Dbt

[MeghanHF]

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Is anyone using DBT and if so will you share some of your thoughts about it? I understand there's a strong evidence base for its effectiveness in lessening self-injurious and suicidal behaviors but does it accomplish more in your opinion? I also understand there’s a telephone component in addition to individual and group therapy. Would you please say something about how that works and setting limits around it? Also, if there are any critics of DBT, I'd like to hear from them. Thanks in advance.

 

[MeghanHF]

Just so I don’t get stuck out here on an empty thread, I’ll add a follow-up question that ought to entice someone…are there any meds that have been shown to be effective in the tx of Borderline Personality Disorder and how could RxP help with the enormous cost of tx for that population? Would DBT + medication be the treatment of choice given current research? 😉

 

[Nelle]

Just so I don’t get stuck out here on an empty thread, I’ll add a follow-up question that ought to entice someone…are there any meds that have been shown to be effective in the tx of Borderline Personality Disorder and how could RxP help with the enormous cost of tx for that population? Would DBT + medication be the treatment of choice given current research? 😉

I assume you are just playing devil's advocate with this question ["I’ll add a follow-up question that ought to entice someone…"]. Anyway... I would feel concerned about medicating a person for having a primary diagnosis of BPD. I am unaware of any medication designed specifically for BPD and I wonder how one could effectively medicate what essentially is maladjusted personality (state rather than trait?). Just to pass the bucket: I know there are cases where diagnosticians are and have been having a hard time differentiating between bipolar disorder and BPD because of some overlap in symptomatology. So some patients with BPD may receive medication, but for bipolar disorder.

This is a very intereting topic. I hope to see comments from others with thoughts on this and/or experience in the area.

 

[Logic Prevails]

I attended a recent psychiatry rounds where there was a talk (from a world renown fellow in this area) about the drug treatment of bipolar disorder.

I don't know a hell of a lot about bipolar disorder myself, but here were some of the points that were made (take them for what they're worth):

1) Depression is a huge problem and is often overlooked with BPD. Among those who recover, 80% will relapse into depression
2) Medicated Tx is important and has been shown in several studies to significantly reduce the rate of suicide (big problem with BPD).
3) Antidepressants alone can induce manic phases (in BPD-I); it is therefore important to treat with concomitant antidepressants (i.e. Fluoxetine) AND an atypical antipsychotic (i.e. Olanzapine) - works best with 'rapid cyclers.'

Those are the main points I got out of it. I am only vaguely familiar with Linehan's DBT; I know that she's apparently the "cats meow" when it comes to treating bipolar. Worth looking into.

 

[Psyclops]

Some of what littel I know. First, just to avoid confusion lets differentiate between BAD (Bipolar affective disorder) and BPD (Borderline personality disorder). Almost every BPD patient I have ever seen ahs been prescribed medication. They almost always had a axis-I diagnosis at the time as well. To fully answer this question I thnk we need to look at the hx of the DSM for a second.

The first two DSM's (1952, 1968) did not have the multi axial system. Personality disorders were not diagnosed on another axis. Consequently, personality disorders were not being diagnosed when they cooccured with what are today considered axis-1 idsorders. With the advent of DSM-III (1980) the authors decided to create another axis deveoted entirely to PDs (MR too) to encourage thier diagnosis as well. This has enabled a better study of their comorbidity with axis 1 disorders.

There apears to be very high comorbidity between BPD and BAD. Although these studies are difficult to perform because of the low base rate of BAD in epidemiological samples. But you can do studies with clinical samples. Now, some have suggested that many of the PDs are on a the same spectrum as the axis 1 diosrders, for example avoidant PD and agoraphobia, schyzotypal PD and schizophrenia, if any of you remember depressive pd and dpression of course, etc. One of the suggestions, is BPD and BAD. To better understand this please look up articles on the dimensional models of psychopathology. Briefly, these models (which are empirically derived) assume there are a few latent traits that underlie psychopathology, and can be contrasted with current systems of diagnosis that assume a categorical structure of psychopathology, and that each category (diagnosis) is qualitatively different from each other and from normal functioning. This flies in the face of all evidence to the contrary (e.g., high rates of comorbidity, SSRIs work for many disorders, etc.). For references please PM me.

Some have suggested the BPD be renamed something like affective dysregulation PD, because borderline is so confusing. But many believe it might be on the same spectrum as BAD, being a quantitaively but not qualitatively difference

 

[LM02]

Brad3117 - what you posted about bipolar disorder is dead-on. Unfortunately, it seems that this thread was started with borderline PD in mind. As Psyclops pointed out, there has been some theoretical discussion as to whether or not they exist on the same continuum, but they are not the same.

In any case, my understanding of the empirical support for DBT is similar to what has been posted - that it has been shown to predict decreases in self-harm, but not necessarily in overall affective instability. But those data are actually consistent with the treatment model - which promotes acceptance that the mood states are going to be there, and provides patients with alternative ways of coping when they experience significant dysregulation. So maybe the ultimate outcomes for DBT aren't overall reductions in mood problems, but rather better coping.

I have some clinical experience with DBT, and have found it to be useful in that it can provide patients with a new framework (e.g., through opposite action, wise mind, radical acceptance, etc.) to cope with their symptoms and functional impairment. But it does seem tough for people to implement when they are in crisis.

As for meds, I thought I'd post this abstract from a chapter that I have found to be useful:

From: Soloff, P.H. (2005). Pharmacotherapy in borderline personality disorder. In J.G. Gunderson & P.H. Hoffman (Eds.), Understanding and treating borderline personality disorder: A guide for professionals and families, (pp. 65-82). Washington, DC, US: American Psychiatric Publishing.

(from the chapter) The recommendations for pharmacotherapy in BPD presented in this chapter are derived from review of the existing empirical literature, consensus among members of the American Psychiatric Association (2001) practice guideline work group and its reviewers, and my own years of experience in studying BPD. It is important to recognize that recommendations for pharmacological management are based on a relatively small number of studies. The American Psychiatric Association work group that wrote the Practice Guideline for the Treatment of Patients with Borderline Personality Disorder found only 40-50 published scientific reports on the drug treatment of BPD. This is a woefully inadequate database. Through this experience it has been learned that drug effects in BPD are modest and that residual symptoms are the rule. Medication does not change character and should be viewed as an adjunctive part of a comprehensive psychosocial treatment plan, which may include psychotherapy and psychoeducation. This section describes the medications used to treat each of the three symptom domains in BPD: cognitive symptoms, affective dysregulation, and impulsivity.

 

[Logic Prevails]

Brad3117 - what you posted about bipolar disorder is dead-on. Unfortunately, it seems that this thread was started with borderline PD in mind. As Psyclops pointed out, there has been some theoretical discussion as to whether or not they exist on the same continuum, but they are not the same.

Haha.... yeah, it was a late night when I typed that up... 😴

For some reason I thought we were talking about Bipolar... at any rate I meant all of that info to be relevant to Bipolar Disorder. Sorry for the confusion. 😎

 

[pingouin]

I second LM02's post. It's largely about the development of better coping techniques. I have a DBT skill-building manual from when I worked at a CMHC that offered DBT groups. Since my private office doesn't have the space to run groups, I take the information and work with my patients individually. So far it's worked fairly well- we'll talk about the previous week's skill-building exercise, talk about how they practiced it, go over the homework and discuss it in-depth.. and then depending on the patient's confidence level with that skill, I will either move onto the next one or re-assign the previous week's so that they can practice some more.

The book that I have also includes "The Experience of Being Borderline", which is someone's personal narrative. Once the borderline diagnosis has been established and explained to the patient, the first thing we do is read that together. Then I have this nasty little habit of giving them a copy and telling them to re-write it in their own words to tell me what their personal experience is. The patients don't like it initially b/c it's a big assignment, but I get back some amazing stuff from them.

 

[MeghanHF]

Thanks for the info everyone! I got swamped with work but checked back tonight to find interesting posts. The descriptions of DBT are helpful (certainly reducing self-injurious behaviors is a good thing) and I wonder if those of you using DBT also incorporate other kinds of psychotherapeutic interventions. Also I wonder if you’ve found a strong correlation between BPD and childhood abuse and if so, how do you incorporate that into your understanding of the disorder and how does that inform your tx plan?

Yes Nelle, I was being a bit cheeky with my follow-up question 😉 …but I tend to agree with those who feel that since there are often co-occurring Axis I disorders with BPD – PTSD, mood disorders, eating disorders, substance abuse - medication may be helpful in reducing the Axis I symptoms and ultimately helpful in reaching the character pathology.

Psyclops - I wasn’t aware that there is a high comorbidity rate between bipolar and borderline personality and my gut reaction is that may be more about misdiagnosis. I’m tempted to insert some feminist critique of diagnostic systems targeting “crazy ladies” but well…I guess I just did. I’m curious about your comments on dimensional models of psychopathology. Are you referencing the PDM and more psychodynamic type models?

 

[MeghanHF]

Brad - I like your blue monster guy.

 

[Psyclops]

Psyclops - I wasn’t aware that there is a high comorbidity rate between bipolar and borderline personality and my gut reaction is that may be more about misdiagnosis. I’m tempted to insert some feminist critique of diagnostic systems targeting “crazy ladies” but well…I guess I just did. I’m curious about your comments on dimensional models of psychopathology. Are you referencing the PDM and more psychodynamic type models?

I don't know what PDM is to be honest. And these aren't psychodynamic models per se. They tend to be empirically driven models, based on comorbidity and statistical analyses, and different theoretical assumptions. For example, the categorical system assumes that each diagnosis is different qualitatively from other types of pathology and from normal functioning. This has a hard time accounting for the fact that so many diagnoses cooccur at higher than chance rates. Furthermore that some cooccur at very high rates, such as GAD and MDD (some say as high as 90%) but with DSm exclusionary rules they don't always get diagnosed. Also, these cooccurences aren't just randomly happening they are showing patterns that are interesting. These patterns suggest underlying factors that could account for the variation in pathology better and more accurately than the current DSM system.

 

[Doc Samson]

http://www.psych.org/psych_pract/treatg/pg/Practice Guidelines8904/BorderlinePersonalityDisorder.pdf

Long, but covers all of the therapeutic and pharmacologic approaches to Borderline PDO.

 

[pingouin]

http://www.psych.org/psych_pract/treatg/pg/Practice Guidelines8904/BorderlinePersonalityDisorder.pdf

Long, but covers all of the therapeutic and pharmacologic approaches to Borderline PDO.

That's awesome! It's a yicky day here and finals are over as of yesterday.. looks like I have today's reading material!

Thanks, Doc S!

 

[MeghanHF]

I don't know what PDM is to be honest.

I don't think many people know what the Psychodynamic Diagnostic Manual is and I haven't yet seen it since it's release early this year. In some ways, it sounds similar to what you're referring to with greater dimensionality. Anyway, if anyone is interested bleow is the description from the publishers. Sorry to get off topic...although I think this bit - "Treatment outcome studies point to the importance of dealing with the full complexity of emotional and social patterns and show that the therapeutic relationship is the major predictor of outcomes." is important to the tx of borderline personality.

Developed by a Task Force selected by the presidents of the five major psychoanalytic organizations, the PDM covers adults, children and adolescents, and infants, emphasizing individual variations as well as commonalities. In focusing on the full range of mental functioning, the PDM complements the DSM and ICD efforts in cataloguing symptoms. It systematically describes:

* Healthy and disordered personality functioning
* Individual profiles of mental functioning , including patterns of relating, comprehending, and expressing feelings, coping with stress and anxiety, observing one's own emotions and behaviors, and forming moral judgments
* Symptom patterns , including differences in each individual's personal or subjective experience of his or her symptoms

The PDM is based on current neuroscience and treatment outcome studies (discussed in the research section) that demonstrate the importance of focusing on the full range and depth of emotional and social functioning. For example, research on the mind and brain and their development shows that the patterns of emotional, social, and behavioral functioning involve many interconnected areas working together, rather than in isolation. Treatment outcome studies point to the importance of dealing with the full complexity of emotional and social patterns and show that the therapeutic relationship is the major predictor of outcomes. They further show that treatments that focus on isolated symptoms or behaviors are not effective in sustaining gains or addressing complex personality patterns.

The PDM was developed on the premise that a clinically useful classification of mental health disorders must begin with an understanding of healthy mental functioning. Mental health involves more than simply the absence of symptoms. It involves a person's overall mental functioning, including relationships, emotional regulation, coping capacities, and self-observing abilities. Just as healthy cardiac functioning cannot be defined simply as an absence of chest pain, healthy mental functioning is more than the absence of observable symptoms of psycho pathology. It involves the full range of human cognitive, emotional, and behavioral capacities.

That a full conceptualization of health is the foundation for describing disorders may seem self-evident, and yet the mental health field has not developed its diagnostic procedures accordingly. In the last two decades, there has been an increasing tendency to define mental problems more and more on the basis of presenting symptoms and their patterns, with overall personality functioning and levels of adaptation playing a minor role. The whole person has been less visible than the various disorder constructs on which researchers attempt to find agreement. Recent reviews of this effort raise the possibility that such a strategy was misguided. Ironically, emerging evidence suggests that oversimplifying mental health phenomena in the service of attaining consistency of description (reliability) and capacity to evaluate treatment empirically (validity) may have compromised the laudable goal of a more scientifically sound understanding of mental health and psychopathology. Most problematically, reliability and validity data for many disorders are not as strong as the mental health community had hoped they would be. Allen Frances, MD, Chair of the DSM-IV American Psychiatric Association Task Force , commented in The New Yorker magazine (Spiegel, 2005) that the reliability hoped for has not been realized and that, in fact, the reliability among practicing clinicians is very poor. Consequently, in moving towards DSM-V, the APA Task Force is reported to be shifting towards a more dimensional, rather than purely categorical, approach.

The psychoanalytic tradition has a long history of examining overall human functioning in a searching and comprehensive way, with an emphasis on both dimensionality and context of mental problems. Nevertheless, the diagnostic precision and usefulness of psychoanalytic approaches have been compromised by at least two problems. First, until fairly recently, in an attempt to capture the full range and subtlety of human experience, psychodynamic accounts of mental processes have been expressed in competing theories and metaphors that have, at times, inspired more disagreement and controversy than consensus. Second, there has been difficulty distinguishing between speculative constructs on the one hand, and phenomena that can be observed or reasonably inferred on the other.

In recent years, however, having developed empirical methods to quantify and analyze complex mental phenomena, depth psychology has been able to offer clear operational criteria for a more comprehensive range of human social and emotional functioning, as described by Westen, Shevrin, Shedler, Blatt, Dahlbender and others in the PDM Research Section. The challenge has been to systematize these advances with a growing body of rich clinical experience in order to provide a widely usable framework for understanding and specifying complex and subtle mental phenomena.

The PDM uses a multi dimensional approach to describe the intricacies of the patient's functioning and ways of engaging in the therapeutic process. It begins with a classification of the spectrum of personality patterns and disorders found in individuals. It then describes a “profile of mental functioning” that permits a clinician to look in more detail at each of the patient's capacities. This is followed by a description of the patient's symptoms, but with a focus on the patient's internal experiences as well as surface behaviors. In this way, the PDM provides a comprehensive profile of an individual's mental life.

 

[psychgeek]

Is anyone using DBT and if so will you share some of your thoughts about it? I understand there's a strong evidence base for its effectiveness in lessening self-injurious and suicidal behaviors but does it accomplish more in your opinion? I also understand there’s a telephone component in addition to individual and group therapy. Would you please say something about how that works and setting limits around it? Also, if there are any critics of DBT, I'd like to hear from them. Thanks in advance.

I’ve had experience treating people with borderline PD using both DBT and more classically psychodynamic approaches. In my opinion (based upon my own meandering experience) DBT does a great job of teaching distress tolerance and problem solving around self-injurious behavior and is not quite as good at altering maladaptive interpersonal patterns or addressing underlying trauma. My clients have found it a little too prescriptive in these last two domains of psychopathology and seem to respond better to a more open approach modeled after interpersonal and object relations theory once the self-injury is under control and more exploratory therapy can be tolerated.