New Treatments For BPD an Easy to Understand Detailed Overview (2012-2013) Part 1

(I will try to keep updating this as time goes by & new studies are published...)

*2012 Video update Coming Soon!* It will include the latest scientific info from review papers on RCTs on drugs & therapies for BPD (more recent than Wikipedia,which I plan to update after I've finished the video) You can subscribe to my YouTube to know when I've uploaded it http://www.youtube.com/user/ROMI1AAT
But here is a sneak preview while I'm finishing

Artist-Ferian Moon

We will be looking at Long & Short –Term Treatments like:

DBT (Dialectical Behaviour Therapy)
MBT (Mentalisation Based Treatment) (partial
hospitalization & outpatient)
SFT (Schema-Focused Therapy)
TFP (Transference-Focused Psychotherapy)
STEPPS (Systems Training for Emotional Predicatibility & Problem Solving)
GPM (General Psychiatric Management)
DDT(Dynamic Deconstructive Therapy)
NET (Narrative Exposure Therapy)

DBT-ACES (Accepting the Challenges of Exiting the System)
Drug Treatment,ECT & Alternative Treatments

Artist-Rahmennoodlez

The following therapies that will be described were effective at reducing core BPD symptoms (eg.emotional instability,irrational/intense anger, suicidal behavior,self -harm) & associated mental health problems (such as depression and anxiety)

According to a review of 28 randomized controlled trials *called "Psychological therapies for people with borderline personality disorder"(Cochrane Library)

The most effective therapies (they have the most solid evidence) long-term treatments for BPD are:

1. DBT (Dialectical Behaviour Therapy) then

2 .MBT (Mentalization Based Therapy) (partial hospitalization & outpatient)

3. SFT (Schema-Focused Therapy)

4. TFP (Transference-Focused Psychotherapy)

Dialectical Behavior Therapy (DBT) 

DBT was shown to help with :

(statistically significant findings)

self-harm

inappropriate anger

suicidality

depression

anxiety

general functioning

BPD severity

para-suicidality (making half-hearted suicide attempts)

Dialectical Behaviour Therapy (DBT) is a weekly individual & group therapy. Dialectical means 2 opposite things can exist at the same time. The focus is on accepting your faults while recognizing that changes like learning better coping skills need to be made to improve quality of life.

Stage 1 focuses on:

 decreasing life threatening behaviors

 (suicide,parasuicide acts,plans,threats…)

 behaviors that interfere with therapy

(missing sessions/coming late,not returning calls)

quality of life threatening behaviors

(eg.depression,substance abuse,homelessness,chronic unemployment)

Increasing skills (4 skill groups will be described soon) that will replace ineffective coping behaviors.

move from behavioral dyscontrol ->  behavioral control.

Stage 2

You learn to emotionally experience life in a more positive way.

Goal- Move from suffering “in silence”/ emotionally shut down to experiencing emotions fully(becoming used to feeling strong emotions instead of suppressing/avoiding them)

Past trauma and PTSD are treated.

The BPDs negative thinking about themselves are challenged (self invalidation, self stigmatization)

Stage 3

Focuses on problems in living, with the goal being that the client has a life of ordinary happiness and unhappiness

Stage 4

Goal-to move from a sense of incompleteness towards a life that has the ability to have continuous experiences of joy & freedom.

PLEASE NOTE that not all stages may be offered.

Stage 1 is the most commonly offered stage especially in the

National Health Service (NHS) in the UK

My own art-feel free to use,no copyright

The skills focus on :
Affective (emotional) instability
Behavioural instability
Interpersonal (relationship) instability


There are 4 main groups of skills:

1.Distress Tolerance

2.Mindfulness

3.Emotion Regulation

4.Interpersonal Effectiveness


1.Distress Tolerance

Learning how to get through a crisis without making it worse using skills to reduce your suffering (eg.self-soothing,distraction,relaxation, coping statements...)

2.Mindfullness (meditation)

Focusing on the moment without judging it,so that there will be less focus on the painful past or worrying future events. It creates a balance between the emotional and reasonable mind so that you enter "wise mind".Attention is brought to physical sensations, actions,emotions & thoughts in the present moment without judging/criticizing them 

It helps with:

anxiety

binge eating

distress tolerance

reduces the chances of having another depressive episode 

3.Emotion Regulation

Helps you recognize what you feel without being overwhelmed by the emotion(s).This helps you cope with reactions in a healthy way.You also learn things such as how to reduce vulnerabilities so you can decrease the intensity of emotions,increase positive emotions,emotion exposure to reduce fear of emotions,doing the opposite of your negative emotional urges,looking at behavior that leads to emotional outbursts...

4.Interpersonal Effectiveness

You learn relationship/social skills in areas such as limit setting,listening,expressing your beliefs and needs,problem solving/how to cope with conflict in effective ways,reducing fear of abandonment,how to keep a healthy relationship,learning from problem interactions

DBT also helps to reduce symptoms of :

Substance Dependence 87%

Major Depressive Disorder (MDD) 68%

Eating Disorder 64%

and to a lesser amount Anxiety Disorders

Artist-Rosary of Sighsx  

Mentalization Based Therapy (MBT)

MBT was shown to help with :

Partial Hospitalization : suicidality,parasuicidality(making half-hearted suicide attempts),interpersonal problems,depression

Outpatient: suicidality, parasuicidality,depression,general functioning,relationship problems,general psychopathology (general mental illness/ problems)

Schema Focused Therapy (SFT)

SFT group therapy was shown to help with :

impulsivity

BPD severity

general functioning

emotional instability

dissociation/psychosis

overall mental health status

interpersonal (reationship) problems,general psychopathology (general mental illness/problems)

GPM (General Psychiatric Management)

A strict control condition used in studies.It is is usually delivered once a week for one year by trained therapists.

 It can be made up of the following parts:

• psychodynamic psychotherapy .The therapy tries to create a “containing environment” within which patients can learn to trust and feel

• case management-a professional helps assess what treatment(s) are needed,planning & review of the treatment

•  prescribed mediaction usually based on symptoms but mainly for treating mood lability,impulsivity & aggressiveness, as presented in the APA guideline(which are outdated at the moment)
• family interventions as needed

GPM is as effective for treating BPD as DBT for pathology-related outcomes but could be more easily available as it is less theory-bound and easier to learn.It helps with reducing: BPD symptoms (including remission- meeting no more than 2 criteria for BPD for 1 year in this study.),self-harm,ER visits,suicide attempts,anger & depression.

GPM is still not widely available but some therapists have been trained in GPM in Amsterdam,Rhode Island, Massachusetts and Minnesota.

DBT vs GPM

DBT

Skills training-emotion regulation,mindfulness (being in the now,non-judgmental)

Focus on therapy interfering & self-harm

Behaviour strategies-exposure,behaviour analysis,diary cards

Use skills indtead of pills

GPM

Focus on relationships,attachment,

Less focus on self-harm than DBT

Focus on signs of negative transference

Less structured allows patients to talk about what they think is important

 

Common Features

Helping Relationship

Empathy and validation

Focus on :emotions and on the present (here & now)

Therapists attended weekly supervision meetings

Artist-DamaiMikaz 

DBT-ACES is a 2 year outpatient program focused on building a life worth living outside the public mental health system.
The focus is on :

Artist -Tobba

skills training

self-sufficiency

goal setting

problem solving

trouble shooting

dialectics

enforcement

This new intensive program has been designed specifically for psychiatrically disabled individuals with severe BPD to help them to achieve recovery and leave the public mental health system and work/study(take them off disability benefits & help them get a job/go to school).DBT-ACES is provided after standard (“famous” M.Linehan’s) DBT has been finished successfully.

Patients are encouraged to get active during the first year doing something normative(acting like you don’t have emotional problems) and productive(with goals,structured,active,rewarding) outside the mental health system.They gradually increase the number of hours per week spent doing things like voluntary/paid work,socializing,going to a gym…things they didn't do before, to reach their goal of 20 hours of structure activities per week.


During the 2nd year if they meet criteria to be accepted which basically shows they are capable of handling this additional year of DBT and have mastered the skills learnt in the 1st year of DBT ACES.The ACES clients(patients/sufferers) attend weekly DBT classes with 1 skills group per week.These classes focus on decreasing anxiety,depression/other mental health issues,problem solving…

More info on their Facebook & Program Video

Some goals & issues dealt with in DBT ACES :

• Keep the things that were gained during DBT (reduced self- harm,suicide attempts,inpatient hospitalization & ER visits…) 
• Set up independent living,re-employment 
• Increase quality of life (rated by the BPD) 
• How to handle & prevent relationships problems at work 
• Be a member of an organized active recreational activity 
• that is fun/meaningful
• Building a life outside work with friends who share similar values & at least 1 person who they can have casual interactions with, at least 1 person who is supportive & who they can be intimate with,discuss private issues...who is not their therapist  
• Disengage(withdraw from)relationships with  friends/family that are destructive/ineffective,choosing relationships that are compatible in lifestyle, needs & 
• values, to have an effective romantic relationship if they want one.
• Self-sufficiency-having a budget & savings before finding a job for safety. 
• Have effective methods for managing chronic pain- so it doesn't have a big impact on quality of life/preventing psychiatric symptoms from affecting functioning.
• Learning how to be your own therapist 
• Time management

Recovery Through Poetry,Artist-Unrealityxx

Artist-Unrealityxx

Lasts about 3 months

Helps with BPD severity, anger, affective instability, impulsivity, dissociation, depression and anxiety with moderate to very large effects.


2hours a week of skills coaching where you learn mindfulness,acceptance,change,emotional regulation,distress tolerance & interpersonal effectiveness)

 

Emotion Regulation Group Training (ERG)

Lasts about 3.5 months.ERG combines parts of DBT and Acceptance and Commitment Therapy (ACT),emotion-focused and behavioral therapy.

It showed encouraging results for improvement of BPD severity, affective (emotional) instability,impulsivity, parasuicidality,depression and anxiety.

Artist-Blackmustang13

STEPPS was shown to help with interpersonal problems, dissociation and mental health status .STEPPS with IT (individual therapy) was shown to help with general psychopathology.The individual therapy with STEPPS is an add-on where its purpose is to help re-enforce the newly learnt skills and to encourage BPDs to use them into their daily life. The STEPPS group remains the main therapy.

There was a tendency for the combined treatments of STEPPS and IT to have better outcomes but the differences were not significant.

STEPPS follows a manual containing weekly lesson plans for 20 two-hour weekly group meetings led by two co-therapists. It combines cognitive-behavioural elements and skills training (like DBT)with a systematic approach by involving the BPD’s relatives and other treatment provider(therapist…) Each session has a specific emotion and behavior management skill. BPDs monitor thoughts, feelings, and behaviors during the course of the program. This allows them to recognize and (monitor) keep track of changes in their emotional ups & downs.

The goals of STEPPS are to educate family members, friends and health care professionals about BPD, giving them guidance on how to interact effectively with the BPD sufferer using the STEPPS approach and terminology (specific STEPPS language).The program is designed to be combined with other treatments, such as medication or individual psychotherapy.

STEPPS has been put in place in many locations such as Argentina, Australia, Canada, Italy, the Netherlands, New Zealand, Norway, Spain,the United States and the United Kingdom.

Artist-Archangelmetatron

Artist- Omigosh-joo-n-zoey

Manual Assisted Cognitive Training (MACT)
MACT was shown to help with suicidality & para-suicidality.It is a 6 week treatment based around a self-help book.

Common Features of Therapies that make them Effective

In areas where DBT,MBT,SFT,TFP…are not available/limited common features of therapies can be used to help.

Good therapists need to be active ,non-reactive and maintain consistent expectations of change and participation from the BPD.

Structured-the therapy has a structured manual that supports the therapist and provides recommendations for common clinical problem.The structure encourages increased activity,pro-activity ( taking control of situations by causing something to happen rather than waiting to respond to it after it happens such as planning Christmas shopping so you won’t get very stressed at the last minute)

A respectful, supportive ,cooperative, open and non-judgmental relationship with

the BPD

Encourages a powerful attachment relationship between therapist and patient (trust and closeness with the therapist), where they validate the BPD’s distress, listen to the BPD & show empathy.This helps BPDs recognize and accept themselves as unique and worthy.

Therapists are supervised for managing counter transference (their repressed feelings in reaction to the emotions, experiences, or problems of the patient)

Has a model of pathology (disease)  that is carefully explained

An atmosphere of hope and optimism

Specialized for BPD-  clearly focused e.g. on problem behaviour such as self-harm or a relationship pattern…

Progress is monitored using goals (more functioning,less symptoms)

Focusing on the patient’s mind, rather than his or her behaviour and helping the patient understand what lies behind maladaptive behaviour

Has a crisis plan and contracting

Mentalizing (more about that later)

 Things to keep in mind

Patients with borderline personality disorder (BPD) tend to have strong placebo responses to medication; thus, impressive short-term improvement might occur and unexpectedly fade.Benzodiazepines are not recommended because they reduce inhibitions and are likely to increase impulsivity and because BPDs are likely to get addicted to sedatives.

Choosing the right treatment for your symptoms

If you are lucky enough to be able to choose from different treatments it is best to choose one based on which symptoms & other diagnoses you have.

The authors examined three yearlong outpatient treatments for borderline personality disorder: dialectical behavior therapy, transference-focused psychotherapy, and a dynamic supportive treatment.The results:

Patients in all three treatment groups showed significant positive change in depression, anxiety, global functioning, and social adjustment across 1 year of treatment.

Transference-focused psychotherapy and dialectical behavior therapy were significantly associated with improvement in suicidality.

Transference-focused psychotherapy and supportive treatment were associated with improvement in anger and improvement in facets of impulsivity

Only transference-focused psychotherapy was significantly predictive of change in irritability and verbal and direct assault.

more info about the study : http://ajp.psychiatryonline.org/article.aspx?articleID=98504&atab=7

BPD with PTSD

Narrative Exposure Therapy

Artist-Emily Raczelowski

Narrative Exposure therapy can improve borderline symptoms for patients with co-morbid (also present) Post Traumatic Stress Disorder (PTSD) in about 11 to 19 sessions (depends on the traumas...)even in not so ideal places such as psychiatric wards.It also helps people who just have PTSD.

Dialectical Behavior Therapy with Prolonged Exposure

Artist-MauserGirl

This new therapy brings together an evidence-based treatment for PTSD Prolonged Exposure Therapy with Dialectical Behavior Therapy in a way that is safe, effective, and personalized to the specific needs of the BPD sufferer with PTSD.

A very small study in which 13 women with BPD & PTSD who had recent or approaching future serious intentional self-injury. These subjects had an average of 7 psychiatric diagnoses, and the most common index traumas were childhood sexual abuse (62%) and adult rape (15%).A complete course of DBT lasts for 1 year (with individual and group therapy). Prolonged Exposure was added only after subjects had completed enough Dialectical Behavior Therapy to meet the investigators’ criteria for starting PTSD treatment, including a requirement that patients did not have any suicidal and self-injurious behaviors for at least 2 months. Patients met these readiness criteria after an average of 18 weeks of therapy. The average length of the Prolonged Exposure protocol was 13 sessions, and 70% of patients didn't drop out of the treatment.

The rate at which symptoms reduced from PTSD in this study was 71% for those who completed the Prolonged Exposure protocol, and 60% in the sample overall. The rate of suicide attempts and self-injury in this sample was low (27%)during the year of therapy.Studies on DBT with similar populations have typically found that 60%–80% of patients have at least one episode of self harm during treatment.

BPD Treatment with Medication(s)

Click On The Charts To Make Them Bigger-> FGA-1st generation anti-psychotic   SGA-2nd generation anti-psychotic 

 

 

 

Medication for Crises

There is very little research on this,sedatives (such as a sedative antihistamines) are sometimes used for the short-term (1 week maximum) because of  low risk of  side-effect, addiction and relative safety in overdose,the NICE guidelines list this option for crises.

 

 Sleep Disturbances Short-Term Drug Treatment

Some BPDs have found the occasional use of sedative antihistamines useful when sleeping problems are associated with emotional instability.Hypnotic drugs (short-term treatment) may be used for severe insomnia.(See NICE insomnia guidelines for treatment information) 

 

Electroconvulsive Therapy (ECT)"Shock Therapy" for BPD with Major Depression

There is little research on this,but the existing research
suggests that ECT is probably not very effective for
BPDs with co-morbid depression.When compared to
patients with personality disorders other than BPD and
depressed patients with no personality disorder,
patients with BPD (& co-morbid depression) had less
symptom improvement up to 8 days after ECT.

Responses can be no response to significant improvement.Deep brain stimulation may be effective
but there’s little research. Side Effects should be thoroughly discussed !!! These treatments are best when combined with an evidenced based therapy such as DBT and MBT.

Artist-Stellalunaravenwolf    antipretty.com

*
Randomised Controlled Trial (RCT) is a study in which people are divided at random to receive one of several interventions in this case psychotherapies.It is a simple but powerful research method.It is called random because the people placed in each group are divided randomly. eg.Therapy A is compared to Therapy B





1Soloff PH, Lynch KG, Kelly TM. Childhood abuse as a risk factor for suicidal
behavior in borderline personality disorder. J Pers Disord 2002;16:201–14.