New Research on Borderline New Research on Borderline Personality DisorderPersonality Disorder

New Research on Borderline New Research on Borderline Personality DisorderPersonality Disorder

Blaise Aguirre, MDMedical Director , 3East Residential Assistant Professor of Psychiatry

Harvard Medical SchoolBelmont, MA

Alec L. Miller, PsyDCo-Founder, Cognitive & Behavioral Consultants of Westchester, LLP

White Plains, NY Professor of Clinical Psychiatry and Behavioral Sciences

Montefiore Medical Center/Albert Einstein College of MedicineBronx, NY

NAMI 9/5/14

Blaise Aguirre, MDMedical Director , 3East Residential Assistant Professor of Psychiatry

Harvard Medical SchoolBelmont, MA

Alec L. Miller, PsyDCo-Founder, Cognitive & Behavioral Consultants of Westchester, LLP

White Plains, NY Professor of Clinical Psychiatry and Behavioral Sciences

Montefiore Medical Center/Albert Einstein College of MedicineBronx, NY

NAMI 9/5/14

• BPD diagnosis, prevalence, and self-harmBPD diagnosis, prevalence, and self-harm–The 5 problem areasThe 5 problem areas

• Existing evidence-based BPD treatmentsExisting evidence-based BPD treatments• DBT researchDBT research

–First adolescent RCTFirst adolescent RCT• Early InterventionEarly Intervention• PreventionPrevention• BPD and Trauma researchBPD and Trauma research• Future DirectionsFuture Directions

• BPD diagnosis, prevalence, and self-harmBPD diagnosis, prevalence, and self-harm–The 5 problem areasThe 5 problem areas

• Existing evidence-based BPD treatmentsExisting evidence-based BPD treatments• DBT researchDBT research

–First adolescent RCTFirst adolescent RCT• Early InterventionEarly Intervention• PreventionPrevention• BPD and Trauma researchBPD and Trauma research• Future DirectionsFuture Directions

OutlineOutlineOutlineOutline

Borderline Personality DisorderDisorder (Re-organized in DBT)

Borderline Personality DisorderDisorder (Re-organized in DBT)

Emotion Dysregulation Affective lability Problems with anger

Interpersonal Dysregulation Chaotic relationships Fears of abandonment

Self Dysregulation Identity disturbance/ difficulties with sense of self Sense of emptiness

Behavioral Dysregulation Parasuicidal behavior Impulsive behavior

Cognitive Dysregulation Dissociative responses/ paranoid ideation

Emotion Dysregulation Affective lability Problems with anger

Interpersonal Dysregulation Chaotic relationships Fears of abandonment

Self Dysregulation Identity disturbance/ difficulties with sense of self Sense of emptiness

Behavioral Dysregulation Parasuicidal behavior Impulsive behavior

Cognitive Dysregulation Dissociative responses/ paranoid ideation

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BPD in ADULTSBPD in ADULTS BPD in ADULTSBPD in ADULTSDSM-IV and epi studies find BPD in:DSM-IV and epi studies find BPD in:1.8% of the general population, 1.8% of the general population, 8 to 11% of psychiatric outpatients, 8 to 11% of psychiatric outpatients, and 14 to 20% of inpatients.and 14 to 20% of inpatients.

****NIAAA Study of 34,653 adults found: NIAAA Study of 34,653 adults found: Prevalence of lifetime BPD was 5.9%, Prevalence of lifetime BPD was 5.9%, with no significant difference between with no significant difference between gender (J of Clin Psychiatry, 2008)gender (J of Clin Psychiatry, 2008)

DSM-IV and epi studies find BPD in:DSM-IV and epi studies find BPD in:1.8% of the general population, 1.8% of the general population, 8 to 11% of psychiatric outpatients, 8 to 11% of psychiatric outpatients, and 14 to 20% of inpatients.and 14 to 20% of inpatients.

****NIAAA Study of 34,653 adults found: NIAAA Study of 34,653 adults found: Prevalence of lifetime BPD was 5.9%, Prevalence of lifetime BPD was 5.9%, with no significant difference between with no significant difference between gender (J of Clin Psychiatry, 2008)gender (J of Clin Psychiatry, 2008)

6

BPD isBPD is

associated withassociated with

fatal and non-fatal fatal and non-fatal

suicidal behaviors as well suicidal behaviors as well as nonsuicidal self-as nonsuicidal self-injurious behaviorsinjurious behaviors

BPD isBPD is

associated withassociated with

fatal and non-fatal fatal and non-fatal

suicidal behaviors as well suicidal behaviors as well as nonsuicidal self-as nonsuicidal self-injurious behaviorsinjurious behaviors

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BPD Can Be FatalBPD Can Be FatalBPD Can Be FatalBPD Can Be Fatal

• Among SUICIDES,Among SUICIDES,

–40-65% have PD40-65% have PD

• Among PDs,Among PDs,–BPD is most associated with suicidal BPD is most associated with suicidal

behaviorbehavior

• Among BPD,Among BPD, –8-10% commit suicide 8-10% commit suicide –up to 75% attempt suicideup to 75% attempt suicide–69-80% self-mutilate69-80% self-mutilate

• Among SUICIDES,Among SUICIDES,

–40-65% have PD40-65% have PD

• Among PDs,Among PDs,–BPD is most associated with suicidal BPD is most associated with suicidal

behaviorbehavior

• Among BPD,Among BPD, –8-10% commit suicide 8-10% commit suicide –up to 75% attempt suicideup to 75% attempt suicide–69-80% self-mutilate69-80% self-mutilate

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ESTs for BPD:ESTs for BPD:Mentalization (Bateman & Fonagy)Mentalization (Bateman & Fonagy)

•AJP, 1999; 2013AJP, 1999; 2013

•JAACAP, 2012 (Roussow & Fonagy) -JAACAP, 2012 (Roussow & Fonagy) -ADOLESCENTSADOLESCENTS

Transference-focused (Kernberg, Clarking, Levy et al)Transference-focused (Kernberg, Clarking, Levy et al)•JCCP 2006; AJP, 2007; Archives, 2006; BJP, 2010 JCCP 2006; AJP, 2007; Archives, 2006; BJP, 2010

Schema-focused (Young et al.)Schema-focused (Young et al.)•Archives, 2006; 2009Archives, 2006; 2009

STEPPS (Blum et al.)STEPPS (Blum et al.)•2008; 20102008; 2010

Cognitive Analytic Therapy (Chanen et al.)Cognitive Analytic Therapy (Chanen et al.)•BJP, 2008; 2012BJP, 2008; 2012

DBT (Linehan et al.) DBT (Linehan et al.) •Archives, 1991, 1993, 1998, 1999, 2006, etc, >18 RCTsArchives, 1991, 1993, 1998, 1999, 2006, etc, >18 RCTs

•JAACAP, in press (Mehlum et al.)-JAACAP, in press (Mehlum et al.)-ADOLESCENTSADOLESCENTS

ESTs for BPD:ESTs for BPD:Mentalization (Bateman & Fonagy)Mentalization (Bateman & Fonagy)

•AJP, 1999; 2013AJP, 1999; 2013

•JAACAP, 2012 (Roussow & Fonagy) -JAACAP, 2012 (Roussow & Fonagy) -ADOLESCENTSADOLESCENTS

Transference-focused (Kernberg, Clarking, Levy et al)Transference-focused (Kernberg, Clarking, Levy et al)•JCCP 2006; AJP, 2007; Archives, 2006; BJP, 2010 JCCP 2006; AJP, 2007; Archives, 2006; BJP, 2010

Schema-focused (Young et al.)Schema-focused (Young et al.)•Archives, 2006; 2009Archives, 2006; 2009

STEPPS (Blum et al.)STEPPS (Blum et al.)•2008; 20102008; 2010

Cognitive Analytic Therapy (Chanen et al.)Cognitive Analytic Therapy (Chanen et al.)•BJP, 2008; 2012BJP, 2008; 2012

DBT (Linehan et al.) DBT (Linehan et al.) •Archives, 1991, 1993, 1998, 1999, 2006, etc, >18 RCTsArchives, 1991, 1993, 1998, 1999, 2006, etc, >18 RCTs

•JAACAP, in press (Mehlum et al.)-JAACAP, in press (Mehlum et al.)-ADOLESCENTSADOLESCENTS

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18 Randomized Clinical Trials18 Randomized Clinical Trials18 Randomized Clinical Trials18 Randomized Clinical TrialsDBT Superior to Comparison DBT Superior to Comparison

TreatmentsTreatments

Reducing:Reducing:• Suicide attemptsSuicide attempts and self-injury and self-injury• Premature Premature drop-outdrop-out• InpatientInpatient/ER admissions and days/ER admissions and days• Drug abuseDrug abuse• Depression, hopelessnessDepression, hopelessness, anger, anger• ImpulsivenessImpulsiveness

Increasing:Increasing:• Global adjustmentGlobal adjustment• Social adjustmentSocial adjustment

DBT Superior to Comparison DBT Superior to Comparison TreatmentsTreatments

Reducing:Reducing:• Suicide attemptsSuicide attempts and self-injury and self-injury• Premature Premature drop-outdrop-out• InpatientInpatient/ER admissions and days/ER admissions and days• Drug abuseDrug abuse• Depression, hopelessnessDepression, hopelessness, anger, anger• ImpulsivenessImpulsiveness

Increasing:Increasing:• Global adjustmentGlobal adjustment• Social adjustmentSocial adjustment See Lieb, K., Zanarini, M., Linehan, M., See Lieb, K., Zanarini, M., Linehan, M.,

& Bohus, M., 2004.& Bohus, M., 2004.

9

10

to severe and chronic multi-diagnostic, difficult-to-treat patient

with both Axis I and Axis II disorders

10

11

INVALIDATIONINVALIDATION

OF OF SELF-CONSTRUCTSSELF-CONSTRUCTS

The Problem

Impaired Cognitive Processing +

Intense Effort to Control

FOCUS ON FOCUS ON CHANGECHANGE !!AROUSAL!!!!AROUSAL!!

SENSE OFSENSE OF OUT-OF-CONTROLOUT-OF-CONTROL

No New Learning – No CollaborationNo New Learning – No Collaboration

11

12

INVALIDATIONINVALIDATION

OF OF SUFFERINGSUFFERING

The ProblemFurther

FOCUS ON FOCUS ON ACCEPTANCEACCEPTANCE !!AROUSAL!!!!AROUSAL!!

SENSE OFSENSE OF OUT-OF-CONTROLOUT-OF-CONTROL

No New Learning – No No New Learning – No CollaborationCollaboration

12

13

Solution Was to ApplySolution Was to Apply

A Approach BalancingA Approach Balancing

Solution Was to ApplySolution Was to Apply

A Approach BalancingA Approach Balancing

AcceptanceAcceptanceStrategiesStrategies

AcceptanceAcceptanceStrategiesStrategies

ChangeChangeStrategies Strategies

DialecticsDialectics

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Problem AreasProblem Areas SkillsSkills Problem AreasProblem Areas SkillsSkills

1.1. Confusion about Self Confusion about Self 1.1. Mindfulness Mindfulness

2.2. Impulsivity Impulsivity 2.2. Distress Tolerance Distress Tolerance

3.3. Emotional Instability Emotional Instability 3.3. Emotion Regulation Emotion Regulation

4.4. Interpersonal Problems Interpersonal Problems 4.4. Interpersonal Interpersonal EffectivenessEffectiveness

5.5. Adolescent - Family Adolescent - Family 5.5. Walking the Middle Walking the Middle

DilemmasDilemmas Path Path

1.1. Confusion about Self Confusion about Self 1.1. Mindfulness Mindfulness

2.2. Impulsivity Impulsivity 2.2. Distress Tolerance Distress Tolerance

3.3. Emotional Instability Emotional Instability 3.3. Emotion Regulation Emotion Regulation

4.4. Interpersonal Problems Interpersonal Problems 4.4. Interpersonal Interpersonal EffectivenessEffectiveness

5.5. Adolescent - Family Adolescent - Family 5.5. Walking the Middle Walking the Middle

DilemmasDilemmas Path Path

Adolescent Outpatient DBT ModesAdolescent Outpatient DBT ModesAdolescent Outpatient DBT ModesAdolescent Outpatient DBT ModesPhase I: Phase I: 4-6 months4-6 months

• Multi-family Multi-family skills training group skills training group • Individual psychotherapyIndividual psychotherapy• Telephone consultation (w/ teenTelephone consultation (w/ teen & parent) & parent)• Family therapy Family therapy • Therapist consultation meetingTherapist consultation meeting

Phase II: Phase II: 16 weeks & recommit16 weeks & recommit• Graduate group Graduate group • Individual psychotherapy (phase out)Individual psychotherapy (phase out)• Telephone consultationTelephone consultation• Family therapy, PRNFamily therapy, PRN*All patients are eligible for pharmacotherapy*All patients are eligible for pharmacotherapy

Phase I: Phase I: 4-6 months4-6 months• Multi-family Multi-family skills training group skills training group • Individual psychotherapyIndividual psychotherapy• Telephone consultation (w/ teenTelephone consultation (w/ teen & parent) & parent)• Family therapy Family therapy • Therapist consultation meetingTherapist consultation meeting

Phase II: Phase II: 16 weeks & recommit16 weeks & recommit• Graduate group Graduate group • Individual psychotherapy (phase out)Individual psychotherapy (phase out)• Telephone consultationTelephone consultation• Family therapy, PRNFamily therapy, PRN*All patients are eligible for pharmacotherapy*All patients are eligible for pharmacotherapy

L.Mehlum 2012

Dialectical Behavior Therapy for Adolescents with Recent and Repeated

Suicidal and Self harm Behavior - a Randomized Controlled Trial

Mehlum, L, Tormoen, A, Ramberg, M, Haga, E, Diep, L, Laberg, S, Larsson, B, Stanley, B, Miller, AL, Sund, A, Groholt, B. (In press,

Journal of the American Academy of Child and Adolescent Psychiatry).

L.Mehlum 2012

Overall aim

To determine the efficacy of DBT-A compared to

enhanced usual care in adolescents with recent and

repetitive self harm and with three or more borderline personality disorder criteria.

L.Mehlum 2012

Design

• Randomized Controlled Trial with independent and blinded pre-, post and follow-up evaluations

• Measurements at: – Baseline (interview, self-report and testing)

– 6 weeks (self-report)

– 12 weeks (self-report)

– 16 weeks - End of treatment (interview, self-report and testing)

– 1 year posttreatment follow-up (interview, self-report and testing)

– 2 years posttreatment follow-up (interview, self-report and testing)

• Ten year follow-up planned

L.Mehlum 2012

Treatment methods1. DBT – Adapted for adolescents – 16 weeks

2. Enhanced Usual Care (EUC) – 16 weeks

Psychodynamic or CBT oriented therapy (non-DBT)

Treatments were delivered at five Child and Adolescent Outpatient Clinics in Oslo, Norway

Adolescent Outpatient DBT ModesAdolescent Outpatient DBT ModesAdolescent Outpatient DBT ModesAdolescent Outpatient DBT ModesPhase I: Phase I: 4 months (RESEARCH STUDY)4 months (RESEARCH STUDY)

• Multi-family Multi-family skills training group skills training group • Individual psychotherapyIndividual psychotherapy• Telephone consultation (w/ teenTelephone consultation (w/ teen & parent) & parent)• Family therapy Family therapy • Therapist consultation meetingTherapist consultation meeting

Phase II: Phase II: 16 weeks & recommit (NOT RESEARCH)16 weeks & recommit (NOT RESEARCH)• Graduate group Graduate group • Individual psychotherapy (phase out)Individual psychotherapy (phase out)• Telephone consultationTelephone consultation• Family therapy, PRNFamily therapy, PRN*All patients are eligible for pharmacotherapy*All patients are eligible for pharmacotherapy

Phase I: Phase I: 4 months (RESEARCH STUDY)4 months (RESEARCH STUDY)• Multi-family Multi-family skills training group skills training group • Individual psychotherapyIndividual psychotherapy• Telephone consultation (w/ teenTelephone consultation (w/ teen & parent) & parent)• Family therapy Family therapy • Therapist consultation meetingTherapist consultation meeting

Phase II: Phase II: 16 weeks & recommit (NOT RESEARCH)16 weeks & recommit (NOT RESEARCH)• Graduate group Graduate group • Individual psychotherapy (phase out)Individual psychotherapy (phase out)• Telephone consultationTelephone consultation• Family therapy, PRNFamily therapy, PRN*All patients are eligible for pharmacotherapy*All patients are eligible for pharmacotherapy

L.Mehlum 2012

DBT therapists

• Recruited from five Child & Adolescent outpatient psychiatric clinics at the Oslo University Hospital

• MDs and Psychologists• All therapists were new to DBT and trained for the purpose of

the trial and hired if/when reaching a consistently high adherence level (score >= 4.0 on Linehan adherence coding instrument)

• Trained for the purpose of the trial in suicide risk assessment and management

• All treaments were conducted at and paid for by the Oslo University Hospital

Coding of 166 individual therapy sessions

Mean score = 4.11 SD = 0.14

L.Mehlum 2012

Participants• Patient inclusion: March 2008 thru March 2012

• Altogether 77 patients were included and randomly allocated to receive:

– DBT-A (n=39)

– or

– EUC (n=38)

• Stratified by gender, presence of major depression and suicide intent at most severe self-harm episode last 4 months before enrollment.

L.Mehlum 2012

RCT of DBT-A vs EUC for self-harming and suicidal adolescents with emotion dysregulation (N=77)

Patient characteristics - baseline

Dialectical Behaviour Therapy

N=39

Enhanced Usual CareN=38

N % N %

Girls (%) 34 87.2 34 89.5

Completed high school 13 41.9 7 25.0

Parents currently married 17 43.6 17 44.7

Mean SD Mean SD

Age (yrs) 15.9 1.4 15.3 1.6

C-GAS 55.3 8.0 57.9 10.1

No significant differences between groups

L.Mehlum 2012

RCT of DBT-A vs EUC for self-harming and suicidal adolescents with emotion dysregulation (N=77)

Patient characteristics – baseline cont.Dialectical Behaviour

TherapyN=39

Enhanced Usual CareN=38

N % N %

Psychiatric treatment (past) 28 73.7 23 62.2

Pharmacotherapy (past) 2 5.4 6 17.1

Child protection (past) 10 26.3 11 28.9

Child protection (current) 6 15.4 7 18.4

Mean SD/SE Mean SD/SE

CBCL (total no of problems) 69.6 11.0 68.4 8.6

Lifetime NSSH episodes (mean/rate) 29.8 2.8 25.9 3.0

Lifetime suicide attempts (mean/rate) 3.2 0.6 3.1 0.6

No significant differences between groups

L.Mehlum 2012

So what about the outcomes?

L.Mehlum 2012

Conclusions

• Patients receiving DBT-A experienced significant reductions in all 3 primary outcome measures, in contrast to patients receiving EUC where only self-reported depression was significantly reduced

• Patients who received DBT-A had a significantly– Stronger reduction in the number of self-harm episodes

– Stronger decline in suicidal ideation

– Stronger reduction in interviewer rated depressive symptoms

– Stronger reduction in hopelessness feelings

– Stronger reduction in borderline symptoms

L.Mehlum 2012

Next steps in Norway

• 1 year posttreatment follow-up (interview, self-report and testing) - ongoing

• 2 years posttreatment follow-up (interview, self-report and testing) – ongoing

• 10 year posttreatment follow-up – planned

• Evaluate effectiveness of Adolescent DBT Graduate Group as a maintenance, continuation phase of treatment

Prevention & Early Intervention

DBT in School SettingsDBT in School SettingsDBT in School SettingsDBT in School Settings• Secondary and Tertiary Prevention:Secondary and Tertiary Prevention:

–Middle and HSMiddle and HS–Elementary schoolsElementary schools

• Primary Prevention InterventionsPrimary Prevention Interventions–Elementary schoolsElementary schools

• Secondary and Tertiary Prevention:Secondary and Tertiary Prevention:–Middle and HSMiddle and HS–Elementary schoolsElementary schools

• Primary Prevention InterventionsPrimary Prevention Interventions–Elementary schoolsElementary schools

DBT in SchoolsDBT in SchoolsDBT in SchoolsDBT in Schools• School InterventionsSchool Interventions

– Ulster County HS Health Class Curriculum (1999)Ulster County HS Health Class Curriculum (1999)– Far Rockaway HSFar Rockaway HS

• Salley et al, (2002)Salley et al, (2002)– New Haven Elementary School/Yale UniversityNew Haven Elementary School/Yale University

• Perepletchikova et al, (2010) Perepletchikova et al, (2010) – PS 8 Bronx, NY/Albert Einstein College of MedicinePS 8 Bronx, NY/Albert Einstein College of Medicine

• Lander, Miller, Edwards, et al, (2009-2012)Lander, Miller, Edwards, et al, (2009-2012)– Ardsley School District, NY (2008-present)Ardsley School District, NY (2008-present)

• School-based Mental Health Teams in MS and HS and School-based Mental Health Teams in MS and HS and • Now teaching in Health ClassNow teaching in Health Class• Presented data at conferences (Catucci et al.; Mason et al)Presented data at conferences (Catucci et al.; Mason et al)

– Pleasantville, NY School District (2009-present)Pleasantville, NY School District (2009-present)• School-based Mental Health Teams in MS and HS School-based Mental Health Teams in MS and HS

– Mamaroneck, NY School District (2010-present)Mamaroneck, NY School District (2010-present)– Rockland County BOCES HS (2012-present)Rockland County BOCES HS (2012-present)– New Rochelle and Florida, NY School Districts (2012-present)New Rochelle and Florida, NY School Districts (2012-present)– University of Washington, MS & HS EducationUniversity of Washington, MS & HS Education

• Mazza & Mazza (2010-) Mazza & Mazza (2010-)

• School InterventionsSchool Interventions– Ulster County HS Health Class Curriculum (1999)Ulster County HS Health Class Curriculum (1999)– Far Rockaway HSFar Rockaway HS

• Salley et al, (2002)Salley et al, (2002)– New Haven Elementary School/Yale UniversityNew Haven Elementary School/Yale University

• Perepletchikova et al, (2010) Perepletchikova et al, (2010) – PS 8 Bronx, NY/Albert Einstein College of MedicinePS 8 Bronx, NY/Albert Einstein College of Medicine

• Lander, Miller, Edwards, et al, (2009-2012)Lander, Miller, Edwards, et al, (2009-2012)– Ardsley School District, NY (2008-present)Ardsley School District, NY (2008-present)

• School-based Mental Health Teams in MS and HS and School-based Mental Health Teams in MS and HS and • Now teaching in Health ClassNow teaching in Health Class• Presented data at conferences (Catucci et al.; Mason et al)Presented data at conferences (Catucci et al.; Mason et al)

– Pleasantville, NY School District (2009-present)Pleasantville, NY School District (2009-present)• School-based Mental Health Teams in MS and HS School-based Mental Health Teams in MS and HS

– Mamaroneck, NY School District (2010-present)Mamaroneck, NY School District (2010-present)– Rockland County BOCES HS (2012-present)Rockland County BOCES HS (2012-present)– New Rochelle and Florida, NY School Districts (2012-present)New Rochelle and Florida, NY School Districts (2012-present)– University of Washington, MS & HS EducationUniversity of Washington, MS & HS Education

• Mazza & Mazza (2010-) Mazza & Mazza (2010-)

30

Do not reproduce or distribute without written permission from CBC. © CBC 2012

STEPS-A (Emotional Problem Solving for Adolescents; Mazza et al, in preparation) is a Universal program – Teacher administered 42-minute/class DBT curriculum

Using an RTI model

Using Mental Health model

Tier IUniversal Population

Tier IISelected Population

Tier IIIIndicated

80-85%

10-15%

5-10%

Dialectical Behavior Therapy in Public Schools

(Mazza, 2012)

Why DBT in Schools?Why DBT in Schools?Why DBT in Schools?Why DBT in Schools?

•Mounting pressure to keep ED Mounting pressure to keep ED (emotionally disabled) students (emotionally disabled) students within Districtwithin District– Costs District @ 100K/per student per Costs District @ 100K/per student per

year when sent out of District for year when sent out of District for specialized programs.specialized programs.

•Mounting pressure to keep ED Mounting pressure to keep ED (emotionally disabled) students (emotionally disabled) students within Districtwithin District– Costs District @ 100K/per student per Costs District @ 100K/per student per

year when sent out of District for year when sent out of District for specialized programs.specialized programs.

32Do not reproduce or distribute without written permission from CBC. © CBC 2012

Why DBT in Schools?Why DBT in Schools?Why DBT in Schools?Why DBT in Schools?

•Schools often urge staff to send Schools often urge staff to send students to ER when suicidal students to ER when suicidal thinking or self-harm is reported.thinking or self-harm is reported.

•ERs are flooded with visits from ERs are flooded with visits from students who do not necessarily students who do not necessarily need hospitalization.need hospitalization.

•Sending students to ER may Sending students to ER may reinforce problem reinforce problem (escape/avoidance) behaviors.(escape/avoidance) behaviors.

•Schools often urge staff to send Schools often urge staff to send students to ER when suicidal students to ER when suicidal thinking or self-harm is reported.thinking or self-harm is reported.

•ERs are flooded with visits from ERs are flooded with visits from students who do not necessarily students who do not necessarily need hospitalization.need hospitalization.

•Sending students to ER may Sending students to ER may reinforce problem reinforce problem (escape/avoidance) behaviors.(escape/avoidance) behaviors. 33

Do not reproduce or distribute without written permission from CBC. © CBC 2012

Data from SchoolsData from SchoolsData from SchoolsData from Schools•Preliminary results from an open Preliminary results from an open

trial at Ardsley High School (Mason, trial at Ardsley High School (Mason, Catucci, Lusk, and Johnson, 2011)Catucci, Lusk, and Johnson, 2011)– Reduced referrals to assistant principalReduced referrals to assistant principal

– Reduced cutting classReduced cutting class

– Reduced detentions and suspensionsReduced detentions and suspensions

– Anecdotal reduction in depression, Anecdotal reduction in depression, anxiety, NSSIanxiety, NSSI

– Requires change of culture re: how Requires change of culture re: how schools manage problem behaviorschools manage problem behavior

•Preliminary results from an open Preliminary results from an open trial at Ardsley High School (Mason, trial at Ardsley High School (Mason, Catucci, Lusk, and Johnson, 2011)Catucci, Lusk, and Johnson, 2011)– Reduced referrals to assistant principalReduced referrals to assistant principal

– Reduced cutting classReduced cutting class

– Reduced detentions and suspensionsReduced detentions and suspensions

– Anecdotal reduction in depression, Anecdotal reduction in depression, anxiety, NSSIanxiety, NSSI

– Requires change of culture re: how Requires change of culture re: how schools manage problem behaviorschools manage problem behavior

34Do not reproduce or distribute without written permission from CBC. © CBC 2013

Why DBT in schools?Why DBT in schools?Why DBT in schools?Why DBT in schools?

• It may be more cost-effectiveIt may be more cost-effective• It may reduces problem behaviors that It may reduces problem behaviors that

often result in suspensions, ER visits, etcoften result in suspensions, ER visits, etc•DBT is skills based, can be taught in DBT is skills based, can be taught in

groups/classesgroups/classes• It can be applied transdiagnosticallyIt can be applied transdiagnostically•DBT has observable and measurable DBT has observable and measurable

outcomesoutcomes• It may PREVENT BPD symptoms?It may PREVENT BPD symptoms?

• It may be more cost-effectiveIt may be more cost-effective• It may reduces problem behaviors that It may reduces problem behaviors that

often result in suspensions, ER visits, etcoften result in suspensions, ER visits, etc•DBT is skills based, can be taught in DBT is skills based, can be taught in

groups/classesgroups/classes• It can be applied transdiagnosticallyIt can be applied transdiagnostically•DBT has observable and measurable DBT has observable and measurable

outcomesoutcomes• It may PREVENT BPD symptoms?It may PREVENT BPD symptoms?

35Do not reproduce or distribute without written permission from CBC. © CBC 2013

DBT in SchoolsDBT in SchoolsDBT in SchoolsDBT in Schools

Reference :

Mazza, JJ, Dexter-Mazza, ET, Murphy, HE, Miller, Mazza, JJ, Dexter-Mazza, ET, Murphy, HE, Miller, AL, & Rathus, JH (In preparation). AL, & Rathus, JH (In preparation). Skills Skills Training for Emotional Problem Solving for Training for Emotional Problem Solving for Adolescents (STEPS-A):Adolescents (STEPS-A): Implementing DBT Implementing DBT skills training in schoolsskills training in schools . . Guilford Press.Guilford Press.

Reference :

Mazza, JJ, Dexter-Mazza, ET, Murphy, HE, Miller, Mazza, JJ, Dexter-Mazza, ET, Murphy, HE, Miller, AL, & Rathus, JH (In preparation). AL, & Rathus, JH (In preparation). Skills Skills Training for Emotional Problem Solving for Training for Emotional Problem Solving for Adolescents (STEPS-A):Adolescents (STEPS-A): Implementing DBT Implementing DBT skills training in schoolsskills training in schools . . Guilford Press.Guilford Press.

Do not reproduce or distribute without written permission from CBC. © CBC 2012

Dalai LamaDalai LamaDalai LamaDalai Lama

Early Intervention in BPD

Current evidence supports: the development of indicated prevention and early intervention programs for the emerging BPD phenotype (Chanen et al. 2007, 2008)

Benefits of Early Intervention are likely to outweigh risks, such as stigmatizing attitudes from clinicians.

(Chanen et al. 2007, 2008)

Potential opportunities for Early Intervention is frequently missed

Identification of outpatient youth with DSM-IV BPD is feasible through screening (Chanen et al. 2008)

The Evidence

15-18 yo (41 to CAT vs. 37 to GCC vs. 32 TAU) ≥ 2 DSM-IV BPD criteria one or more childhood risk factors for young adult

generic PD childhood PD symptoms disruptive behavior disorder symptoms low socio-economic status depressive symptoms history of childhood abuse or neglect

Assessments

Baseline (n=78) 6-months (n=70) 12-months (n=70) 24-months (n=68) At least three time points in 92%

of sample

Outcome Variables

Total BPD score (SCID-II) Youth self-report (YSR; Achenbach, 1991)

Internalizing Externalizing

Social and occupational functioning (SOFAS) Parasuicidal behaviors

suicide attempts and non-suicidal self-injury semi-structured interview coded as: none, monthly, weekly and daily

Main Results

At 24-month follow-up: CAT and GCC was more effective than TAU CAT yielded the greatest median improvement on the four continuous measures CAT had lower levels of and a faster rate of

improvement in externalizing, compared to GCC* CAT had lower levels of and a significantly faster rate of

improvement in both internalising and externalising, compared to TAU

GCC had lower levels of internalising and a faster rate of improvement in SOFAS, compared to TAU

All treatment groups demonstrated significant and clinically substantial improvement.

Conclusions

Early intervention for BPD is possible Patients 13-15 years younger than in

recent RCTs GCC not ineffective perhaps easier to

teach Need longer-term follow-up

gains sustained? divert patients from unhelpful

engagement with adult treatment settings?

Childhood Trauma and Adolescent Borderline Personality Disorder Co-morbidity: Clinical and

Treatment Implications

Blaise Aguirre, MDMedical Director 3East Residential

Assistant Professor of PsychiatryHarvard Medical School

BPD, PTSD and Childhood Maltreatment

Prevalence of borderline personality disorder (BPD) comparable or slightly higher in adolescents vs. adults

2+% adulthood (APA, 2000) 3%-6% in adolescence (Zanarini, 2003; Chabrol et al., 2004)

In the Adult BPD Population Childhood maltreatment/trauma – as high as 85% (Venta et. al., 2012) Prevalence of PTSD-33%-58% (Harned & Linehan, 2008) Trauma and PTSD increases the likelihood of remission from BPD (Zanarini et. al.,

2005)

In the Adolescent BPD Population Only a few studies have explored the link between BPD and trauma in adolescents Childhood sexual abuse successfully discriminated between patients with BPD and

MDD

Co-occurrence of Borderline Personality Disorder (BPD),Trauma and Post-Traumatic Stress Disorder (PTSD)

BPD inpatients have rates of PTSD from 56-58%; BPD outpatients have rates of PTSD from 36-50%1

Epidemiologic research has indicated that 30.2% of individuals with BPD have PTSD, whereas 24.2% of individuals with PTSD have BPD2

Childhood abuse in BPD pop. found to be from 61% to 76%3

BPD clients experience adult traumas at a higher rate than non-BPD peers with rates as high as 90%4

Co-occurring PTSD is associated with greater impairment in individuals with BPD and lower likelihood of long-term remittance of BPD5

BPD clients with PTSD engage in more frequent NSSI than those without PTSD6

1 Zanarini et. al., 1998, 2004;Linehan et. al., 2006 4Zanarini et. al., 20052Pagura et. al., 2010 5Harnad et. al., 2010; Zanarini et. al., 20063Zanarini et. al., 1997, 2006 6 (Rusch et al., 2007)

Our Research Data

Female adolescents (n = 157) Ages 13-20 (Mean age = 17.21; SD= 2.39) Short-Term Residential Program Length of Stay (Mean = 72days)

Pre- and Post-Treatment Assessments BPD Criterion and Symptoms PTSD Symptoms Depressive Symptoms Childhood Maltreatment Risky Behavior Engagement

Results

Relationship of Trauma to Initial BPD Criterion Behaviors

Adolescents with moderate-severe trauma report higher initial levels of borderline psychopathology (t=-2.47, p=.02)

Robust association between childhood emotional/sexual trauma and severity of borderline psychopathology as measured by ZAN-B (r=.18, p=.05) and MSI (r=.28, p=.002)

Adolescents with trauma history also report greater risky behavior engagement as measured by Total RBQ scores which were highly correlated with both physical (r=.23, p=.01) and sexual abuse (r=.19, p=.03)

Impact of Trauma in Adolescence

Childhood Sexual Abuse (CSA) is a strong predictor of substance abuse, conduct disorder and depression1

Up to 20% of all adolescent suicide attempts are attributable to CSA; CSA victims are 8X more likely than non-abused counterparts to attempt suicide repeatedly in adolescence2

Adolescents with sexual-abuse-related PTSD also have more high-risk sexual behaviors as adolescents3

Trauma survivors with PTSD are more likely to report health problems than those without PTSD4 (Schnurr & Green 2004) making it a public health problem.

1 Diamond et. al., 2001 3 Stiffman, 19922 Brown et. al, 1999 4 Schnurr & Green 2004

Initial Level of Borderline Symptoms as a Function of Trauma

Risky Behavior by Trauma History

With Standard (DBT)

Although showing decreases in PTSD over time, a significant proportion (56.7%) of patients with histories of childhood abuse still met clinical criteria for PTSD on the CPSS at the time of program discharge

Patients with a history of childhood abuse/maltreatment showed relatively less change in PTSD scores then their non-abused counterparts

Many of our patients with trauma histories reported using BPD criterion behaviors as way to manage their PTSD symptoms and traumatic memories

Overall this data suggests that childhood trauma may play a pivotal role in the genesis of BPD and increase the intractability of PTSD

Effectiveness of Standard DBT for BPD+PTSD

DBT is the most empirically supported treatment available for SI and NSSI, particularly among individuals with BPD1,2

In recent study of DBT for suicidal BPD women, however, only 13% of clients with co-occurring PTSD achieved full remission after one year3

DBT alone has not been shown to help achieve remission of PTSD as an Axis-I diagnosis, either with or without SI/SB/NSSI4,5

1 Harnad, Comtois and Linehan, 2010 4, (Feigenbam et. al.,2 Harned & Linehan, 2008 5Harnad-Invited Chapter, in preparation)

3 Harned et. al.,  2008

Suicide and Self-Injury in BPD

Among inpatients with BPD, 70% have multiple episodes of NSSI and 60% report multiple suicide attempts1

BPD clients with PTSD engage in more NSSI than those without PTSD2

The rate of completed suicide among individuals with BPD is estimated to be 8-10%3

Clients with BPD+PTSD are more likely than those with BPD alone to report a variety of trauma-related cues for self-injury4

Relationship betweenCSA and NSSI may be mediated by the PTSD symptom clusters of re-experiencing and avoidance/numbing5

1 Zanarini et. al., 2008 4 Harned, in press2 Harned et. al., 2010 5 Weierich & Nock, 20083 Linehan et. al., 2000

Treatment Dilemmas for the PTSD/BPD Client with SI/NSSI/SA

Empirical support is robust for Cognitive Behavioral Therapy (CBT) with Prolonged Exposure (PE) as treatment of choice for both adults and adolescents with PTSD1

Pendulum of treatment swung in the late 90’s to exclusion of individuals with SI, SB or NSSI from established PTSD treatments involving activation of trauma memories2

Current  practice guidelines stipulate, "if significant suicidality is present it must be addressed before any other treatment is initiated”1 

Left unanswered how to treat adolescents with self-injury, SA, Dissociation and PTSD that is moderate to severe and intractible to other interventions.

1 Foa et. al., 20092 Stirman, 2008

Current Exclusion Criteria for Prolonged Exposure (PE)Treatment *

Imminent threat of SB or Homicidal Behaviors

Serious NSSI in past three months Current psychosis High risk of being assaulted from

environment Lack of clear/sufficient memory of

trauma Substance abuse Severe Dissociation

*Foa et. al., 2009

Evidence for DBT as ‘Primer’ Treatment for BPD+PTSD

DBT is efficacious in reducing suicidal/NSSI behaviors in clients with BPD/PTSD1

Using this approach for clients with BPD/PTSD, both imminent self-injury and imminent suicide risk decreased over a one year period2

BPD+PTSD clients showed a significant decrease in severe dissociation and substance dependence decreased  from pre-to-post treatment2

Among BPD+PTSD clients who became eligible for exposure treatment, the majority (82%) still continued to meet criteria for PTSD

Some BPD patients are unable to stop target behaviors until their PTSD is resolved; challenge is to find ways to safely make PTSD treatment available to these clients.

1 Harnad & Linehan, 2008 2 (Harnad et. al., 2010)

Integrated Treatment: DBT+DBT/PE Protocol

  

Provides integrated treatment for BPD and PTSD

Focus is specifically on BPD + self-injury

Uses standard DBT in combination with PE for PTSD

Recent evidence shows that treatment is feasible with no worsening of target/safety behaviors or increased drop-out from treatment.1

Remission rates comparable to those found in meta-

analysis of exposure treatments to PTSD on single-diagnosis populations.

1 Harnad, 2011

An Integrated DBT /PE Treatment Approach:Further Modifications for Adolescents with

BPD+PTSD

Dialectical Behavior Therapy Prolonged Exposure Protocol Prolonged Exposure Protocol (Harned et. al., 2012))

Eligible patients completed 2-5 exposures per week Baseline PTSD symptoms Developed an exposure hierarchy focusing on imaginal

exposures

During exposures Pre and post-exposure SUDS were measured Pre-and-post ratings were done for the primary emotions, urges

for self-harm and Radical Acceptance

Aims: (a) changes in PTSD symptoms and (b) changes in levels of rated emotions, urges and cognitions

Importance of Parental Involvement

Parents are key sources of information about patient, trauma history and family functioning

Parents/Family should receive education about PTSD and be enlisted to support patient in recovery

Issue of  patient’s confidentiality/privacy should be directly addressed with both patient and family

Use joint meetings to develop contract for ongoing family involvement including detailing specific role in crisis management, homework/hierarchy completion and treatment meetings.

Stress the Importance of joint exposure and skill development in instances of family trauma/loss

Final Points

Trauma is present in many patients with BPD

PTSD worsens the prognosis and symptoms expression in BPD

PTSD does not remit in a non integrated DBT+PE treatment

Data suggests that very suicidal BPD patients with trauma can treated far sooner than we ever imagined!

Future Directions for BPD Future Directions for BPD ResearchResearch

Future Directions for BPD Future Directions for BPD ResearchResearch

•Early identificationEarly identification

•PreventionPrevention

•Involving families (e.g,. Family Connections)Involving families (e.g,. Family Connections)

•TreatmentTreatment

•NEABPD Think Tank 2014 and beyondNEABPD Think Tank 2014 and beyond

•Early identificationEarly identification

•PreventionPrevention

•Involving families (e.g,. Family Connections)Involving families (e.g,. Family Connections)

•TreatmentTreatment

•NEABPD Think Tank 2014 and beyondNEABPD Think Tank 2014 and beyond