out of treatment); reducing sever quality of life interfering behaviors (including Axis I disorders, such as depression and eating or / and substance abuse disorders); increasing skillful coping behaviors, including distress tolerance emotion regulation, interpersonal effectiveness, and mindfulness; reducing traumatic emotional experiencing, including post-traumatic stress responses (for example, continuing reactions to childhood trauma); enhancing self-respect and mastery and reducing problems in lying; and resolving a sense of incompleteness.
• Enhancing Generalization. Learning to be effective in a therapist's office or an inpatient or residential setting is useless if the new behaviors do not generalize to the patient's everyday life settings. The third task of therapy, therefore, is to ensure generalization of new behaviors to the natural environment. In DBT this is generally done by phone consultations between patient and individual therapist. In inpatient, residential, and day treatment settings this might be done by on site consultants with "office hours" for skills consultation.
•
•
• Enhancing Therapist's Capability and Motivation. An effective treatment is useless if the therapist is unable or unmotivated to apply the treatment when it is required. Enhancing the therapist's capabilities and motivation to treat effectively is an unrecognized but essential part of any treatment program. In DBT, this function of treatment is met by weekly team consultation meetings of all DBT therapists. The goal of these meetings is to provide consultation and support for therapists in their attempts to apply DBT.
•
•
•
• MEDICATION:
•
•
• Pharmacological treatments are often prescribed based on specific target symptoms shown by the individual patient. Antidepressant drugs and mood stabilizers may be helpful for depressed and/or unstable mood. Antipsychotic drugs may also be used when there are distortions in thinking.
• Serotonin, norepinephrine, and acetylcholine are among the chemical messengers in these circuits that play a role in the regulation of emotions, including sadness, anger, anxiety, and irritability. Drugs that enhance Serotonin’s function may improve emotional symptoms in BPD. Likewise, mood-stabilizing drugs that are known to enhance the activity of GABA (Gamma-Amino Butyric Acid), the brain’s major inhibitory neurotransmitter, may help people who experience BPD-like mood swings. Such brain- based vulnerabilities can be managed with help from behavioural interventions and medications, much like people manage susceptibility to diabetes or high blood pressure (NIMH, )
•
•
•
• MINDFULNESS
•
•
•
•
•
• Capability Enhancement focuses on increasing behavioral and self regulation. All patients in DBT receive psycho-educational skills training in five areas: mindfulness (to improve control of attention and the mind), interpersonal skills and conflict management, emotional regulation, distress tolerance, and self management.
• Motivational Enhancement focuses on making sure that clinical progress is reinforced (rather than punished), that maladaptive behavior is not reinforced, and on reducing other factors (such as emotions or beliefs) that inhibit or interfere with clinical progress. Generally, this requires intensive (at least weekly sessions of one to one and a half hours) individual therapy. The full range of effective cognitive and behavioral therapies are integrated into the treatment targeting in order of importance: reducing suicidal and other life threatening behaviors; reducing therapy-interfering behaviors (including noncompliance and dropping out of treatment); reducing sever quality of life interfering behaviors (including Axis I disorders, such as depression and eating or / and substance abuse disorders); increasing skillful coping behaviors, including distress tolerance emotion regulation, interpersonal effectiveness, and mindfulness; reducing traumatic emotional experiencing, including post-traumatic stress responses (for example, continuing reactions to childhood trauma); enhancing self-respect and mastery and reducing problems in lying; and resolving a sense of incompleteness.
• Enhancing Generalization. Learning to be effective in a therapist's office or an inpatient or residential setting is useless if the new behaviors do not generalize to the patient's everyday life settings. The third task of therapy, therefore, is to ensure generalization of new behaviors to the natural environment. In DBT this is generally done by phone consultations between patient and individual therapist. In inpatient, residential, and day treatment settings this might be done by on site consultants with "office hours" for skills consultation.
•
•
• Enhancing Therapist's Capability and Motivation. An effective treatment is useless if the therapist is unable or unmotivated to apply the treatment when it is required. Enhancing the therapist's capabilities and motivation to treat effectively is an unrecognized but essential part of any treatment program. In DBT, this function of treatment is met by weekly team consultation meetings of all DBT therapists. The goal of these meetings is to provide consultation and support for therapists in their attempts to apply DBT.
•
•
•
• MEDICATION:
•
•
• Pharmacological treatments are often prescribed based on specific target symptoms shown by the individual patient. Antidepressant drugs and mood stabilizers may be helpful for depressed and/or unstable mood. Antipsychotic drugs may also be used when there are distortions in thinking.
• Serotonin, norepinephrine, and acetylcholine are among the chemical messengers in these circuits that play a role in the regulation of emotions, including sadness, anger, anxiety, and irritability. Drugs that enhance Serotonin’s function may improve emotional symptoms in BPD. Likewise, mood-stabilizing drugs that are known to enhance the activity of GABA (Gamma-Amino Butyric Acid), the brain’s major inhibitory neurotransmitter, may help people who experience BPD-like mood swings. Such brain- based vulnerabilities can be managed with help from behavioural interventions and medications, much like people manage susceptibility to diabetes or high blood pressure (NIMH, )
•
•
•
• MINDFULNESS
•
•
•
•