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COMBAT Conference Kansas City, Missouri Ronda Oswalt Reitz, PhD Missouri Department of Mental Health Helping people find lives worth living through relentless compassion and effective behavior change strategies. Nine DSM Criteria—the only diagnosis that includes self-harm as a criteria. Historically considered as an “excess of aggression” disorder. Evolved into a disorder about which treaters became hopeless, burned out. Now viewed as a relative of “mood disorders” 11% of psychiatric outpatients meet DSM-IV criteria for BPD 19% of psychiatric inpatients meet criteria 33% of personality-disordered outpatients meet criteria 63% of personality-disordered inpatients meet criteria 74% of BPD population is female 70-75% have a history of at least one selfinjurious act Suicide rates for BPD are 9% Those with history of self-injurious behavior have at least double the risk of completed suicide One Year Health Care Costs Per Patient Estimated for Treatment as Usual (TAU) Individual Psychotherapy Group Psychotherapy Day Treatment Emergency Room Care Psychiatric Inpatient Days Medical Inpatient Days Behavioral Tech, LLC 2003 2,915 147 876 56 12,008 1,094 17,609 N BPD/OPD Golier et al, 2003 72/108 BPD 25%* OPD 13%* Yen et al, 2002 51%* 29% 56%* 22% 153/305 (w/trauma) Zanarini et al, 1998 379/125 Johnson et al., 1999, 2001: • 636 youths ages 1-11 and mothers, followed into young adulthood, with Child Protective Services records and self-report assessment of maltreatment • Childhood Physical Abuse, Sexual Abuse, Verbal “Abuse, and Neglect predicted adulthood PBD criteria/diagnosis • Those with abuse or neglect were 4.5 to 7.7 times more likely to have BPD • • • • • Trauma is associated with many psychiatric disorders other than BPD—almost all (Paris, 1998) Only 25% of traumatized children develop adult psychiatric disorders (Werner and Smith, 1992) Impact of abuse on psychiatric disorders depends on severity; only 25% of patients with BPD report severe trauma (Paris, 1997) The association of BPD and Sexual Abuse across studies is not very strong (Fossati et al., 1999) Physical Abuse, Sexual Abuse, and/or Severe Neglect are associated with childhood BPD (Goldman et al., 1992; Guzder et al., 1996) raising question of the direction of association in longitudinal research • Gunderson & Sabo (1993) BPD creates vulnerability to trauma, which leads to PTSD • Southwick et al. (1993) Trauma leads to chronic PTSD which contributes to personality adjustment including BPD features Longitudinal study of adult patients with BPD (n=290) and other PDS (n=72) over 6 years; • BPD was associated with higher rates of verbal, emotional, physical, and sexual abuse • Rates of abuse declined over time • Continued presence of verbal, emotional, and physical abuse predicted non-remission of the BPD diagnosis Zanarini et al, 2005 Axelrod, Morgan, Southwick, 2005 • Looked at Pre- and Post-combat veterans and found that BPD creates a vulnerability to the development of PTSD. • Trauma, particularly in individuals who were younger and who experienced more severe trauma, led to the development of BPD features. • If PTSD symptoms exist prior to trauma, then it increases the probability that an individual will develop BPD symptoms following additional trauma. When compared to TAU, DBT significantly reduced: Frequency of self-harm behaviors The severity of self-harm behaviors Treatment drop-out Inpatient psychiatric days (Linehan, Armstrong, Suarez, Allmon, & Heard, 1991) TAU Individual Psychotherapy 2,915 Group Psychotherapy 147 Day Treatment 876 Psychiatric Inpatient Days 12,008 Medical Inpatient Days 1,094 17,609 DBT 3,885 1,514 11 2,614 360 8,610 Applies research about emotions and their management to treatment. Based heavily upon principles of behavior therapy, cognitive therapy, and Zen practices. A “stages of treatment” model with hierarchies of targets at each stage. High Emotional Sensitivity Immediate reaction Low threshold for emotional arousal High Emotional Reactivity Extreme reaction Hard to think clearly Slow Return to Baseline Long-lasting reactions Sensitized before next event Emotional Dysregulation Interpersonal Rapidly shifting feelings and moods Problems with anger Chaotic relationships fear of being left alone/abandoned Fluctuating or absent sense of self sense of emptiness Dissociation paranoid thinking/overpersonalization Self-harm behaviors impulsive behaviors Dysregulation Self Dysregulation Cognitive Dysregulation Behavioral Dysregulation Adds a sixth area of dysregulation in complex trauma: Somatic or physiological dysregulation Dialectical Dilemna Emotional Vunerability Sense of emotional agony, falling into the abyss, loss of control, task impossibility Biological Social Self invalidation (self-directed hate and contempt; dismissal of pain & difficulty; unrealistic expectations) Individuals with significant mood and behavioral dysregulation that would benefit from skill training in any of the following areas: 1. Attention/Concentration 2. Interpersonal Effectiveness 3. Emotion Regulation 4. Distress Tolerance Individual DBT-based treatment One hour per week Group Skills Training Two hours per week Skills Coaching Limited by individual therapist Consultation Team Two hours per week Structuring the Environment Enhancing client capabilities Generalizing skills to the natural environment Improving client motivation Enhancing the capabilities and improving the motivation of staff What Makes DBT Work??? Dialectics “Both…And” Validation “Yes…And” Helping clients find true balance in emotion, thoughts, and behavior and/or choices. Teaching them, as well as showing them how live in balance. Acknowledging another person’s reality, noting that their thoughts, feelings, sensations, and responses are real, and are valid in their own right. Practice, Practice, Practice Acceptance Change www. Behavioraltech.org DBT in a Nutshell Research Summary Implementation Models [email protected]