Dialectical Behavior Therapy: Stage I Treatment for Trauma

1. Dialectical Behavior Therapy: Stage I Treatment for Trauma COMBAT Conference Kansas City, Missouri Ronda Oswalt Reitz, PhD Missouri Department of Mental Health

2. Helping people find lives worth living through relentless compassion and effective behavior change strategies.

3. What is BPD? • 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”

4. BPD is Common • 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

5. BPD is often Lethal • 70-75% have a history of at least one self-injurious act • Suicide rates for BPD are 9% • Those with history of self-injurious behavior have at least double the risk of completed suicide

6. BPD is Expensive One Year Health Care Costs Per Patient Estimated for Treatment as Usual (TAU) Individual Psychotherapy 2,915 Group Psychotherapy 147 Day Treatment 876 Emergency Room Care 56 Psychiatric Inpatient Days 12,008 Medical Inpatient Days 1,094 17,609 Behavioral Tech, LLC 2003

7. How Much Overlap in BPD and PTSD is There? N BPD/OPDBPDOPD Golier et al, 2003 72/108 25%* 13%* Yen et al, 2002 153/305 51%* 29% (w/trauma) Zanarini et al, 1998 379/125 56%* 22%

8. Does Trauma Cause BPD?Prospective Research 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

9. Reconsidering the Relationship between BPD and PTSD 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

10. Alternative Explanations 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

11. Trauma Maintains BPD 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

12. Combat Trauma 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.

13. DBT Reduces Symptoms 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)

14. DBT Reduces Costs TAUDBT Individual Psychotherapy 2,915 3,885 Group Psychotherapy 147 1,514 Day Treatment 876 11 Psychiatric Inpatient Days 12,008 2,614 Medical Inpatient Days 1,094 360 17,609 8,610

15. The Dialectical Behavior TherapyApproach to Treatment • 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.

16. Emotional Vulnerability • 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

17. A Disorder of Dysregulation • Emotional Dysregulation • Interpersonal Dysregulation • Self Dysregulation • Cognitive Dysregulation • Behavioral Dysregulation • 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/over-personalization • Self-harm behaviors impulsive behaviors

18. Bessel van derKolkComplex Trauma Adds a sixth area of dysregulation in complex trauma: Somatic or physiological dysregulation

20. Inclusionary Criteria 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

21. Four Components of DBT • 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

22. Five Functions of a Comprehensive Treatment • Structuring the Environment • Enhancing client capabilities • Generalizing skills to the natural environment • Improving client motivation • Enhancing the capabilities and improving the motivation of staff

23. What Makes DBT Work???

24. What Makes DBT Work? Dialectics Helping clients find true balance in “Both…And” emotion, thoughts, and behavior and/or choices. Teaching them, as well as showing them how live in balance. Validation Acknowledging another person’s reality, “Yes…And” noting that their thoughts, feelings, sensations, and responses are real, and are valid in their own right. Practice, Practice, Practice

25. The Fundamental Dialectic Acceptance Change

26. Resources www. Behavioraltech.org DBT in a Nutshell Research Summary Implementation Models ronda.reitz@dmh.mo.gov