Transcript DIALECTICAL BEHAVIOR THERAPY

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.
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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”
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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
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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
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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
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Gunderson & Sabo (1993)
BPD creates vulnerability to trauma, which leads to
PTSD
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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;
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BPD was associated with higher rates of verbal, emotional,
physical, and sexual abuse
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Rates of abuse declined over time
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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
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(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
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2,614
360
8,610
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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.
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High Emotional Sensitivity
 Immediate reaction
 Low threshold for emotional arousal
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High Emotional Reactivity
 Extreme reaction
 Hard to think clearly
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Slow Return to Baseline
 Long-lasting reactions
 Sensitized before next event
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Emotional Dysregulation
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Interpersonal
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Rapidly shifting feelings and
moods Problems with anger
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Chaotic relationships fear of
being left alone/abandoned
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Fluctuating or absent sense of
self sense of emptiness
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Dissociation
paranoid thinking/overpersonalization
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Self-harm behaviors
impulsive behaviors
Dysregulation
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Self Dysregulation
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Cognitive Dysregulation
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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
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Individual DBT-based treatment
 One hour per week
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Group Skills Training
 Two hours per week
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Skills Coaching
 Limited by individual therapist
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Consultation Team
 Two hours per week
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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
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