Dialectical Behaviour Therapy (DBT)

dbt

Dialectical Behaviour Therapy is a specialized type of talking therapy under the general category of Cognitive Behavioural Therapy (CBT).  This kind of CBT was developed by psychologist, Marsha M. Linehan, in the 1980’s  to especially focus on treating Borderline Personality Disorder (BPD) and has since proven to be a valuable treatment for this particular mental illness.

What does “Dialectic” in DBT mean?

The word dialectic in the term Dialectical Behaviour Therapy refers to the unification or synthesis of two opposing positions, concepts, or realities.  DBT seeks to meld two key concepts that naturally oppose each other:  acceptance and change.

Acceptance refers to coming to terms with who you are—your emotions, experiences, and natural responses.  Change means altering your responses and thoughts toward more positive behaviour and coping strategies in order to reach personal and social goals in becoming a more integrated individual.

People with Borderline Personality Disorder have very heightened negative emotions.  As a result, they are often acutely emotionally unstable and have a tendency toward inflicting self harm and attempting suicide.  DBT seeks to help BPD patients accept their personal liabilities and to help them acquire new behavioural skills to replace their ineffective and damaging responses for achieving emotional stability and personal goals.

Four Stages of Treatment with Dialectic Behaviour Therapy

The end goal of all four stages is to mould the patient toward making their own paradigm shift from feelings of worthlessness to:  I am worth as much as everyone else; life is worth living.

Stage 1:  Achieving Behavioural Control

At the start of therapy, the patient’s condition may be dangerously low—in psychological misery, out of control, and therefore may be self-destructive with drug and alcohol use, sexual promiscuity, or binge eating.  They may also be suicidal with a history of attempts or still at the contemplation stage.  The objective of Stage 1 therapy is to assist the patient into gaining command of his spiralling out-of-control thoughts and behaviour.

Stage 1 is all about setting and achieving three main goals:

  1. Stop suicidal or self-harming behaviour
  1. Rid the patient of obstacles or behaviour that prevent or interfere with therapy — the patient may justify to himself why he does not need to go on with therapy or his family may be embarrassed about his condition and prevent him from getting needed treatment.
  1. Addressing issues that lower patient’s quality of life — Problems like depression, unstable relationships, or being expelled from school may be issues distressing the patient to a volatile degree.

At this stage, the therapist tries to equip the patient with emotion-managing skills so that the patient can disengage from dangerous behaviour and gain some mastery over his negative thought patterns.

Stage 2:  Emotional Experiencing

Although Stage 1 behaviour control has been achieved, the patient continues to suffer quietly.  Their emotional turmoil is usually due to past trauma and invalidated feelings.  For those with Post Traumatic Stress Disorder (PTSD), past trauma is explored and analysed and its accompanying negative beliefs and behaviours, verified.  PTSD is treated at this stage.

The goal of stage 2 is to move the patient past suffering with inhibited emotions and on to a level where they experience their emotions in full.  At this second stage, the therapy involves the following:

  1. The patient is encouraged to remember and accept the traumatic event.
  2. Reduction of stigmatization
  3. Reduction of self-blame
  4. Lowering incidences of negative intrusive and denial syndromes

Stage 2 goals can only be achieved once negative behaviour is under control.

Stage 3:  Learning to Live

Stage 3 focuses on building self-esteem, owning one’s behaviour, creating trust and value for one’s self, and goal setting.  The patient is gradually led toward coming to terms with happy and unhappy events in life, thus enabling him to live life normally.

Stage 4:  Building Capacity for Joy

Some people stop at stage 3 but for others, stage 4 is an important part of recovery.  Stage 4 is all about spiritual fulfilment which helps the patient feel connected to humanity as a whole.  The goal at this stage is to help the patient go beyond just living day to day and be able to incorporate the ability to experience joy and freedom.

DBT-Skills

Scientific evidence has proven Dialectical Behaviour Therapy to be effective in lowering rates of suicides, self-harm, dropouts in treatment, depression, hospitalization, and substance abuse.  DBT has indeed helped many patients to improve functioning and relationships in their personal and social lives.

Personality Disorders

 

personality disorder

Personality disorders are a class of mental disorders that involve the maladaptive way a person acts, feels, thinks, and perceives things which often deviate from normal norms.  These abnormal patterns of cognition and perception are enduring and disrupt an individual’s personal, social, and career lives.

A personality disorder may be diagnosed as such if it falls under the criteria outlined in the mental and behavioural disorders section of the International Classification of Diseases (ICD), published by the World Health Organization.  The ICD is the international “standard diagnostic tool for epidemiology, health management, and clinical purposes.”

Normal Personalities vs. Personality Disorders

Although normal people do behave differently from one another, they still have a set pattern of behaviour and thinking which are fairly predictable and conform to the general accepted criteria.  Normal healthy personalities are flexible enough to adapt to life changes or mistakes.  People with personality disorders on the other hand have limited coping mechanisms and are therefore more inflexible in the face of stress.  Because of the curtailed range of emotions, attitudes, and behaviours,  people with personality disorders often find life changes, whether minor or major, difficult to manage and so that daily life becomes a constant struggle.  Consequently it also becomes difficult for other people to adequately relate to them.

Personality disorders become markedly distinct in adolescence or early adulthood, although these illnesses may have begun in childhood.  Because the affliction distorts perceptions and behaviour, it often makes working with or relating to other people, difficult.  Unstable personalities often feel isolated or alienated because people may seem scary, threatening, or simply not very understanding of the way they see things, for the most part.

Types of Personality Disorders

As the term personality disorder refers to an umbrella malady, there exist many types of mental illnesses under this broad category which are further divided into three sub-categories:

  1. Cluster A

This group tends to exhibit more eccentric or strange behaviours as its constituents seem to exist in a world of their own.  Disorders under this sub-category are:

  • Paranoid personality disorder — characterized by suspicion and distrust.  Paranoid people tend to:
    • read threats where none exists
    • be constantly watchful of signs of hostility and betrayal in other people
    • be mistrustful even of close friends or family
    • often think they are being fooled or being taken advantage of
  • Antisocial personality disorder (ASPD) — characterized by an absence of consideration for other people because these types behave for themselves without regard for other people’s antisocialfeelings or situations.  Antisocial people may show the following behaviour:
    • reckless and impulsive actions without thought about consequences to self and other people
    • may be aggressive, constantly irritable, and may pick fights with others
    • may engage in criminal or illegal actions
    • may truly believe in the survival of the fittest philosophy in which he grabs every opportunity to the detriment of others and even to himself
    • may have had a misdemeanour or disorderly conduct charge before the age of 15.
    • possess no guilt or regret for hurting others and therefore would put his needs over anyone else’s always
  • Schizoid personality disorder — typified by the following characteristics:
    • uninterested in forming close relationships with anyone, including family
    • cold and emotionally distant
    • wants to live alone away from the company of others
    • have little interest in sex or intimacy
    • has a very negative outlook or perception about life
  • Schizotypal personality disorder — manifests weird or aberrant behaviour.  People with this disorder tend to:
    • express themselves unusually like using their own language or vocabulary for certain things
    • believe they have extraordinary powers or gifts such as a sixth sense or future forecasting
    • have extreme difficulty in forming any social relationship, even with a family member
    • behave oddly
    • exhibit paranoia and anxiety in social situations
    • feel tense and nervous around anyone who do not share their beliefs
  1. Cluster B

The Cluster B personality disorder group struggles to control their emotions which often swing erratically between positive and negative moods.  Behaviour from this group is often unpredictable, exaggerated, and disturbing.  Disorders that fall under this group are:

  • Narcissistic personality disorder — symptomised by:
    • an extreme and pervading feeling of entitlement that puts the individual in a rank above others
    • having low self-esteem that needs to be fed by recognition of one’s worth and needs by others
    • selfishness
    • resentment of other people’s achievements and successes
    • having the capacity to take advantage of other people
  • Histrionic personality disorder — A person with this disorder always needs to be the centre of attention and is very needy about getting the approval of others.  A histrionic personality will flirt, seduce, or “put on a show” to get the attention and focus he craves.

 

  1.  Cluster C

This third group struggles with chronic anxiety and fear and therefore manifests antisocial behaviour that is more withdrawn than hostile.  This group includes:

  • Avoidant personality disorder — People in this group are often extremely shy and inhibited because of overwhelming feelings of inadequacy.  Rejection is often a very sensitive spot for people in this category.
  • Dependent personality disorder — typified by extreme passiveness and submissiveness stemming from very low self confidence and severe neediness.  People with a dependency disorder may not be able make their own decisions or function well without help or support.  These people view themselves as so much less capable than others in many aspects.
  • Obsessive-Compulsive Personality Disorder (OCPD) — characterized by the obsessive need for perfectionism.  OCPD is different from Obsessive-Compulsive Disorder (OCD) which is a form of behaviour rather than a personality type.

 

People with a personality disorder may find hope in recovery over time.  What is needed is adequate support and professional help.  Mild to moderate personality disorders may improve with psychotherapy alone.

 

 

 

Antipsychotic Medication

Antipsychotic medications are prescribed drugs used to treat people with some form psychosis.  Psychosis is an umbrella of mental disorders that are characterized by radically impaired emotions and thought patterns, so convoluted that the afflicted person actually loses touch with reality.  These mental disorders include bipolar disorder, borderline personality disorder (BPD), schizophrenia, and paranoia, all of which include the psychotic marks of delusions and hallucinations in their roster of symptoms.

ANTIPSYCHOTIC-DRUGS

How Do Antipsychotic Drugs Work?

Antipsychotic drugs target the neurotransmitters in the brain which are dopamine, noradrenaline, serotonin, and acetylcholine.  These brain chemicals have the main hand in regulating moods, emotions, and behaviour.  Of all these neurotransmitters, dopamine is the most important target.

By changing the effect these neurotransmitters currently have on an individual’s brain, antipsychotic drugs can suppress, reduce, or even prevent the onslaught of:

  • hallucinations (ex. hearing voices)
  • delusions (perceiving things, situations, and events not based on reality.  Ex.  A delusional person may firmly believe that the restaurant waitresses are laughing at him because they know his spouse has been cheating with someone else…even if they do not know him.)
  • Extreme mood swings
  • Thought disorders

What antipsychotics cannot do is cure a patient of his mental disorder.  These drugs can only act on the symptoms not on the entire illness.

Types and Side Effects

Antipsychotic medication was introduced in the 1950s and has to a large extent been successful in alleviating hallucinatory and delusional symptoms in psychotic patients so much so that these individuals have been able to lead a relatively normal life.  Although a boon to the mental health field at that time, early antipsychotics (termed typical) possessed its fair share of mild to severe side effects which manifested as:

  • muscle stiffness
  • tremors and spasms
  • restlessness
  • increased skin sensitivity to sunlight
  • low blood pressure
  • liver poisoning; so with some typical medications, liver tests may be mandatory
  • Parkinson’s disease-like symptoms
  • gastrointestinal disturbance
  • weight loss
  • skin rashes, ranging from mild to serious cases which may develop into Stevens-Johnson syndrome, a life-threatening illness  (rare side effect)
  • spontaneous ejaculation
  • tinnitus (ringing in the ears)
  • vertigo
  • drooling
  • excessive thirst

These typical drugs are still prescribed today because there are patients who tolerate these better than the newer atypical drugs.

Atypical antipsychotic drugs are considered the newbies in its category although the first, clozapine (Clorazil) was formulated over twenty years ago in 1990.  Atypicals have fewer side effects thanantipsychotic meds the older typical antipsychotics and are thus more often prescribed as a first-line treatment.

Most of the atypical drugs were developed for the treatment of schizophrenia and mania.  These are contraindicated for people with cardiovascular problems or with a history of epilepsy or Parkinson’s disease.  Many of these drugs such as risperidone and olanzapine should not be prescribed to older people as they increase the risk for stroke.  Atypical drugs may also compromise cognitive skills such as driving or operating heavy machinery.

The most noteworthy side effect of atypical antipsychotics is weight gain, increased appetite, and other metabolic issues.  Other side effects are:

  • dizziness
  • extreme sleepiness
  • low blood pressure when standing
  • fainting
  • rapid heartbeat (tachychardia); slow heartbeat, irregular heartbeat
  • tardive dyskinesia — uncontrollable movements of the lips, tongue, face, trunk, and limbs.  Usually a side effect of long-term drug use.
  • Parkinsonism
  • insomnia
  • anxiety; restlessness; agitation
  • raised prolactin levels provoking milk production
  • sexual problems
  • seizures
  • indigestion
  • headache
  • lethargy; lack of energy; tiredness
  • drooling
  • impulsive behaviour like gambling (attributable to Aripiprazole)
  • unusual taste sensations
  • numb lips and mouth
  • still muscles
  • raised levels of enzymes in liver
  • loss of menstrual periods
  • blurred vision

Side effects vary from individual to individual.  Other symptoms not on the common list may manifest as well; so, medical monitoring is crucial.

Withdrawing Intake of Antipsychotic Drugs

It is highly inadvisable to suddenly stop taking the prescribed drugs once already under antipsychotic medication.  Doctor’s approval is highly recommended as one has to follow a medical plan for a gradual and slow withdrawal from the drug over a period of several weeks or months.  While there are people who can stop taking their prescriptions without issues, the majority usually experience a recurrence of psychotic symptoms when suddenly going off their medications.

Furthermore, withdrawing from the drug is not a simple matter of gradual decrease of intake.  Situational factors such as timing of circumstances and availability of support from family and friends are crucial to making this huge leap.  Withdrawal can begin when there are no life-changing events or stressful things going on such as moving house, getting a new job, travelling to a new place, etc.  But as people can never be pigeon-holed, there are some patients that do withdrawals well when preoccupied with new things going on in their life.  No matter what type of patient one is, it is important to know that the manner of withdrawing from antipsychotic drugs is crucial because the aim is to avoid relapses.

Borderline Personality Disorder (BPD)

Adolescents typically experience a lot of mood changes from overactive hormones and from the pressure of learning how to deal with the world on a larger scale. Kayla, however, experienced her low mood dips more than most and suspected that her emotional experiences were much more intense and persistent than those of her peers. Hers felt over-the-top and she could not help drowning in an overwhelming tide of separation anxiety, fear of abandonment, and depression. As a consequence, she became solitary, falling behind academically and socially. In 2007, she tried to end her life to stop the persistent avalanche of negative emotions but was rescued in time by a friend. It was only by the time she turned 30 that she got her answer to her uncontrollable emotions and subsequent bad behaviour: Borderline Personality Disorder.

What BPD Is

Borderline Personality Disorder is often a marginalized or misunderstood mental illness. In fact, not many people know such a mental condition exists. BPD requires closer scrutiny as it is a dangerous mental issue with its victims turning to self harm and later, suicide, as a behavioural response to persistent heightened negative emotions. A person with BPD often feels that he cannot possibly control or manage his emotional burdens.my mind is killing me

Borderline Personality Disorder is marked by unstable moods and behaviour. Because of the high degree of emotional instability, persons with BPD have trouble maintaining stable relationships. For decades, people with BPD were dismissively labelled as drama queens, clingers, manipulators, and attention-seekers. As there exist such personality types who are not mentally afflicted, the addition of persistent reckless, impulsive behaviours; hallucinations and delusions; and social unpredictability to these traits punctuates the diagnosis for BPD.

As Lottie, a BPD sufferer says, “It’s one of the biggest misconceptions, but we are not attention seekers. We struggle more than we ever let on. The last thing we want is to sit in A&E or in a police cell under section 136. We don’t do this for fun. We fight a battle in our heads every single day, even with a smile on our faces.”

It was only in 1980 that the BPD was recognized as a diagnosable illness in the “Diagnostic and Statistical Manual for Mental Disorders, Third Edition” (DSM-III).

The term “borderline” refers to the fact that BPD exhibits borderline symptoms of other mental disorders. One may find tinges of neurosis, bipolar, schizophrenia, and other versions of mental illness. Thus, it can co-exist with depression, anxiety, self-harm, substance abuse, eating disorders, suicidal behaviours, and other atypical behaviours. BPD is a serious condition because an estimated 60-70% of sufferers attempt suicide sometime in their lives. A few succeed.

Statistics show that women are unfortunately more susceptible to BPD than men. Female patients are more likely to exhibit anxiety disorders, major depression, or eating disorders. Male sufferers typically indulge in substance abuse and antisocial behaviour.

Symptoms of BPD

According to the 4th edition of the DSM, a diagnosis for Borderline Personality Disorder may be made if the patient exhibits a chronic pattern of at least five of these behaviours or symptoms:

• Extreme anxiety, fury, depression, panic, and other negative reactions to abandonment, whether the abandonment is real or simply perceived.

• Intense, bipolar-like mood swings that last from a few hours to a few days. A person with BPD may feel light and glowy in the morning and feel utterly dejected by afternoon.

• Unstable and unpredictable relationship patterns with family and friends marked by intense closeness and love (idealization) for some time and suddenly deviating to severe dislike (devaluation) for another, and back again. In this case, BPD patients cannot form much less maintain strong, stable personal and work relationships.

• Problematic anger management issues

• Weak sense of identity which changes depending on whom the BPD patient is with. The patient often changes plans, goals, values, and opinions and is therefore very prone to manipulative intentions of other people.

• Impulsive behaviours which may cause the sufferer harm. Behaviours may range from quitting jobs, going on spending sprees to indulging in unsafe sex and dangerous thrill-seeking activities without much regard for safety.

• Recurring thoughts and actions concerning suicide

• Self harming behaviours such as cutting, burning, banging head on wall, etc.

• Constant feelings of emptiness, loneliness, and boredom.

• Paranoia

• Psychotic experiences; hallucinations, delusions, or hearing things other people do not

• Severe dissociative signs such as feeling numb, observing one’s self like a third person, and losing touch with reality.

What Causes BPD?

BPD is still not very well understood; but scientists agree that both heredity and environment play a role in its inception. Studies have shown that people can inherit temperament particularly impulsiveness and aggression. Traumatic events in childhood such as parental neglect and emotional abuse can instigate BPD development.

BPD

 

Possible Treatments

BPD is not easy to diagnose simply because it usually is accompanied by symptoms from other mental conditions. Eighty five percent of the time, BPD meets the diagnostic criteria for other mental disorders. As such, one may be misdiagnosed with bipolar syndrome when a broader Borderline Personality Disorder is the true case.

Psychotherapy is a common approach to treating BPD. It is important for a mental health professional to achieve a relationship of trust with his patient as the very nature of BPD makes it very difficult for patients to maintain a bond with their therapist. Psychotherapy can help patients reframe the way they perceive themselves; control intense feelings and destructive behaviours, and improve relationships in the patient’s milieu. This may be conducted as a one-to-one session or in a group setting.

The family of the BPD patient may also stand to benefit from therapy. Oftentimes, the stress of living with a BPD patient takes its toll and may provoke actions, knowingly or unknowingly, detrimental to the BPD sufferer.

It is interesting to note that Omega-3 fatty acid supplementation has helped people with BPD reduce their aggressive and depressive symptoms. In a study done on 30 women, Omega-3 supplements helped stabilize mood in BPD patients and with fewer side effects.

Although difficult to treat, Borderline Personality Disorder does have a silver lining and people with this affliction may improve their mental health over time. It is important to recognize that people with BPD be given appropriate emotional support so that they may have the patience to weather the time it takes for healing to take place.