Dr Michaela SwalesConsultant Clinical Psychologist, BCUHB

Senior Lecturer, North Wales Doctoral Programme in Clinical Psychology, School of Psychology, Bangor

University

Treatment of BPD NICE (2009) � No pharmacological treatments recommended;

polypharmacy named as a problem

� Hospitalisation not recommended except for acute exacerbations of suicide risk and then only brief admissions with specific goals

� Cautioned against use of brief, unimodal psychological interventions especially where presentations more severe

� Recommended multi-modal interventions delivered by a coherent team following a clear theoretical model that encompassed supervision

� Recommended considering DBT where SH reduction is a treatment priority in adult women

DBT for young people� Practice-based evidence

� Six studies:

� Miller & Rathus 2002

� Trupin et al 2002

� Katz et al 2004

� McDonnell et al 2010

� James et al, 2008

� James et al 2011

Miller & Rathus 2002� 111 adolescents, 12 week programme� Two-arm, parallel study: DBT versus TAU (weekly

individual and weekly group). DBT group more severe at admission

� Pre and post measures� DBT group had lower drop-out rates and significant

decreases in:� Suicide ideation� Global Severity Index� Life Problems Inventory

� DBT=TAU� Suicide attempts

Trupin at al 2002� 90 female adolescents in Juvenile Detention Centre. 4

week DBT programme.

� Compared with educational, vocational and recreational programme

� Three arm, parallel pre / post-test design

� Decrease in behaviour problems in mental health DBT programme but not in the ‘general population’programme

� Levels of staff training differed on these two units

Katz et al 2004� Inpatient study

� 62 adolescents randomised to different units on admission. 2 wk DBT programme

� Two-arm parallel pre / post test design

� DBT group had a lower drop out rate

� DBT=TAU� Length of stay (18 days av)

� BDI

� KHS

� SIQ

McDonnell et al 2010� Retrospective case controlled study

� 106 consecutive admissions to long-term psychiatric hospital in the USA compared to a group of historical controls for those with the highest rate of NSIB

� Adolescents receiving DBT had statistically significant increases in overall functioning and decreases in number of psychotropic medications and NSIB.

� Adolescents who received DBT less likely to engage in NSIB relative to historical controls.

James et al 2008� 16 female adolescents in an out-patient setting. Drop-

out rate 12%

� Beneficial effects of DBT in terms of:

� Reduction in self-reported depression & hopelessness

� Decreased episodes of self-harm

� Increase in general functioning

James et al 2011� 25 (22 F) adolescents in a Children Looked After Service

aged 13-17. 7 dropped out (2 immediately and 5 after pre-treatment)

� Modified programme with strong emphasis on engagement and motivation incorporating techniques from outreach services / residential programmes

� Skills training for staff, carers, schools

� Completers had significant reductions in depression, hopelessness and frequency of self-harm and increased global functioning. Improved social functioning also evident

� At end of treatment 14 had stopped harming altogether

Evidence Summary� For adolescents, evidence base is extremely limited

� Indicates only that DBT may be a helpful model in routine practice settings

� Many confounds within the studies

� Properly conducted RCT with minimal confounds required

� Current RCT in Oslo in Norway has almost completed recruitment (Larsson, Grohult & Mehlum, 2006)

Issues in treating BPD� Conceptualising personality disorder

� Structuring treatment for therapists and service users

� Comprehensively treating the young person’s problems

� Keeping the young person in treatment

� Keeping the therapist therapeutic

� Process of treatment

� Dialectical balance

� Comprehensive problem-solving

� Generalisation of behavioural change

Case Conceptualisation in DBT

Development of borderline

behaviour patterns� Biological / emotional vulnerability

� Sensitivity

� Reactivity

� Slow return to baseline

Invalidating environments� Indiscriminate rejection of communication as valid

� Adolescent learns to self-invalidate

� Intermittent reinforcement of emotional escalation� Adolescent learns to oscillate between emotional inhibition

and extreme emotional styles

� Oversimplifying solution of problems� Adolescent learns to respond with high negative arousal to

failure, form unrealistic goals and expectations and hold perfectionist standards

Diagnosis of BPD: reframed� Emotional Dysregulation

� Affective lability

� Problems with anger

� Interpersonal Dysregulation

� Chaotic relationships

� Fears of abandonment

� Self Dysregulation

� Identity disturbance

� Sense of emptiness

Diagnosis of BPD: reframed� Behavioural Dysregulation

� Suicidal and self-injurious behaviours

� Impulsive behaviour

� Cognitive Dysregulation

� Transient stress-related paranoid ideation or severe dissociative syymptoms

DBT conceptualisation of BPD� Capability deficits

� Motivational deficits

� Particular difficulties in the management and experience of affect

� Leads to regulation difficulties in:� Interpersonal relationships

� Sense of self

� Behavioural control

� Cognition

Programmatic Structure of DBT� Multi-function treatment

� Treats multiple problems / diagnoses

� Structured into stages

� Explicit focus on targeted behaviours

With adolescents:

� Involvement of family / carers

Comprehensive Treatment� Enhance capabilities

� E.g skills training groups

� Enhance motivation� DBT individual psychotherapy

� Assure generalisation� E.g. between-session skills coaching

� Structure the environment� Programme management

� Enhance therapist capabilities and motivation� Consultation Team

Modifications to Modalities for adolescents

� Skills training: - Briefer course- Fifth module: ‘Walking the middle path’

� Generalisation: - Family included in skills training

� Structure environment: - DBT informed family therapy- Between session family coaching

Targeted Treatment� Stage 1

� Life-threatening behaviours

� Suicidal / parasuicidal / homicidal behaviours including threats and urges

� Therapy-Interfering behaviours

� On the part of both the client and therapist

� Quality-of-life interfering behaviours

� Other Axis 1 disorders

� Seriously destabilizing behaviours

A Community of Therapists treating a

Community of Patients

TaskAssumptionsAgreements

Treatment model

Principles of Treating the

therapist

�Adhere to all consultation team agreements� Fallibility

� Dialectical

� Phenomenological empathy

�Obtain precise behavioural definition of the problem

�Remain mindful� Non-judgemental

� Awake to interpretations / assumptions - always assess never assume

�Validate the therapist

�Apply the full force of the treatment

Using the Team to Treat the

therapist

� Therapist experiencing burnout with a client who repeatedly rejects solutions suggested by the therapist

� Therapist decides to use exposure to treat unwarranted shame but avoids implementing the procedure as he is afraid the client will become more suicidal

� Therapist repeatedly late or missing for team consultation

Balance Treatment StrategiesChange

�Problem Solving�Skills

� Emotion regulation� Interpersonal

effectiveness

�Irreverence�Consultation-to-the-

patient

Acceptance

�Validation

�Skills� Mindfulness

� Distress Tolerance

�Reciprocity

�Environmental intervention

Treating variables that lead to high risk behaviours

Prompting event

Vulnerability FactorsTarget behaviour

Consequences of the behaviour

Links in the chain – affect, cognition, behaviour, bodily sensations

Problem- Solving 1� Behavioural Analysis:

� Establish the sequence of events in the chain

� Affective links

� Cognitive links

� Behavioural links

� Classically conditioned links

� Establish the consequences of the behaviour:

� What is the function of the behaviour?

� To the therapist the behaviour is the problem; for the client, the behaviour is the solution

Chain Analysis� VF: poor sleep, restricted

eating, argument with peer

� PE: Text from Mum cancelling a visit

� Sadness (3/5)

� ‘She always cancels’

� ‘We are never going to have a good relationship

� Sadness (5/5)

� Withdraws to room, curls up on bed

� ‘Its all my fault. All the things I’ve done’

� Shame (5/5)

� Ties ligature

� Shame

� Lightheaded ‘buzz’

� Staff find her, cut ligature

� Obs level

� Mum visits next day

Problem-Solving 2� Solution Analysis:

� Replace problematic links in the chain with more functional / effective behaviours

� Skills

� Treat problematic links

� Contingency management

� Exposure

� Cognitive modification

� Teach and troubleshoot new solutions

� Obtain commitment to implement

� Reinforce and shape approximations to more skillful behaviour

Solution analysis� VF: poor sleep, restricted

eating, argument with peer

� PE: Text from Mum cancelling a visit

� Sadness (3/5)

� ‘She always cancels’� ‘We are never going to

have a good relationship� Sadness (5/5)

� Sleep hygiene routine, meal plan, interpersonal effectiveness

� Phone Mum. Interpersonal skills

� Experience sadness, exposure to cues eliciting sadness

� Mindfulness / Cognitive restructuring

� Act opposite to action urge� Do something that gives a

‘buzz’

Solution analysis� Withdraws to room, curls up on

bed

� ‘Its all my fault. All the things I’ve done’

� Shame (5/5)� Ties ligature� Shame � Lightheaded ‘buzz’� Staff find her, cut ligature� Obs level � Mum visits next day

� Stay in lounge, socialise with peers, speak to staff, ask for more support (chat with staff, increased obs, PRN)

� Mindfulness / Cognitive restructuring (self validation) / Radical acceptance

� Act opposite to curling up� Dispose of means� Intervene with positive reinforcers

(staff intervention; Mum visiting) earlier

� Extinguish positive reinforcers: do not increase obs; block Mum from visiting after self-harm

� Add positive punishers (e.g. problem-behaviour protocol)

Shaping new behavioural

repertoires� Skills acquisition

� Skills training groups

� Skills strengthening� Individual therapy

� Generalisation� Telephone consultation

� Separating these functions out may be especially important in BPD because affective dysregulation provides a variable intra personal context for learning

Summary� Principles in treating severe BPD / repetitive self-

harm:� Coordinated structured programme

� Lower case loads, high-intensity treatment

� Treatment team with clear leadership, shared model & well supervised

� Capacity to tolerate and treat high risk behaviours

� Supportive organisational structure

� In adults PD impacts on treatment outcome

� Whether assessing for PD in adolescents will improve treatment outcomes is unknown