NADA: A Simple Tool to Aid in the Recovery from Borderline Personality Disorder

Libby Stuyt, MD Department of Psychiatry University of Colorado Health Sciences Center Colorado Mental Health Institute at Pueblo May 2014

Borderline Personality Disorder

Borderline Personality Disorder

Etiology

• Multifactorial but extensive research supports the notion that early abuse and neglect is a significant factor

• Early childhood separations, chaotic home environments, insensitivity to the child’s feelings and needs, emotional discord in the family and trauma of varying degrees have all been implicated in the etiology

Consequences of Early Childhood Trauma

• Hippocampus vulnerable to the effects of stress • Reduced hippocampal volume found in adult

patients with borderline personality disorder • Early trauma may promote hemispheric

lateralization and adversely affect integration of the right and left hemispheres ▫ Abused children used their left hemisphere when

thinking about neutral memories and their right hemisphere for frightening memories, control group used both left and right equally regardless of memory content

Failure of Hemispheric Integration

• Reflected in “splitting” – major defense mechanism

• Tend to compartmentalize self and object representations into “all good” and “all bad”

Absence of Secure Attachment

• Difficulty discerning their own mental states or those of others – diminished capacity for mentalization – recognizing that someone else has a different mind from their own

• Almost delusional conviction that their perception is a direct reflection of reality rather than a representation of reality based on their internal belief, feelings and past experiences

Symptoms Include

• Frantic attempts to avoid real or imagined abandonment (reject first before being rejected)

• Highly unstable relationships – over idealizing one minute, devaluing the next

• Rapid mood swings (minute to minute), feelings of emptiness, anger

• Impulsive, self-destructive behavior (risky sex, excessive spending, reckless driving, binge eating, substance abuse)

Neuropeptide Model of BPD Stanley B and Siever LJ Am J Psychiatry 2010;167:24-39

• Low basal opioid levels (leading to chronic dysphoria and lack of sense of well-being) with compensatory super sensitivity of µ-opioid receptors (SIB results in heightened relief of pain and restoration of sense of well-being)

• Dysregulation of oxytocin may distort the reading of social cues, establishment of trust and capacity for attachment

• Vasopressin associated with aggression

Oxytocin attenuates amygdala responses to emotional faces regardless of valence Domes G et al.Biol Psychiatry 2007;62:1187-1190

• 13 healthy, non-smoking males, oxytocin and placebo – intranasally 45 minutes before fMRI sessions, observed pictures of facial affect with different intensity levels

• Higher activation in right amygdala in response to emotional faces compared with neutral faces in placebo condition

• A single dose of oxytocin attenuates right-sided amygdala responses to emotional faces

Substance Abuse Treatment • The most stable predictor of positive treatment

outcomes is retention in treatment • Prevalence rates of Axis II disorders – 70-80%

among drug dependent persons treated inpatient or in residential programs

• Personality disorders (especially ASPD, BPD) are consistently associated with risk for early drop out from all types of substance abuse treatment

Impact of borderline personality disorder on residential substance abuse treatment dropout among men (Tull MT & Gratz KL, Drug and Alcohol Dependence 2012;121:97-102) • Patients with borderline personality disorder

(BPD) are significantly more likely to prematurely drop out of substance abuse treatment

• This study focused on males – 159; 34 with BPD • Found that BPD significantly predicted

treatment dropout (38.2% versus 16% of those without BPD)

• Particularly true in center initiated treatment dropouts (26.5% versus 6.4%, p<0.01)

NADA and Self-Injurious Behavior • Nixon MK, Cheng M, Cloutier P. An open trial of auricular

acupuncture for the treatment of repetitive self-injury in depressed adolescents. Canadian Child and Adolescent Psychiatry Review. 2003;12:10-12. ▫ 9 adolescents, NADA treatments once a week for three weeks with

metallic balls on tape on all five points after needles ▫ Comparison of baseline frequency of SIB and urges to one week

and four weeks post treatment, also BDI, HDRS, STAXI ▫ Significant reduction in SIB at 1 week (p=.004), and at 4 weeks

(p=.03) ▫ No change on depression rating scales but significant reduction in

internalizing anger scores ▫ “I felt as if the stress was relieved.” “I was calmer and didn’t have

any urges (to self injure).” treatments “three times per week would be better.”

Circle Program

• 90-day inpatient dual diagnosis program • We have had a different experience • We are mandated to treat those who have failed

everything else • We have really good success with people with

borderline pd • Used outcome study to explain this

Optimum Treatment Components • Because they come from a back ground of chaos they

think this is their “normal” and will seek to create chaos when it doesn’t exist, to feel normal

• They benefit from grounding techniques to experience a “new normal” – anything to increase the parasympathetic tone is helpful

• First step = NADA 5-point ear acupuncture protocol • Then - Dialectical Behavioral Therapy (DBT) – mindful

meditation • Heartmath® • TFT, EFT, BST, Yoga, Tai Chi

Medications • Should be seen as an aid only • Pills often used as “transferential objects” (avoid

benzos and opiates – “iatrogenic addiction”) • Naltrexone – self injurious behavior - +/- benefit • Mood stabilizers • Antidepressants • Antipsychotics • My goal is to reduce medication and discontinue

if at all possible (remove external locus of control – encourage internal locus of control)

Circle Program Outcome Study

• 231 patients, 78 with borderline personality disorder, 37 patients with antisocial personality disorder and 49 with no personality disorder or marked personality traits

• 98% of those with no Axis II diagnosis successfully completed program

• 87 % of those with BPD completed (13% dropout)

• 59% of those with ASPD completed (41% dropout)

Borderline PD patients and Acudetox sessions

• 49 females – 83% completed program ▫ 44 (90%) of those completing used acudetox Average number of sessions = 12 ± 8

▫ 7 (70%) of those not completing used acudetox Average number of sessions = 6 ± 6

• 19 males – 100% completed program ▫ 18 (95%) used acudetox ▫ Average number of sessions = 14 ± 9

NADA helps with

• Distress tolerance • Anger/acting out • Developing therapeutic alliance • Improved motivation to engage in treatment

Acupunct Med doi:10.1136/acupmed-2014-010540 Ear acupuncture for co-occurring substance abuse and borderline personality disorder: an aid to encourage treatment retention and tobacco cessation

0

20

40

60

80

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120

LOS

-5 0 5 10 15 20 25 30 35acudetox sessions

Y = 48.441 + 1.592 * X; R^2 = .155

Regression PlotSplit By: tobacco p txCell: plans to smoke

0

20

40

60

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LOS

-5 0 5 10 15 20 25 30 35acudetox sessions

Y = 84.307 + .137 * X; R^2 = .01

Regression PlotSplit By: tobacco p txCell: wants to quit

p=.001

Length of stay (LOS) in days in the program by number of acudetox sessions compared with attitude about tobacco use

after discharge

p=.2714

Cell: Plans to use tobacco as soon as possible N=67

Cell: Wants to stay quit from tobacco N=126

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2

4

6

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12

14

Antisocial PD N=37

Borderline PD N=78

no Axis II N=49

6 7

11

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13 12

aver

age

nu

mb

er o

f ac

ud

etox

ses

sion

s Program completion by acudetox sessions

did not complete

completed program

0%

10%

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30%

40%

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60%

Sober and doing well

Deceased Incarcerated Relapsing

54%

3%

24% 19%

55%

2%

18%

25%

Status at end of year follow-up

Total Group N=140

Borderline PD N=51

60%

69%

28%

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Not using tobacco on admission

N=20

Resumed tobacco use after

treatment N=102

Quit tobacco use in treatment

N=18

months

Per

cen

t

Tobacco Use

Quitting tobacco in treatment improves the ability to maintain sobriety one year after tobacco-free substance abuse treatment

Relapsed to drugs/alcohol

Average time to first relapse in months

p=.0115

p=.008

Those with BPD more likely to quit tobacco use • BPD – 12% not using tobacco on admission, 33%

not using tobacco at the end of year • ASPD – 6% not using tobacco on admission, 12%

not using tobacco at end of year • No Axis II – 23% not using tobacco on

admission, 29% not using tobacco at end or year • Those not using tobacco at end of year had more

acudetox sessions in treatment – 15 ± 9 vs 12 ± 8 sessions in those still using tobacco (p=.04)

Management Tips

• Because their boundaries were always blurred growing up – they are constantly seeking what the boundaries are

• Establish boundaries immediately but remember that the boundaries need to be consistent and flexible

• Provide a secure base and give support and encouragement, establish realistic expectations and give feedback (positive and negative)