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Dialectical Behaviour Therapy and Borderline Personality Disorder. Presentation Outline • • • • • Psychoanalysis and BPD. Dialectical Behavior Therapy Studies Positive and Negative aspects of DBT Evaluation Borderline Personality Disorder Five or more of the following to be present for a significant period of time: • Frantic efforts to avoid real or imagined abandonment. [Not including suicidal or self-mutilating behavior covered in Criterion 5] • A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. • Identity disturbance: markedly and persistently unstable self-image or sense of self. • Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, promiscuous sex, eating disorders, substance abuse, reckless driving, binge eating). [Again, not including suicidal or self-mutilating behavior covered in Criterion 5] • Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior. • Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days) • Chronic feelings of emptiness. • Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights). • Transient, stress-related paranoid ideation or severe dissociative symptoms. Psychoanalysis and BPD • Traditional psychoanalytic treatments of BPD required longer hospitalization periods. They relayed on patients being in a controlled environment. • Long hospitalization periods are rarer nowadays. • Psychoanalysis requires longer periods of commitment to treatment, which is incompatible with Borderline Personality Disorder. Dialectical Behaviour Therapy - Dialectical Behaviour Therapy(DBT) is a form of cognitive behavioural therapy for borderline personality disorder patients developed by Marsha Linehan. It was developed in the 1990´s. - DBT was first developed for “chronically suicidal individuals”. - This form of therapy is called “Dialectical” because it deals with emotional and rational aspects, and with acceptance and change. - DBT mixes cognitive behavior therapy with mindfulness techniques. - Individual Therapy and Group Therapy. Reasoning behind DBT - BPD has a biological basis, which affects emotional regulation. Social environments may reinforce their dysfunctional behaviour (Biosocial theory). - DBT encourages clients to be aware of the current moment and accept reality. - DBT tries to replace rigid/dichotomous worldviews. It emphasizes the importance of a more holistic approach to life. - DBT also stresses that balance is important in life. Clients should achieve a middle ground between reason and emotion. Four Modules • • • • Mindfulness Interpersonal effectiveness Distress endurance Emotion regulation Pre- treatment stage 1) - Agreeing on goals Individualized treatment lists :decrease behaviours which prolong hospitalization (parasuicidal, therapy interfering behaviour), decrease behaviours that affect quality of life, increase life skills, decrease stress, increase self-esteem. 2)Committing to treatment plans - Most patients enter the hospital involuntarily. Stages Stage one - Decrease behaviour which prolong hospitalization - Increase skills for getting out and staying out of the hospital. - Crisis survival skills : distress tolerance module Stage 2 - Deal with stress related problems Stage 3 - Increase self- esteem - Treatment goals Stage 4 Diary Cards Effectiveness of dialectical behavior therapy for Borderline personality disorder in an inpatient setting - Fifty inpatients diagnosed with BPD were evaluated at three different points in time. The patients were screened for substance abuse, bipolar I, dementia and schizophrenia. - Each patient went to individual therapy sessions once a week and group sessions three times a week - Sixty-two percent of patients also received antidepression medication. Benzodiapines were also used. - Symptoms were reduced, but not eliminated. - Findings confirmed the effectiveness of DBT. It was also proved that DBT can be used in an inpatient setting. Positive aspects of DBT Reduced - suicidal behaviour - Hospitalizations - Length of hospitalization - treatment dropout - Depression scores - Anger - Dissociation - Substance use Increased - interpersonal functioning - Global functioning Negative aspects of DBT - The first stage alone takes one year at least. - Expensive - Long- waiting lists Evaluation • There are few studies about DBT. Most studies use small samples. • There were no follow-up studies of the original research. • Personality disorders are difficult to treat. Parasuicidal behaviours are hard to control. However, DBT seems to help most patients. • It is possible to adapt DBT to other situations and settings.