new research on borderline personality disorder blaise aguirre, md medical director, 3east...
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New Research on Borderline New Research on Borderline Personality DisorderPersonality Disorder
New Research on Borderline New Research on Borderline Personality DisorderPersonality Disorder
Blaise Aguirre, MDMedical Director , 3East Residential Assistant Professor of Psychiatry
Harvard Medical SchoolBelmont, MA
Alec L. Miller, PsyDCo-Founder, Cognitive & Behavioral Consultants of Westchester, LLP
White Plains, NY Professor of Clinical Psychiatry and Behavioral Sciences
Montefiore Medical Center/Albert Einstein College of MedicineBronx, NY
NAMI 9/5/14
Blaise Aguirre, MDMedical Director , 3East Residential Assistant Professor of Psychiatry
Harvard Medical SchoolBelmont, MA
Alec L. Miller, PsyDCo-Founder, Cognitive & Behavioral Consultants of Westchester, LLP
White Plains, NY Professor of Clinical Psychiatry and Behavioral Sciences
Montefiore Medical Center/Albert Einstein College of MedicineBronx, NY
NAMI 9/5/14
• BPD diagnosis, prevalence, and self-harmBPD diagnosis, prevalence, and self-harm–The 5 problem areasThe 5 problem areas
• Existing evidence-based BPD treatmentsExisting evidence-based BPD treatments• DBT researchDBT research
–First adolescent RCTFirst adolescent RCT• Early InterventionEarly Intervention• PreventionPrevention• BPD and Trauma researchBPD and Trauma research• Future DirectionsFuture Directions
• BPD diagnosis, prevalence, and self-harmBPD diagnosis, prevalence, and self-harm–The 5 problem areasThe 5 problem areas
• Existing evidence-based BPD treatmentsExisting evidence-based BPD treatments• DBT researchDBT research
–First adolescent RCTFirst adolescent RCT• Early InterventionEarly Intervention• PreventionPrevention• BPD and Trauma researchBPD and Trauma research• Future DirectionsFuture Directions
OutlineOutlineOutlineOutline
Borderline Personality DisorderDisorder (Re-organized in DBT)
Borderline Personality DisorderDisorder (Re-organized in DBT)
Emotion Dysregulation Affective lability Problems with anger
Interpersonal Dysregulation Chaotic relationships Fears of abandonment
Self Dysregulation Identity disturbance/ difficulties with sense of self Sense of emptiness
Behavioral Dysregulation Parasuicidal behavior Impulsive behavior
Cognitive Dysregulation Dissociative responses/ paranoid ideation
Emotion Dysregulation Affective lability Problems with anger
Interpersonal Dysregulation Chaotic relationships Fears of abandonment
Self Dysregulation Identity disturbance/ difficulties with sense of self Sense of emptiness
Behavioral Dysregulation Parasuicidal behavior Impulsive behavior
Cognitive Dysregulation Dissociative responses/ paranoid ideation
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BPD in ADULTSBPD in ADULTS BPD in ADULTSBPD in ADULTSDSM-IV and epi studies find BPD in:DSM-IV and epi studies find BPD in:1.8% of the general population, 1.8% of the general population, 8 to 11% of psychiatric outpatients, 8 to 11% of psychiatric outpatients, and 14 to 20% of inpatients.and 14 to 20% of inpatients.
****NIAAA Study of 34,653 adults found: NIAAA Study of 34,653 adults found: Prevalence of lifetime BPD was 5.9%, Prevalence of lifetime BPD was 5.9%, with no significant difference between with no significant difference between gender (J of Clin Psychiatry, 2008)gender (J of Clin Psychiatry, 2008)
DSM-IV and epi studies find BPD in:DSM-IV and epi studies find BPD in:1.8% of the general population, 1.8% of the general population, 8 to 11% of psychiatric outpatients, 8 to 11% of psychiatric outpatients, and 14 to 20% of inpatients.and 14 to 20% of inpatients.
****NIAAA Study of 34,653 adults found: NIAAA Study of 34,653 adults found: Prevalence of lifetime BPD was 5.9%, Prevalence of lifetime BPD was 5.9%, with no significant difference between with no significant difference between gender (J of Clin Psychiatry, 2008)gender (J of Clin Psychiatry, 2008)
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BPD isBPD is
associated withassociated with
fatal and non-fatal fatal and non-fatal
suicidal behaviors as well suicidal behaviors as well as nonsuicidal self-as nonsuicidal self-injurious behaviorsinjurious behaviors
BPD isBPD is
associated withassociated with
fatal and non-fatal fatal and non-fatal
suicidal behaviors as well suicidal behaviors as well as nonsuicidal self-as nonsuicidal self-injurious behaviorsinjurious behaviors
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BPD Can Be FatalBPD Can Be FatalBPD Can Be FatalBPD Can Be Fatal
• Among SUICIDES,Among SUICIDES,
–40-65% have PD40-65% have PD
• Among PDs,Among PDs,–BPD is most associated with suicidal BPD is most associated with suicidal
behaviorbehavior
• Among BPD,Among BPD, –8-10% commit suicide 8-10% commit suicide –up to 75% attempt suicideup to 75% attempt suicide–69-80% self-mutilate69-80% self-mutilate
• Among SUICIDES,Among SUICIDES,
–40-65% have PD40-65% have PD
• Among PDs,Among PDs,–BPD is most associated with suicidal BPD is most associated with suicidal
behaviorbehavior
• Among BPD,Among BPD, –8-10% commit suicide 8-10% commit suicide –up to 75% attempt suicideup to 75% attempt suicide–69-80% self-mutilate69-80% self-mutilate
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ESTs for BPD:ESTs for BPD:Mentalization (Bateman & Fonagy)Mentalization (Bateman & Fonagy)
•AJP, 1999; 2013AJP, 1999; 2013
•JAACAP, 2012 (Roussow & Fonagy) -JAACAP, 2012 (Roussow & Fonagy) -ADOLESCENTSADOLESCENTS
Transference-focused (Kernberg, Clarking, Levy et al)Transference-focused (Kernberg, Clarking, Levy et al)•JCCP 2006; AJP, 2007; Archives, 2006; BJP, 2010 JCCP 2006; AJP, 2007; Archives, 2006; BJP, 2010
Schema-focused (Young et al.)Schema-focused (Young et al.)•Archives, 2006; 2009Archives, 2006; 2009
STEPPS (Blum et al.)STEPPS (Blum et al.)•2008; 20102008; 2010
Cognitive Analytic Therapy (Chanen et al.)Cognitive Analytic Therapy (Chanen et al.)•BJP, 2008; 2012BJP, 2008; 2012
DBT (Linehan et al.) DBT (Linehan et al.) •Archives, 1991, 1993, 1998, 1999, 2006, etc, >18 RCTsArchives, 1991, 1993, 1998, 1999, 2006, etc, >18 RCTs
•JAACAP, in press (Mehlum et al.)-JAACAP, in press (Mehlum et al.)-ADOLESCENTSADOLESCENTS
ESTs for BPD:ESTs for BPD:Mentalization (Bateman & Fonagy)Mentalization (Bateman & Fonagy)
•AJP, 1999; 2013AJP, 1999; 2013
•JAACAP, 2012 (Roussow & Fonagy) -JAACAP, 2012 (Roussow & Fonagy) -ADOLESCENTSADOLESCENTS
Transference-focused (Kernberg, Clarking, Levy et al)Transference-focused (Kernberg, Clarking, Levy et al)•JCCP 2006; AJP, 2007; Archives, 2006; BJP, 2010 JCCP 2006; AJP, 2007; Archives, 2006; BJP, 2010
Schema-focused (Young et al.)Schema-focused (Young et al.)•Archives, 2006; 2009Archives, 2006; 2009
STEPPS (Blum et al.)STEPPS (Blum et al.)•2008; 20102008; 2010
Cognitive Analytic Therapy (Chanen et al.)Cognitive Analytic Therapy (Chanen et al.)•BJP, 2008; 2012BJP, 2008; 2012
DBT (Linehan et al.) DBT (Linehan et al.) •Archives, 1991, 1993, 1998, 1999, 2006, etc, >18 RCTsArchives, 1991, 1993, 1998, 1999, 2006, etc, >18 RCTs
•JAACAP, in press (Mehlum et al.)-JAACAP, in press (Mehlum et al.)-ADOLESCENTSADOLESCENTS
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18 Randomized Clinical Trials18 Randomized Clinical Trials18 Randomized Clinical Trials18 Randomized Clinical TrialsDBT Superior to Comparison DBT Superior to Comparison
TreatmentsTreatments
Reducing:Reducing:• Suicide attemptsSuicide attempts and self-injury and self-injury• Premature Premature drop-outdrop-out• InpatientInpatient/ER admissions and days/ER admissions and days• Drug abuseDrug abuse• Depression, hopelessnessDepression, hopelessness, anger, anger• ImpulsivenessImpulsiveness
Increasing:Increasing:• Global adjustmentGlobal adjustment• Social adjustmentSocial adjustment
DBT Superior to Comparison DBT Superior to Comparison TreatmentsTreatments
Reducing:Reducing:• Suicide attemptsSuicide attempts and self-injury and self-injury• Premature Premature drop-outdrop-out• InpatientInpatient/ER admissions and days/ER admissions and days• Drug abuseDrug abuse• Depression, hopelessnessDepression, hopelessness, anger, anger• ImpulsivenessImpulsiveness
Increasing:Increasing:• Global adjustmentGlobal adjustment• Social adjustmentSocial adjustment See Lieb, K., Zanarini, M., Linehan, M., See Lieb, K., Zanarini, M., Linehan, M.,
& Bohus, M., 2004.& Bohus, M., 2004.
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to severe and chronic multi-diagnostic, difficult-to-treat patient
with both Axis I and Axis II disorders
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INVALIDATIONINVALIDATION
OF OF SELF-CONSTRUCTSSELF-CONSTRUCTS
The Problem
Impaired Cognitive Processing +
Intense Effort to Control
FOCUS ON FOCUS ON CHANGECHANGE !!AROUSAL!!!!AROUSAL!!
SENSE OFSENSE OF OUT-OF-CONTROLOUT-OF-CONTROL
No New Learning – No CollaborationNo New Learning – No Collaboration
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12
INVALIDATIONINVALIDATION
OF OF SUFFERINGSUFFERING
The ProblemFurther
FOCUS ON FOCUS ON ACCEPTANCEACCEPTANCE !!AROUSAL!!!!AROUSAL!!
SENSE OFSENSE OF OUT-OF-CONTROLOUT-OF-CONTROL
No New Learning – No No New Learning – No CollaborationCollaboration
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Solution Was to ApplySolution Was to Apply
A Approach BalancingA Approach Balancing
Solution Was to ApplySolution Was to Apply
A Approach BalancingA Approach Balancing
AcceptanceAcceptanceStrategiesStrategies
AcceptanceAcceptanceStrategiesStrategies
ChangeChangeStrategies Strategies
DialecticsDialectics
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Problem AreasProblem Areas SkillsSkills Problem AreasProblem Areas SkillsSkills
1.1. Confusion about Self Confusion about Self 1.1. Mindfulness Mindfulness
2.2. Impulsivity Impulsivity 2.2. Distress Tolerance Distress Tolerance
3.3. Emotional Instability Emotional Instability 3.3. Emotion Regulation Emotion Regulation
4.4. Interpersonal Problems Interpersonal Problems 4.4. Interpersonal Interpersonal EffectivenessEffectiveness
5.5. Adolescent - Family Adolescent - Family 5.5. Walking the Middle Walking the Middle
DilemmasDilemmas Path Path
1.1. Confusion about Self Confusion about Self 1.1. Mindfulness Mindfulness
2.2. Impulsivity Impulsivity 2.2. Distress Tolerance Distress Tolerance
3.3. Emotional Instability Emotional Instability 3.3. Emotion Regulation Emotion Regulation
4.4. Interpersonal Problems Interpersonal Problems 4.4. Interpersonal Interpersonal EffectivenessEffectiveness
5.5. Adolescent - Family Adolescent - Family 5.5. Walking the Middle Walking the Middle
DilemmasDilemmas Path Path
Adolescent Outpatient DBT ModesAdolescent Outpatient DBT ModesAdolescent Outpatient DBT ModesAdolescent Outpatient DBT ModesPhase I: Phase I: 4-6 months4-6 months
• Multi-family Multi-family skills training group skills training group • Individual psychotherapyIndividual psychotherapy• Telephone consultation (w/ teenTelephone consultation (w/ teen & parent) & parent)• Family therapy Family therapy • Therapist consultation meetingTherapist consultation meeting
Phase II: Phase II: 16 weeks & recommit16 weeks & recommit• Graduate group Graduate group • Individual psychotherapy (phase out)Individual psychotherapy (phase out)• Telephone consultationTelephone consultation• Family therapy, PRNFamily therapy, PRN*All patients are eligible for pharmacotherapy*All patients are eligible for pharmacotherapy
Phase I: Phase I: 4-6 months4-6 months• Multi-family Multi-family skills training group skills training group • Individual psychotherapyIndividual psychotherapy• Telephone consultation (w/ teenTelephone consultation (w/ teen & parent) & parent)• Family therapy Family therapy • Therapist consultation meetingTherapist consultation meeting
Phase II: Phase II: 16 weeks & recommit16 weeks & recommit• Graduate group Graduate group • Individual psychotherapy (phase out)Individual psychotherapy (phase out)• Telephone consultationTelephone consultation• Family therapy, PRNFamily therapy, PRN*All patients are eligible for pharmacotherapy*All patients are eligible for pharmacotherapy
L.Mehlum 2012
Dialectical Behavior Therapy for Adolescents with Recent and Repeated
Suicidal and Self harm Behavior - a Randomized Controlled Trial
Mehlum, L, Tormoen, A, Ramberg, M, Haga, E, Diep, L, Laberg, S, Larsson, B, Stanley, B, Miller, AL, Sund, A, Groholt, B. (In press,
Journal of the American Academy of Child and Adolescent Psychiatry).
L.Mehlum 2012
Overall aim
To determine the efficacy of DBT-A compared to
enhanced usual care in adolescents with recent and
repetitive self harm and with three or more borderline personality disorder criteria.
L.Mehlum 2012
Design
• Randomized Controlled Trial with independent and blinded pre-, post and follow-up evaluations
• Measurements at: – Baseline (interview, self-report and testing)
– 6 weeks (self-report)
– 12 weeks (self-report)
– 16 weeks - End of treatment (interview, self-report and testing)
– 1 year posttreatment follow-up (interview, self-report and testing)
– 2 years posttreatment follow-up (interview, self-report and testing)
• Ten year follow-up planned
L.Mehlum 2012
Treatment methods1. DBT – Adapted for adolescents – 16 weeks
2. Enhanced Usual Care (EUC) – 16 weeks
Psychodynamic or CBT oriented therapy (non-DBT)
Treatments were delivered at five Child and Adolescent Outpatient Clinics in Oslo, Norway
Adolescent Outpatient DBT ModesAdolescent Outpatient DBT ModesAdolescent Outpatient DBT ModesAdolescent Outpatient DBT ModesPhase I: Phase I: 4 months (RESEARCH STUDY)4 months (RESEARCH STUDY)
• Multi-family Multi-family skills training group skills training group • Individual psychotherapyIndividual psychotherapy• Telephone consultation (w/ teenTelephone consultation (w/ teen & parent) & parent)• Family therapy Family therapy • Therapist consultation meetingTherapist consultation meeting
Phase II: Phase II: 16 weeks & recommit (NOT RESEARCH)16 weeks & recommit (NOT RESEARCH)• Graduate group Graduate group • Individual psychotherapy (phase out)Individual psychotherapy (phase out)• Telephone consultationTelephone consultation• Family therapy, PRNFamily therapy, PRN*All patients are eligible for pharmacotherapy*All patients are eligible for pharmacotherapy
Phase I: Phase I: 4 months (RESEARCH STUDY)4 months (RESEARCH STUDY)• Multi-family Multi-family skills training group skills training group • Individual psychotherapyIndividual psychotherapy• Telephone consultation (w/ teenTelephone consultation (w/ teen & parent) & parent)• Family therapy Family therapy • Therapist consultation meetingTherapist consultation meeting
Phase II: Phase II: 16 weeks & recommit (NOT RESEARCH)16 weeks & recommit (NOT RESEARCH)• Graduate group Graduate group • Individual psychotherapy (phase out)Individual psychotherapy (phase out)• Telephone consultationTelephone consultation• Family therapy, PRNFamily therapy, PRN*All patients are eligible for pharmacotherapy*All patients are eligible for pharmacotherapy
L.Mehlum 2012
DBT therapists
• Recruited from five Child & Adolescent outpatient psychiatric clinics at the Oslo University Hospital
• MDs and Psychologists• All therapists were new to DBT and trained for the purpose of
the trial and hired if/when reaching a consistently high adherence level (score >= 4.0 on Linehan adherence coding instrument)
• Trained for the purpose of the trial in suicide risk assessment and management
• All treaments were conducted at and paid for by the Oslo University Hospital
Coding of 166 individual therapy sessions
Mean score = 4.11 SD = 0.14
L.Mehlum 2012
Participants• Patient inclusion: March 2008 thru March 2012
• Altogether 77 patients were included and randomly allocated to receive:
– DBT-A (n=39)
– or
– EUC (n=38)
• Stratified by gender, presence of major depression and suicide intent at most severe self-harm episode last 4 months before enrollment.
L.Mehlum 2012
RCT of DBT-A vs EUC for self-harming and suicidal adolescents with emotion dysregulation (N=77)
Patient characteristics - baseline
Dialectical Behaviour Therapy
N=39
Enhanced Usual CareN=38
N % N %
Girls (%) 34 87.2 34 89.5
Completed high school 13 41.9 7 25.0
Parents currently married 17 43.6 17 44.7
Mean SD Mean SD
Age (yrs) 15.9 1.4 15.3 1.6
C-GAS 55.3 8.0 57.9 10.1
No significant differences between groups
L.Mehlum 2012
RCT of DBT-A vs EUC for self-harming and suicidal adolescents with emotion dysregulation (N=77)
Patient characteristics – baseline cont.Dialectical Behaviour
TherapyN=39
Enhanced Usual CareN=38
N % N %
Psychiatric treatment (past) 28 73.7 23 62.2
Pharmacotherapy (past) 2 5.4 6 17.1
Child protection (past) 10 26.3 11 28.9
Child protection (current) 6 15.4 7 18.4
Mean SD/SE Mean SD/SE
CBCL (total no of problems) 69.6 11.0 68.4 8.6
Lifetime NSSH episodes (mean/rate) 29.8 2.8 25.9 3.0
Lifetime suicide attempts (mean/rate) 3.2 0.6 3.1 0.6
No significant differences between groups
L.Mehlum 2012
So what about the outcomes?
L.Mehlum 2012
Conclusions
• Patients receiving DBT-A experienced significant reductions in all 3 primary outcome measures, in contrast to patients receiving EUC where only self-reported depression was significantly reduced
• Patients who received DBT-A had a significantly– Stronger reduction in the number of self-harm episodes
– Stronger decline in suicidal ideation
– Stronger reduction in interviewer rated depressive symptoms
– Stronger reduction in hopelessness feelings
– Stronger reduction in borderline symptoms
L.Mehlum 2012
Next steps in Norway
• 1 year posttreatment follow-up (interview, self-report and testing) - ongoing
• 2 years posttreatment follow-up (interview, self-report and testing) – ongoing
• 10 year posttreatment follow-up – planned
• Evaluate effectiveness of Adolescent DBT Graduate Group as a maintenance, continuation phase of treatment
Prevention & Early Intervention
DBT in School SettingsDBT in School SettingsDBT in School SettingsDBT in School Settings• Secondary and Tertiary Prevention:Secondary and Tertiary Prevention:
–Middle and HSMiddle and HS–Elementary schoolsElementary schools
• Primary Prevention InterventionsPrimary Prevention Interventions–Elementary schoolsElementary schools
• Secondary and Tertiary Prevention:Secondary and Tertiary Prevention:–Middle and HSMiddle and HS–Elementary schoolsElementary schools
• Primary Prevention InterventionsPrimary Prevention Interventions–Elementary schoolsElementary schools
DBT in SchoolsDBT in SchoolsDBT in SchoolsDBT in Schools• School InterventionsSchool Interventions
– Ulster County HS Health Class Curriculum (1999)Ulster County HS Health Class Curriculum (1999)– Far Rockaway HSFar Rockaway HS
• Salley et al, (2002)Salley et al, (2002)– New Haven Elementary School/Yale UniversityNew Haven Elementary School/Yale University
• Perepletchikova et al, (2010) Perepletchikova et al, (2010) – PS 8 Bronx, NY/Albert Einstein College of MedicinePS 8 Bronx, NY/Albert Einstein College of Medicine
• Lander, Miller, Edwards, et al, (2009-2012)Lander, Miller, Edwards, et al, (2009-2012)– Ardsley School District, NY (2008-present)Ardsley School District, NY (2008-present)
• School-based Mental Health Teams in MS and HS and School-based Mental Health Teams in MS and HS and • Now teaching in Health ClassNow teaching in Health Class• Presented data at conferences (Catucci et al.; Mason et al)Presented data at conferences (Catucci et al.; Mason et al)
– Pleasantville, NY School District (2009-present)Pleasantville, NY School District (2009-present)• School-based Mental Health Teams in MS and HS School-based Mental Health Teams in MS and HS
– Mamaroneck, NY School District (2010-present)Mamaroneck, NY School District (2010-present)– Rockland County BOCES HS (2012-present)Rockland County BOCES HS (2012-present)– New Rochelle and Florida, NY School Districts (2012-present)New Rochelle and Florida, NY School Districts (2012-present)– University of Washington, MS & HS EducationUniversity of Washington, MS & HS Education
• Mazza & Mazza (2010-) Mazza & Mazza (2010-)
• School InterventionsSchool Interventions– Ulster County HS Health Class Curriculum (1999)Ulster County HS Health Class Curriculum (1999)– Far Rockaway HSFar Rockaway HS
• Salley et al, (2002)Salley et al, (2002)– New Haven Elementary School/Yale UniversityNew Haven Elementary School/Yale University
• Perepletchikova et al, (2010) Perepletchikova et al, (2010) – PS 8 Bronx, NY/Albert Einstein College of MedicinePS 8 Bronx, NY/Albert Einstein College of Medicine
• Lander, Miller, Edwards, et al, (2009-2012)Lander, Miller, Edwards, et al, (2009-2012)– Ardsley School District, NY (2008-present)Ardsley School District, NY (2008-present)
• School-based Mental Health Teams in MS and HS and School-based Mental Health Teams in MS and HS and • Now teaching in Health ClassNow teaching in Health Class• Presented data at conferences (Catucci et al.; Mason et al)Presented data at conferences (Catucci et al.; Mason et al)
– Pleasantville, NY School District (2009-present)Pleasantville, NY School District (2009-present)• School-based Mental Health Teams in MS and HS School-based Mental Health Teams in MS and HS
– Mamaroneck, NY School District (2010-present)Mamaroneck, NY School District (2010-present)– Rockland County BOCES HS (2012-present)Rockland County BOCES HS (2012-present)– New Rochelle and Florida, NY School Districts (2012-present)New Rochelle and Florida, NY School Districts (2012-present)– University of Washington, MS & HS EducationUniversity of Washington, MS & HS Education
• Mazza & Mazza (2010-) Mazza & Mazza (2010-)
30
Do not reproduce or distribute without written permission from CBC. © CBC 2012
STEPS-A (Emotional Problem Solving for Adolescents; Mazza et al, in preparation) is a Universal program – Teacher administered 42-minute/class DBT curriculum
Using an RTI model
Using Mental Health model
Tier IUniversal Population
Tier IISelected Population
Tier IIIIndicated
80-85%
10-15%
5-10%
Dialectical Behavior Therapy in Public Schools
(Mazza, 2012)
Why DBT in Schools?Why DBT in Schools?Why DBT in Schools?Why DBT in Schools?
•Mounting pressure to keep ED Mounting pressure to keep ED (emotionally disabled) students (emotionally disabled) students within Districtwithin District– Costs District @ 100K/per student per Costs District @ 100K/per student per
year when sent out of District for year when sent out of District for specialized programs.specialized programs.
•Mounting pressure to keep ED Mounting pressure to keep ED (emotionally disabled) students (emotionally disabled) students within Districtwithin District– Costs District @ 100K/per student per Costs District @ 100K/per student per
year when sent out of District for year when sent out of District for specialized programs.specialized programs.
32Do not reproduce or distribute without written permission from CBC. © CBC 2012
Why DBT in Schools?Why DBT in Schools?Why DBT in Schools?Why DBT in Schools?
•Schools often urge staff to send Schools often urge staff to send students to ER when suicidal students to ER when suicidal thinking or self-harm is reported.thinking or self-harm is reported.
•ERs are flooded with visits from ERs are flooded with visits from students who do not necessarily students who do not necessarily need hospitalization.need hospitalization.
•Sending students to ER may Sending students to ER may reinforce problem reinforce problem (escape/avoidance) behaviors.(escape/avoidance) behaviors.
•Schools often urge staff to send Schools often urge staff to send students to ER when suicidal students to ER when suicidal thinking or self-harm is reported.thinking or self-harm is reported.
•ERs are flooded with visits from ERs are flooded with visits from students who do not necessarily students who do not necessarily need hospitalization.need hospitalization.
•Sending students to ER may Sending students to ER may reinforce problem reinforce problem (escape/avoidance) behaviors.(escape/avoidance) behaviors. 33
Do not reproduce or distribute without written permission from CBC. © CBC 2012
Data from SchoolsData from SchoolsData from SchoolsData from Schools•Preliminary results from an open Preliminary results from an open
trial at Ardsley High School (Mason, trial at Ardsley High School (Mason, Catucci, Lusk, and Johnson, 2011)Catucci, Lusk, and Johnson, 2011)– Reduced referrals to assistant principalReduced referrals to assistant principal
– Reduced cutting classReduced cutting class
– Reduced detentions and suspensionsReduced detentions and suspensions
– Anecdotal reduction in depression, Anecdotal reduction in depression, anxiety, NSSIanxiety, NSSI
– Requires change of culture re: how Requires change of culture re: how schools manage problem behaviorschools manage problem behavior
•Preliminary results from an open Preliminary results from an open trial at Ardsley High School (Mason, trial at Ardsley High School (Mason, Catucci, Lusk, and Johnson, 2011)Catucci, Lusk, and Johnson, 2011)– Reduced referrals to assistant principalReduced referrals to assistant principal
– Reduced cutting classReduced cutting class
– Reduced detentions and suspensionsReduced detentions and suspensions
– Anecdotal reduction in depression, Anecdotal reduction in depression, anxiety, NSSIanxiety, NSSI
– Requires change of culture re: how Requires change of culture re: how schools manage problem behaviorschools manage problem behavior
34Do not reproduce or distribute without written permission from CBC. © CBC 2013
Why DBT in schools?Why DBT in schools?Why DBT in schools?Why DBT in schools?
• It may be more cost-effectiveIt may be more cost-effective• It may reduces problem behaviors that It may reduces problem behaviors that
often result in suspensions, ER visits, etcoften result in suspensions, ER visits, etc•DBT is skills based, can be taught in DBT is skills based, can be taught in
groups/classesgroups/classes• It can be applied transdiagnosticallyIt can be applied transdiagnostically•DBT has observable and measurable DBT has observable and measurable
outcomesoutcomes• It may PREVENT BPD symptoms?It may PREVENT BPD symptoms?
• It may be more cost-effectiveIt may be more cost-effective• It may reduces problem behaviors that It may reduces problem behaviors that
often result in suspensions, ER visits, etcoften result in suspensions, ER visits, etc•DBT is skills based, can be taught in DBT is skills based, can be taught in
groups/classesgroups/classes• It can be applied transdiagnosticallyIt can be applied transdiagnostically•DBT has observable and measurable DBT has observable and measurable
outcomesoutcomes• It may PREVENT BPD symptoms?It may PREVENT BPD symptoms?
35Do not reproduce or distribute without written permission from CBC. © CBC 2013
DBT in SchoolsDBT in SchoolsDBT in SchoolsDBT in Schools
Reference :
Mazza, JJ, Dexter-Mazza, ET, Murphy, HE, Miller, Mazza, JJ, Dexter-Mazza, ET, Murphy, HE, Miller, AL, & Rathus, JH (In preparation). AL, & Rathus, JH (In preparation). Skills Skills Training for Emotional Problem Solving for Training for Emotional Problem Solving for Adolescents (STEPS-A):Adolescents (STEPS-A): Implementing DBT Implementing DBT skills training in schoolsskills training in schools . . Guilford Press.Guilford Press.
Reference :
Mazza, JJ, Dexter-Mazza, ET, Murphy, HE, Miller, Mazza, JJ, Dexter-Mazza, ET, Murphy, HE, Miller, AL, & Rathus, JH (In preparation). AL, & Rathus, JH (In preparation). Skills Skills Training for Emotional Problem Solving for Training for Emotional Problem Solving for Adolescents (STEPS-A):Adolescents (STEPS-A): Implementing DBT Implementing DBT skills training in schoolsskills training in schools . . Guilford Press.Guilford Press.
Do not reproduce or distribute without written permission from CBC. © CBC 2012
Dalai LamaDalai LamaDalai LamaDalai Lama
Early Intervention in BPD
Current evidence supports: the development of indicated prevention and early intervention programs for the emerging BPD phenotype (Chanen et al. 2007, 2008)
Benefits of Early Intervention are likely to outweigh risks, such as stigmatizing attitudes from clinicians.
(Chanen et al. 2007, 2008)
Potential opportunities for Early Intervention is frequently missed
Identification of outpatient youth with DSM-IV BPD is feasible through screening (Chanen et al. 2008)
The Evidence
15-18 yo (41 to CAT vs. 37 to GCC vs. 32 TAU) ≥ 2 DSM-IV BPD criteria one or more childhood risk factors for young adult
generic PD childhood PD symptoms disruptive behavior disorder symptoms low socio-economic status depressive symptoms history of childhood abuse or neglect
Assessments
Baseline (n=78) 6-months (n=70) 12-months (n=70) 24-months (n=68) At least three time points in 92%
of sample
Outcome Variables
Total BPD score (SCID-II) Youth self-report (YSR; Achenbach, 1991)
Internalizing Externalizing
Social and occupational functioning (SOFAS) Parasuicidal behaviors
suicide attempts and non-suicidal self-injury semi-structured interview coded as: none, monthly, weekly and daily
Main Results
At 24-month follow-up: CAT and GCC was more effective than TAU CAT yielded the greatest median improvement on the four continuous measures CAT had lower levels of and a faster rate of
improvement in externalizing, compared to GCC* CAT had lower levels of and a significantly faster rate of
improvement in both internalising and externalising, compared to TAU
GCC had lower levels of internalising and a faster rate of improvement in SOFAS, compared to TAU
All treatment groups demonstrated significant and clinically substantial improvement.
Conclusions
Early intervention for BPD is possible Patients 13-15 years younger than in
recent RCTs GCC not ineffective perhaps easier to
teach Need longer-term follow-up
gains sustained? divert patients from unhelpful
engagement with adult treatment settings?
Childhood Trauma and Adolescent Borderline Personality Disorder Co-morbidity: Clinical and
Treatment Implications
Blaise Aguirre, MDMedical Director 3East Residential
Assistant Professor of PsychiatryHarvard Medical School
BPD, PTSD and Childhood Maltreatment
Prevalence of borderline personality disorder (BPD) comparable or slightly higher in adolescents vs. adults
2+% adulthood (APA, 2000) 3%-6% in adolescence (Zanarini, 2003; Chabrol et al., 2004)
In the Adult BPD Population Childhood maltreatment/trauma – as high as 85% (Venta et. al., 2012) Prevalence of PTSD-33%-58% (Harned & Linehan, 2008) Trauma and PTSD increases the likelihood of remission from BPD (Zanarini et. al.,
2005)
In the Adolescent BPD Population Only a few studies have explored the link between BPD and trauma in adolescents Childhood sexual abuse successfully discriminated between patients with BPD and
MDD
Co-occurrence of Borderline Personality Disorder (BPD),Trauma and Post-Traumatic Stress Disorder (PTSD)
BPD inpatients have rates of PTSD from 56-58%; BPD outpatients have rates of PTSD from 36-50%1
Epidemiologic research has indicated that 30.2% of individuals with BPD have PTSD, whereas 24.2% of individuals with PTSD have BPD2
Childhood abuse in BPD pop. found to be from 61% to 76%3
BPD clients experience adult traumas at a higher rate than non-BPD peers with rates as high as 90%4
Co-occurring PTSD is associated with greater impairment in individuals with BPD and lower likelihood of long-term remittance of BPD5
BPD clients with PTSD engage in more frequent NSSI than those without PTSD6
1 Zanarini et. al., 1998, 2004;Linehan et. al., 2006 4Zanarini et. al., 20052Pagura et. al., 2010 5Harnad et. al., 2010; Zanarini et. al., 20063Zanarini et. al., 1997, 2006 6 (Rusch et al., 2007)
Our Research Data
Female adolescents (n = 157) Ages 13-20 (Mean age = 17.21; SD= 2.39) Short-Term Residential Program Length of Stay (Mean = 72days)
Pre- and Post-Treatment Assessments BPD Criterion and Symptoms PTSD Symptoms Depressive Symptoms Childhood Maltreatment Risky Behavior Engagement
Results
Relationship of Trauma to Initial BPD Criterion Behaviors
Adolescents with moderate-severe trauma report higher initial levels of borderline psychopathology (t=-2.47, p=.02)
Robust association between childhood emotional/sexual trauma and severity of borderline psychopathology as measured by ZAN-B (r=.18, p=.05) and MSI (r=.28, p=.002)
Adolescents with trauma history also report greater risky behavior engagement as measured by Total RBQ scores which were highly correlated with both physical (r=.23, p=.01) and sexual abuse (r=.19, p=.03)
Impact of Trauma in Adolescence
Childhood Sexual Abuse (CSA) is a strong predictor of substance abuse, conduct disorder and depression1
Up to 20% of all adolescent suicide attempts are attributable to CSA; CSA victims are 8X more likely than non-abused counterparts to attempt suicide repeatedly in adolescence2
Adolescents with sexual-abuse-related PTSD also have more high-risk sexual behaviors as adolescents3
Trauma survivors with PTSD are more likely to report health problems than those without PTSD4 (Schnurr & Green 2004) making it a public health problem.
1 Diamond et. al., 2001 3 Stiffman, 19922 Brown et. al, 1999 4 Schnurr & Green 2004
Initial Level of Borderline Symptoms as a Function of Trauma
Risky Behavior by Trauma History
With Standard (DBT)
Although showing decreases in PTSD over time, a significant proportion (56.7%) of patients with histories of childhood abuse still met clinical criteria for PTSD on the CPSS at the time of program discharge
Patients with a history of childhood abuse/maltreatment showed relatively less change in PTSD scores then their non-abused counterparts
Many of our patients with trauma histories reported using BPD criterion behaviors as way to manage their PTSD symptoms and traumatic memories
Overall this data suggests that childhood trauma may play a pivotal role in the genesis of BPD and increase the intractability of PTSD
Effectiveness of Standard DBT for BPD+PTSD
DBT is the most empirically supported treatment available for SI and NSSI, particularly among individuals with BPD1,2
In recent study of DBT for suicidal BPD women, however, only 13% of clients with co-occurring PTSD achieved full remission after one year3
DBT alone has not been shown to help achieve remission of PTSD as an Axis-I diagnosis, either with or without SI/SB/NSSI4,5
1 Harnad, Comtois and Linehan, 2010 4, (Feigenbam et. al.,2 Harned & Linehan, 2008 5Harnad-Invited Chapter, in preparation)
3 Harned et. al., 2008
Suicide and Self-Injury in BPD
Among inpatients with BPD, 70% have multiple episodes of NSSI and 60% report multiple suicide attempts1
BPD clients with PTSD engage in more NSSI than those without PTSD2
The rate of completed suicide among individuals with BPD is estimated to be 8-10%3
Clients with BPD+PTSD are more likely than those with BPD alone to report a variety of trauma-related cues for self-injury4
Relationship betweenCSA and NSSI may be mediated by the PTSD symptom clusters of re-experiencing and avoidance/numbing5
1 Zanarini et. al., 2008 4 Harned, in press2 Harned et. al., 2010 5 Weierich & Nock, 20083 Linehan et. al., 2000
Treatment Dilemmas for the PTSD/BPD Client with SI/NSSI/SA
Empirical support is robust for Cognitive Behavioral Therapy (CBT) with Prolonged Exposure (PE) as treatment of choice for both adults and adolescents with PTSD1
Pendulum of treatment swung in the late 90’s to exclusion of individuals with SI, SB or NSSI from established PTSD treatments involving activation of trauma memories2
Current practice guidelines stipulate, "if significant suicidality is present it must be addressed before any other treatment is initiated”1
Left unanswered how to treat adolescents with self-injury, SA, Dissociation and PTSD that is moderate to severe and intractible to other interventions.
1 Foa et. al., 20092 Stirman, 2008
Current Exclusion Criteria for Prolonged Exposure (PE)Treatment *
Imminent threat of SB or Homicidal Behaviors
Serious NSSI in past three months Current psychosis High risk of being assaulted from
environment Lack of clear/sufficient memory of
trauma Substance abuse Severe Dissociation
*Foa et. al., 2009
Evidence for DBT as ‘Primer’ Treatment for BPD+PTSD
DBT is efficacious in reducing suicidal/NSSI behaviors in clients with BPD/PTSD1
Using this approach for clients with BPD/PTSD, both imminent self-injury and imminent suicide risk decreased over a one year period2
BPD+PTSD clients showed a significant decrease in severe dissociation and substance dependence decreased from pre-to-post treatment2
Among BPD+PTSD clients who became eligible for exposure treatment, the majority (82%) still continued to meet criteria for PTSD
Some BPD patients are unable to stop target behaviors until their PTSD is resolved; challenge is to find ways to safely make PTSD treatment available to these clients.
1 Harnad & Linehan, 2008 2 (Harnad et. al., 2010)
Integrated Treatment: DBT+DBT/PE Protocol
Provides integrated treatment for BPD and PTSD
Focus is specifically on BPD + self-injury
Uses standard DBT in combination with PE for PTSD
Recent evidence shows that treatment is feasible with no worsening of target/safety behaviors or increased drop-out from treatment.1
Remission rates comparable to those found in meta-
analysis of exposure treatments to PTSD on single-diagnosis populations.
1 Harnad, 2011
An Integrated DBT /PE Treatment Approach:Further Modifications for Adolescents with
BPD+PTSD
Dialectical Behavior Therapy Prolonged Exposure Protocol Prolonged Exposure Protocol (Harned et. al., 2012))
Eligible patients completed 2-5 exposures per week Baseline PTSD symptoms Developed an exposure hierarchy focusing on imaginal
exposures
During exposures Pre and post-exposure SUDS were measured Pre-and-post ratings were done for the primary emotions, urges
for self-harm and Radical Acceptance
Aims: (a) changes in PTSD symptoms and (b) changes in levels of rated emotions, urges and cognitions
Importance of Parental Involvement
Parents are key sources of information about patient, trauma history and family functioning
Parents/Family should receive education about PTSD and be enlisted to support patient in recovery
Issue of patient’s confidentiality/privacy should be directly addressed with both patient and family
Use joint meetings to develop contract for ongoing family involvement including detailing specific role in crisis management, homework/hierarchy completion and treatment meetings.
Stress the Importance of joint exposure and skill development in instances of family trauma/loss
Final Points
Trauma is present in many patients with BPD
PTSD worsens the prognosis and symptoms expression in BPD
PTSD does not remit in a non integrated DBT+PE treatment
Data suggests that very suicidal BPD patients with trauma can treated far sooner than we ever imagined!
Future Directions for BPD Future Directions for BPD ResearchResearch
Future Directions for BPD Future Directions for BPD ResearchResearch
•Early identificationEarly identification
•PreventionPrevention
•Involving families (e.g,. Family Connections)Involving families (e.g,. Family Connections)
•TreatmentTreatment
•NEABPD Think Tank 2014 and beyondNEABPD Think Tank 2014 and beyond
•Early identificationEarly identification
•PreventionPrevention
•Involving families (e.g,. Family Connections)Involving families (e.g,. Family Connections)
•TreatmentTreatment
•NEABPD Think Tank 2014 and beyondNEABPD Think Tank 2014 and beyond
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