Tuesday June 11th 2013 - NYBH Staff
Dialectical Behavior Therapy
Distress tolerance, or “the perceived or behaviorally demonstrated capacity to withstand emotional or physical distress” can be a life-long skill to practice. For some individuals, such as those with a diagnosis of borderline personality disorder (BPD), this skill can prove more challenging to master than others (Anestis, Lavendar, Marshall-Berenz, Gratz, Tull, & Joiner, 2012, p. 594). BPD is characterized by strained interpersonal relationships, emotion dysregulation, impulsivity, and often self-harming behaviors and/or ideation. The standard treatment of BPD is Dialectical Behavior Therapy (DBT). created by Marcia Linehan (1993). First and foremost, DBT targets self-harm and prioritizes symptoms to target in the order in which they threaten life or quality of life. It is an intensive treatment consisting of a year-long commitment to weekly individual treatment, weekly group skills-based sessions, telephone consultations as necessary, and team meetings for clinicians to troubleshoot treatment issues.
The Need to Reduce Negative Emotions
DBT has four inter-related treatment modules: Mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness training. Individuals with BPD often have exaggerated responses to negative external stimuli, resulting in intense affective distress. Recent research has found that “an individual’s response to intense affective distress may be as important as affect intensity per se in predicting BPD traits” (Bornovalova, Matusiewicz, & Rojas, 2011, p. 745). The researchers highlight further that it may be “interpreted as lower tolerance of emotional arousal, rather than greater affect intensity, among individuals with BPD” (p. 745). For lack of healthy coping skills to manage intense negative affect, individuals with BPD often resort to self-harm and/or other self-defeating behaviors in an attempt to manage or reduce negative emotions. Thus, the importance of a module focused on distress tolerance, or “one’s willingness and ability to persist in a positive behavior or to refrain from engagement in maladaptive behaviors during periods of emotional or physical distress,” is imperative to improvement in global functioning for an individual diagnosed with BPD (Bornovalova et al., 2011, p. 745).
Acceptance of Situations that Cannot Be Changed
Distress tolerance training is reported as attempting “… to equip clients with a range of specific methods aimed at improving the client’s capacity to tolerate aversive situations, feelings, or thoughts; to survive crisis; and to radically accept that which cannot be changed” (Choudhary & Thapa, 2012, p. 49). An example of an intervention aimed at improving distress tolerance may be exposure therapy or systematic desensitization, during which clients are deliberately exposed to aversive situations that trigger negative emotional arousal and are encouraged to either (1) practice emotional de-escalation by trying new coping strategies or (2) practice mindful, non-judgmental experience of negative emotions—all of which should bolster tolerance and confidence in one’s ability to accept and/or endure negative emotions through repeat exposure. Distress tolerance is approached through a multi-faceted treatment strategy comprised of cognitive restructuring, disputation of irrational belief systems, behavioral goal setting, practice with exposure to negative stimuli, and mindfulness and acceptance exercises. As such, it is a critical component of DBT and imperative in the effective treatment for several mental health disorders, including BPD.
Anestis, M., Lavendar, J., Marshall-Berenz, E., Gratz, K., Tull, M, & Joiner, T. (2012). Evaluating distress tolerance measures: Interrelations and associations with impulsive behaviors. Cognitive Therapy and Research, 36(6), 593-602.
Bornovalova, M., Matusiewicz, A., & Rojas, E. (2011). Distress tolerance moderates the relationship between negative affect intensity with borderline personality disorder levels. Comprehensive Psychiatry, 52(6), 744-753.
Choudhary, S. & Thapa, K. (2012). Dialectical behavior therapy for managing interpersonal relationships. Psychological Studies, 57(1), 46-54.
Linehan, M. (1993). Cognitive behavioral treatment of borderline personality disorder. New York: Guilford Press.
Friday June 7th 2013 - NYBH Staff
Dialectical Behavior Therapy
Borderline Personality Disorder (BPD) is characterized by emotion dysregulation, impulsivity, strained interpersonal relationships, and often self-harming thoughts and behaviors. The standard treatment option is Dialectical Behavior Therapy (DBT), a model developed by Linehan (1993) that consists of intensive therapy usually over the course of one-year. DBT consists of weekly individual therapy sessions, weekly skills-based group sessions, telephone consultations when necessary, and weekly treatment team meetings for therapists to troubleshoot issues that arise over the course of each case. The primary focal points of DBT are mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. The following discussion focuses on mindfulness and the importance of mindfulness skills in treatment outcomes for patients with a diagnosis of BPD.
A common definition of mindfulness comes from Kabat-Zinn (1990): “Paying attention in a particular way: on purpose, in the present moment, and non-judgmentally” (Perroud, Nicastro, Jermann, & Huguelet, 2012, p. 189; Kabat-Zinn, 1990). Mindfulness is a key skill for patients undergoing DBT, claims Linehan (1993), who proposed the skill would reduce patients’ “attempts to control their private experiences, empower them to deal with emotionally distressing periods and increase individuals’ ability to experience and tolerate the current moment while helping them to avoid becoming over-involved in the experience” (Perroud et al., 2012, p. 190; Linehan, 1993). There are three components to mindfulness training in DBT: Observing, describing, and participating (Perroud et al., 2012). These three components are to be applied “non-judgmentally, one-mindfully, and effectively” (Perroud et al., 2012, p. 189).
Components of DBT Studied
Observing, as explained by researchers examining the role of mindfulness skills undergoing DBT, is the “direct perception of experiences, without the addition of concepts or categories” (Perroud et al., 2012, p. 189). Elaborating on other components of DBT, they say that describing “… involves adding a descriptive label to what is observed; [and] participating refers to entering fully and completely into an experience” (Perroud et al., 2012, p. 189). Further, to approach the aforementioned tasks non-judgmentally and one-mindfully means to attend to them without good or bad judgments toward self or others and one task at a time. Effectively practicing these tasks means to give up “being right in favor of doing what works” (Perroud et al., 2012, p. 190). To better understand the impact of mindfulness skills, this group of researchers designed a preliminary study which utilized the four discrete behavioral skills associated with mindfulness in DBT: observing, describing, acting with awareness, and accepting without judgment, as documented on the Kentucky Inventory of Mindfulness Skills (KIMS) scale. Participants in the study were referred by treating clinicians and participated in DBT treatment, with mindfulness modules practiced before the others (emotion regulation, distress tolerance, and interpersonal effectiveness).
Improvement in BPD Symptoms
The researchers found that DBT was associated with an “increase in mindfulness skills over time.” In addition, the most significant improvements were seen in “accepting without judgment,” correlated with improved BPD symptoms over time (Perroud et al., 2012, p. 194). The investigators stress the importance of continued research, as this study reveals only preliminary results. However, the implications of a more detailed understanding of the criterion within the modules of DBT will only help clinicians develop more precise and effective interventions and ultimately improve treatment and outcomes.
Baer, R., Smith, G., & Allen, K. (2004). Assessment of mindfulness by self-report: The Kentucky Inventory of Mindfulness Skills. Assessment, 11(3), 191-206.
Kabat-Zinn, J. (1990). Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness. New York: Delta.
Linehan, M. (1993). Dialectical Behavior Therapy for treatment of borderline personality disorder: Implications for the treatment of substance abuse. NIDA Research Monograph, 137, 201-216.
Perroud, N., Nicastro, R., Jermann, F., & Huguelet, P. (2012). Mindfulness skills in borderline personality disorder patients during dialectical behavior therapy: Preliminary results. International Journal of Psychiatry in Clinical Practice, 16(3), 189-196.
Monday June 3rd 2013 - NYBH Staff
Disordered Emotion Regulation
Individuals diagnosed with Borderline Personality Disorder (BPD) struggle with the capacity to regulate emotions, which is integral to an individual’s ability to function in interpersonal relationships and professionally and further complicates identity formation and acceptance. Impulsivity is also a common characteristic in individuals with BPD and is likely adopted as a maladaptive attempt at coping with negative emotions. Disordered emotion regulation is also associated with substance abuse, contributing to a population of patients with co-morbid BPD and substance use disorders (SUD).
Components of DBT
Dialectical Behavior Therapy (DBT) is the preferred treatment for BPD and has been adapted for those with co-morbid SUDs. This treatment targets suicidal and non-suicidal self-harming behaviors first and foremost; attention is then directed to substance use related behaviors that interfere with quality of life. DBT programs are typically a year in duration and consist of weekly individual therapy sessions, weekly group skills-based sessions, telephone consultations as necessary, and weekly clinician team meetings to address treatment obstacles. Improved emotion regulation is a primary target of DBT, with the belief that improvement in this arena will directly impact maladaptive behaviors in addition to mood and global functioning.
Impact of DBT on Emotion Regulation
To better understand the correlation between DBT treatment in individuals with dual diagnoses of BPD and SUD and improved emotion regulation, a group of researchers designed a 20-week experimental study (Axelrod, Perepletchikova, Holtzman, & Sinha, 2011). The subjects consisted of 27 women admitted to a primary substance use clinic in Connecticut and who met diagnostic criteria for BPD. Results of the study indicated that DBT, in fact, made a significant impact on participants’ emotion regulation, measured before and after treatment with the Difficulties in Emotion Regulation Scale (DERS; Gratz & Roemer, 2004). By the end of treatment, patients reported increased confidence in their ability to “attend to, identify, and understand their emotions, and to remain in control when experiencing negative emotions” (Axelrod et al., 2011, p. 6).
Limitations of Studies on Treating BPD
An obstacle that was indicated in this investigation and that applies to treatment of BPD in general is the often-reported low rate of treatment retention. At the end of the study, only 55.6% of participants had completed treatment (Axelrod et al., 2011, p. 6). The researchers noted it is difficult to ascertain the specific reasons for treatment termination as most patients fell out of contact. Engaging lost patients and retaining patients in treatment are major barriers in DBT and in any treatment of BPD. Another limitation of the study is the abbreviated amount of time for treatment as compared to the typical year-long DBT program. Yet, the promising results warrant further examination and additional research in the hopes of refining and improving treatment for this high-risk population.
Axelrod, S., Perepletchikova, F., Holtzman, K., & Sinha, R. (2011). Emotion regulation and substance use frequency in women with substance dependence and borderline personality disorder receiving dialectical behavior therapy. American Journal of Drug and Alcohol Abuse, 37, 37-42.
Gratz, K., & Roemer, L. (2004). Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the Difficulties in Emotion Regulation Scale. Journal of Psychopathological Behavior Assessment, 26, 41-54.
Wednesday May 29th 2013 - NYBH Staff
Can Exercise Ward Off or Delay Alzheimer’s?
According to research, a healthful food diet can lead to a healthy brain and ultimately have an effect on the development of Alzheimer’s disease. What about a daily exercise routine? Can you “workout” your way to a healthy brain? A recent New York Times article summarized a research study that focused on the relationship between daily exercise and the development of Alzheimer’s disease.
Family History of Alzheimer’s
Based on information obtained from The Archives of Neurology, researchers at Washington University collected data from a sample of 201 adults between the ages of 45 and 88. These participants were part of a study at the University’s Knight Alzheimer’s Disease Research Center, and, while they presented no clinical symptoms of the disease, they had a family history of Alzheimer’s.
Amyloid Plaque and Memory Loss
The scientists at Washington University looked for signs of amyloid plaques (deposits that are a hallmark of the disease) in participants’ brains. This was done with the use of positron emission tomography, an advanced scanning technique. Why was this procedure important at the beginning of the experiment? Well, according to researchers, more memory loss is associated with more plaque.
The Gene Variation, APOE-e4
The next step was to examine a particular gene variation of APOE, known as e4, which is involved in cholesterol metabolism. Scientists explain that, while everyone carries the APOE gene, the particular variation of the gene e4 has been found to be associated with the development of Alzheimer’s disease, and, in fact, individuals who carry this variation of the gene are 15 times more at risk of Alzheimer’s than those who don’t. Moreover, out of the 201 participants in this study, 56 turned out positive for APOE-e4.
Evaluating Lifetime Exercise Habits
The goal of this study was to examine the relationship between exercise and Alzheimer’s disease and potentially to identify effects, if any, of exercise on the development of Alzheimer’s. The researchers suggest that “a daily walk or jog could alter the risk of developing Alzheimer’s or change the course of the disease if it begins.” Hence, the next step was for participants to complete questionnaires regarding their exercise habits over the past 10 years.
Exercise, the APOE-e4 Gene, Amyloid Plaque, and Risk for Developing Alzheimer’s
Following is a list of results reported by the investigators and their recommendation.
· Participants who reported walking or jogging for 30 minutes a day for 5 days a week had fewer amyloid plaques;
· Carriers of the APOE-e4 gene (showing higher amyloid plaques) who reported exercising daily decreased their inherited risk for developing the disease (over carriers who did not exercise);
· “activity levels may have an impact on plaque accumulation;”
· In participants who followed an inactive lifestyle, there was an increase in the accumulation of amyloid plaques.
The findings suggest that daily walking, jogging, or other forms of exercise could lower an individual’s risk of developing Alzheimer’s disease, even if he/she is a carrier of the APOE-e4 gene variation and shows more plaque (known to be associated with memory loss). Further, it appears that a non-carrier can increase his/her risk of developing Alzheimer’s by following an inactive lifestyle. Conversely, it is quite possible that the non-carrier may decrease this risk by adhering to a daily exercise regimen). More research on these topics needs to be conducted to enhance our understanding of the effects of exercise on this disease.
Reynolds, G. (2012, January 18). How exercise may keep Alzheimer's at bay. The New York Times. Retrieved from http://well.blogs.nytimes.com/2012/01/18/how-exercise-may-keep-alzheimers-at-bay/?ref=health
Tuesday May 28th 2013 - NYBH Staff
Obsessive-compulsive disorder (OCD) is characterized by obsessions, i.e., intrusive negative thoughts that often produce anxiety. Most people with OCD cope with these thoughts through a series of rituals/behaviors called compulsions (Broderick, Grisham, & Weidemann 2013). There are several different types of OCD. One of the most common types features contamination-based fears and manifests itself as the rigid fear of infection, disease, or pollution from people or objects the individual believes are soiled or dirty (Broderick et al., 2013). Broderick and fellow researchers (2013) highlight recent research that has indicated the contamination-fear related OCD may be distinguishable from other strains of OCD on varying levels, most interestingly to the researchers in abnormalities related to the emotion of disgust (Broderick et al., 2013; Woody & Teachman, 2000).
Role of Disgust in Contamination-Based OCD
Because OCD has typically been characterized as one of anxiety, driven by an “abnormal fear experience” Broderick et al. (2013, p.27) are particularly interested in the role of disgust as it relates to contamination-fear OCD. The researchers note that further research into the particularities of the role of disgust could be critical in improving treatment for contamination-fear OCD. The current standard of treatment for OCD is exposure-based behavioral therapy; however, a significant portion of patients with OCD do not respond well to treatment (Fisher & Wells, 2005). This may be because “self-report findings suggest that disgust is particularly resistant to extinction relative to fear” (Broderick et al., 2013, p. 29; Mason & Richardson, 2010). Thus, it is critical for the advancement of OCD treatment options to further explore the distinctions between standard fear-based OCD and contamination-fear OCD, which is more associated with disgust than with fear.
Reactions During Disgust Experiences
The investigators designed a study to contribute to this canon of literature by determining the normative disgust experience for both populations with high and low contamination fears and examining how the disgust experience is influenced by exposure (Broderick et al., 2013). This study examined change, both physiological and self-reported, over time and exposure of 12-14 minutes. Participants were drawn from the freshman class at a university in Wales and screened for contamination fears. Those with the highest and lowest reports were invited to participate in the study. Participants were hooked up to ECG machines so heart rate could be measured during the session. Then images from two distinct disgust-related categories, body waste and blood injury, were shown. These pictures were shown over four block sessions.
Expose Contamination-Fear OCD Patients to Body Waste Images
The results of the study indicated significant differences between the two image types: “Body waste images elicited a stronger self-report of disgust than blood injury; while blood injury images elicited a stronger self-report of fear than [did] body waste” (Broderick et al., 2013, p. 34). The researchers note the implications of this finding for clinicians seeking to elicit either fear or disgust in patients during exposure therapy. They further concluded that body waste images were perhaps more useful stimuli to use with contamination-fear OCD patients because they elicited a greater degree of disgust than fear (Broderick et al., 2013). Also, consistent with the researchers’ initial hypothesis, the participants with high contamination fears experienced greater overall levels of disgust and fear than their counterparts. Thus, elevated disgust response during disgust provocation may be helpful in differentiating contamination-fearing OCD from other types of OCD. Interestingly, a significant difference was not observed with respect to changes in heart rate after exposure. Thus, the researchers concluded it may be the case that “high contamination fears are associated with elevated subjective, but not cardiovascular, disgust response” (Broderick et al., 2013, p. 35). The researchers are careful to highlight that individuals struggling with contamination-based OCD are not without fear; moreover, that the emotional experiences and motivators of fear and disgust are separate and distinct from one another.
Broderick, J., Grisham, J., & Weidemann, G. (2013). Disgust and fear responding in contamination-based obsessive-compulsive disorder during pictorial exposure. Behavior Therapy, 44(1), 27-38.
Fisher, P., & Wells, A. (2005). How effective are cognitive and behavioral treatments for obsessive-compulsive disorder? A clinical significance analysis. Behavior Research and Therapy, 43(12), 1543-1558.
Mason, E., & Richardson, R. (2010). Looking beyond fear: The extinction of other emotions implicated in anxiety disorders. Journal of Anxiety Disorders, 24(1), 63-70.
Woody, S., & Teachman, B. (2000). Intersection of disgust and fear: Normative and pathological views. Clinical Psychology: Science and Practice, 7(3), 291-311.
Friday May 24th 2013 - NYBH Staff
Versatility of DBT
Dialectical Behavior Therapy (DBT) is an evidenced-based treatment approach most commonly utilized among patients with a diagnosis of Borderline Personality Disorder (BPD). DBT consists of a year-long commitment consisting of weekly individual and skills-based group sessions, telephone consultations as needed, and weekly team meetings for treating clinicians to better refine the interventions. Though designed for suicidal BPD patients, DBT has also had treatment impact on several other populations through its focus on group skills based sessions: Oppositional-defiant adolescents (Nelson-Gray, 2006), adult ADHD (Hesslinger, 2002), treatment-resistant major depressive disorder (Harley, Sprich, Safren, Jacobo, & Fava, 2008), binge-eating disorders (Telch, Agras, & Linehan, 2000), and families of suicidal patients (Rajalin, Wickholm-Pethrus, Hursti, & Jokinen, 2009). Addiction treatment can also benefit from the incorporation of DBT techniques, especially in the case of patients with co-occurring BPD and substance abuse.
Addiction Treatment and the Dialectical Approach
Roes (2008) reviewed the positive relationship between DBT and addiction treatment in an article for Addiction Professional. He writes that, historically, addiction treatment has emphasized the dialectical approach, meaning the combination of two seemingly opposing strategies. In the case of DBT, clinicians work to simultaneously confront clients’ distorted belief systems and maladaptive behaviors and also validate and promote self-acceptance with clients. Roes (2008) writes that the dialectical approach supports research in the addiction field, indicating that improvement in client’s self-esteem allows for better receptivity to constructive confrontation.
Prioritizing Maladaptive Behaviors Targeted by DBT
DBT strategies are aimed, first and foremost, to reduce suicidal and self-injurious behaviors, which are both especially common among individuals with BPD. When used with patients struggling with substance abuse, maladaptive behaviors are subsequently prioritized based on level of threat to individuals’ safety and quality of life; thus substance use is a close second to suicidal ideation/intent. The goal is to reduce use of substances and then to relieve the discomfort the client experiences in the absence of intoxication (Roes, 2008). Additionally, there are several strategies employed to help patients practice forecasting future struggles, problem-solving in advance of those situations, generating alternative behaviors to practice, and making necessary adjustments to their environment. Researchers are encouraged to conduct further research to better refine and support the relationship between DBT and its use in substance abuse patients.
Harley, R., Sprich, S., Safren, S., Jacobo, M., & Fava, M. (2008). Adaptation of dialectical behavior therapy skills group for treatment-resistant depression. Journal of Nervous and Mental Disorders, 196(2), 136-143.
Hesslinger, B., Tebartz van Elst, L., Nyberg, E., Dykierek, P., Richter, H., & Berner, M. (2002). Psychotherapy of attention deficit hyperactivity disorder in adults--a pilot study using a structured skills training program. European Archives of Psychiatry Clinical Neuroscience, 252, 177-184.
Neacsiu, A., Rizvi, S., & Linehan, M. (2010). Dialectical Behavior Therapy skills use as a mediator and outcome of treatment for borderline personality disorder. Behavior Research and Therapy, 48, 832-839.
Nelson-Gray, R., Keane, S., Hurst, R., Mitchell, J., Warburton, J., & Chok, J. (2006). A modified DBT skills training program for opposition-defiant adolescents: promising preliminary findings. Behavior Research and Therapy, 44, 1811-1820.
Rajalin, M., Wickholm-Pethrus, L., Hursti, T., & Jokinen, J. (2009). Dialectical behavior therapy-based skills training for family members of suicide attempters. Archives of Suicide Research, 13, 257-263.
Roes, N. (2008) “DBT fits well in addiction treatment.” Addiction Professional Online. www.addictionpro.com.
Telch, C., Agras, W., & Linehan, M. (2000). Group dialectical behavior therapy for binge-eating disorder: A preliminary, uncontrolled trial. Behavior Therapy, 31, 569-582.
Tuesday April 30th 2013 - NYBH Staff
If stress is making you feel anxious, angry, or fatigued, yoga could be the solution to these problems.
What is Yoga?
According to literature, yoga is a physical, mental, and spiritual discipline whose goal is the attainment of a state of perfect spiritual insight and tranquility. Basically, it’s an ancient technique that helps promote health through meditation, exercises, and regulation of breathing.
Short-Term vs. Long-Term Effects of Yoga on Physical and Mental Status
Research has focused mainly on the short-term effects of yoga and results suggest that it can be very beneficial in terms of reducing stress and improving general health in individuals. That sounds terrific. But what about long-term effects? Fortunately, recent research has shifted the focus from short-term to long-term effects of yoga training, and now we can finally get some answers to that important question.
Research and Results
In order to look at yoga’s long-term effects, a team of researchers collected data from a sample of 38 women who had practiced yoga for two or more years as well as from a control group of 37 healthy adult females who had had no experience with yoga (Yoshihara, Hiramoto, Sudo, & Kubo, 2011). Then they compared the two sets of data. The initial screening had been carried out through the use of self-completed questionnaires and urine samples. The questionnaire used in this study tested for mood disturbance while examining the following mood subscales: tension-anxiety, fatigue, depression, anger-hostility, vigor, and confusion. The urine sample was used to measure psychological stress via levels of cortisol, 8-OHdG (8-hydroxydeoxyguanosine), and biopyrrin as stress–related biochemical indices, and results between the two groups (yoga and non-yoga practitioners) were compared.
The investigators found that long-term yoga training did help to reduce levels of self-related anxiety, anger, and fatigue. However, while more research needs to be done to further explore and more thoroughly evaluate the long term effects of yoga training, we can be relatively sure about one thing: yoga helps decrease levels of stress and negative feelings while promoting mental and physical health.
Conclusion: How Yoga Can Help You
Generally, yoga is known for its therapeutic qualities in terms of mental disorders, but physical diseases as well. According to the researchers (who authored a peer-reviewed article chronicling the data collection and describing the findings), diseases such as asthma, hypertension, rheumatoid arthritis, migraines, musculoskeletal disorders, and cancer-related symptoms, among others, are linked with stress. While stress might not necessarily cause the development of such disease, it may definitely aggravate it. For instance, what happens when someone with chronic hypertension is under a great deal of stress? Blood pressure rises, possibly increasing the levels of stress even more. This becomes a vicious cycle. However, the previously mentioned article suggests that a few simple relaxation/breathing techniques can help to control many health problems. So why would anyone rely solely on pills or medications in other forms to manage health conditions? Why not try something new and make yoga a part of your life? It might work for you and you can move toward a healthier and happier state of being.
Yoshihara, K., Hiramoto, T., Sudo, N., & Kubo, C. (2011). Profile of mood states and stress-related biochemical indices in long-term yoga practitioners. BioPsychoSocial Medicine, 5(1), 6.
Friday April 26th 2013 - NYBH Staff
Co-Existence of BPD and PTSD
There is a high co-morbidity that often exists between diagnoses of Borderline Personality Disorder (BPD) and Posttraumatic Stress Disorder (PTSD), with estimates of 30-50% of people diagnosed with BPD also meeting criteria for PTSD (Harned, Rizvi, & Linehan, 2010). BPD is characterized by emotion dysregulation, severely strained interpersonal relationships, and maladaptive behaviors such as suicidal and non-suicidal self-injury (NSSI) as expressions of the extreme inner pain experienced by many with BPD. PTSD can manifest itself in several secondary diagnoses, including disassociation, depression, anxiety, etc. Understandably, the co-existence of these two often debilitating disorders can exacerbate symptoms (i.e., suicidality and NSSI) and affect treatment outcomes, both long- and short-term.
Despite the notable percentages tying these two disorders together, Harned, Korslund, Foa, & Linehan (2012) note that no current treatments exist that target PTSD in patients expressing suicidal ideations or practicing NSSI. Conversely, treatments for BPD often do not target a patient’s concurrent PTSD. Intuitively, suicidal symptoms must be addressed first and foremost during therapy; issues related to PTSD will have to be tackled once suicidal and NSSI behaviors are under control. Dialectical Behavior Therapy (DBT), the accepted treatment for BPD, follows the model of addressing life-threatening behaviors first. It does recommend exposure therapy in treatment of PTSD but does not specify exactly when or how to implement it within the context of DBT’s larger treatment model. Harned et al. (2012) sought to better understand how to integrate Prolonged Exposure (PE) in treatment of PTSD with a standard year-long DBT program. This treatment program consisted of weekly individual therapy sessions, a weekly group skills-based session, telephone consults when necessary, and weekly treatment meetings among clinicians.
The DBT-PE Protocol
The combined program protocol (DBT-PE) was trialed on 13 participants with dual diagnoses of BPD and PTSD and also exhibiting recent or imminent suicidal or NSSI behaviors. Participants were screened prior to treatment and post one year treatment, with the aim to understand whether DBT-PE was: “(1) associated with improvements in PTSD and intentional self-injury as well as secondary outcomes, (2) feasible to implement, (3) acceptable to patients and therapists, (4) safe to administer” (Harned et al., 2012, p. 382). Patients all started in standard DBT treatment; the PE protocol was not introduced until non-suicidal ideations or NSSI behaviors were reported.
High Retention and Remission from PTSD
The results of this study indicated that combined DBT with DBT-PE Protocol treatment was “acceptable and feasible” to implement for the majority of patients. Patients and therapist both reported positive experiences during the trial, and patients reflected a high retention rate, with only a 23% dropout rate (Harned et al., 2012). Also of note, all patients in the study were able to reach a sufficiently high level of stability to start the PE Protocol treatment. That is, 70% of them continued on to complete the full treatment (13 PE sessions) within the year. Impressively, the rates of relapse for NSSI were as low as 10% and the “majority of patients also achieved remission from PTSD at post-treatment” (Harned et al., 2012, p. 385). The implications of this research are preliminary, and more studies need to be completed to refine and further examine the indications for this approach on a high-risk demographic.
Harned, M., Rizvi, S., & Linehan, M. (2010). The impact of co-occuring posttraumatic stress disorder on suicidal women with borderline personality disorder. American Journal of Psychiatry, 167, 1210-1217.
Harned, M., Korslund, K., Foa, E., Linehan, M. (2012). Treating PTSD in suicidal and self-injuring women with borderline personality disorder: Development and preliminary evaluation of a Dialectical Behavior Therapy Prolonged Exposure Protocol. Behavior Research and Therapy, 50, 381-386.
Sunday April 21st 2013 - NYBH Staff
Low Vitamin D is Risky
Over the past few years, there has been a debate around the relationship between Vitamin D levels and depression. Studies suggest that low Vitamin D levels are already accepted as risk factors for several medical problems, such as autoimmune diseases, heart and vascular disease, infectious diseases, osteoporosis, obesity, diabetes, certain cancers, Alzheimer’s, Parkinson’s, multiple sclerosis (MS), and general cognitive decline. However, the question remains of whether or not Vitamin D levels are linked to depressive symptoms and, if so, what exactly the relationship is.
What High Vitamin D Level Means
UT Southwestern Medical Center, in partnership with Cooper Center Longitudinal Study, has been conducting ongoing research on this topic. In this longitudinal research study, researchers examined results from late 2006 to late 2010 of approximately 12,600 participants. They found that higher Vitamin D levels were associated with lower risk of current depression (mainly in people with prior history of depression).
The Vitamin D – Depression Link
According to findings from this study, in individuals with a history of depression, low vitamin D levels were associated with depressive symptoms. However, there is yet no evidence to support whether increasing Vitamin D levels in those individuals will help reduce depressive symptoms.
The Nature of the Relationship
Moreover, while results from this research support the idea that there is in fact a relationship between Vitamin D levels and depressive symptoms, the exact direction of that relationship is still unclear. However, there is evidence that Vitamin D levels may affect neurotransmitters, inflammatory markers, and other factors, which could help explain how the vitamin is related to depression.
UT Southwestern Medical Center (2012, January 5). Low vitamin D levels linked to depression, psychiatrists report. ScienceDaily. Retrieved January 11, 2012 from http://www.sciencedaily.com/releases/2012/01/120105131645.htm
Tuesday April 9th 2013 - NYBH Staff
Young Adult Females’ Use of Marijuana
Marijuana is a widely used substance throughout the United States and has been linked to varying psychosocial issues, such as poor academic and professional achievement and reliability, accidents while working, and increased susceptibility to mental health disorders like depression and anxiety (de Dios, Herman, Britton, Hagerty, Anderson, & Stein, 2011). Researchers and clinicians have identified increasing use of marijuana as a public health problem, and as such, ample research has been conducted about marijuana users, trends, and treatment outcomes. A gap, however, exists in research targeting young adult female users. In an effort to better understand treatment options for this population, this group of researchers seek to address this gap (de Dios et al., 2011). One of the chief goals of the study they designed is to curb some of the negative consequences associated with use by young adult females, such as inconsistent condom use and increased sexual activity under the influence, both of which heighten the risk of unwanted pregnancy and contraction of sexually transmitted diseases (De Genna, Cornelius, & Cook, 2007; Poulin & Graham, 2001).
The intervention method the researchers chose to assess is motivational interviewing (MI). It is a client-centered method that focuses on decreasing ambivalence about an identified clinical issue/s through psychoeducation, designing strategic goals for wellness, and allowing for self-determination in the client’s treatment journey. Motivation interviews have demonstrated effectiveness in adolescents and young adults in previous research studies (McCambridge & Strang, 2004; Walker, Roffman, Stephens, Wakana, Berghuis, & Kim, 2006). Thus, de Dios et al. (2011) designed a randomized study in which 332 women between the ages of 18 and 24 were assigned to either a 2-session MI intervention or an assessment-only intervention.
Importance of Desire to Quit
The results of the MI intervention were insignificant at one month, significant at 3 months, and no longer significant at 6 months. However, the investigators note that, among the 61% of participants who espoused a desire to quit using marijuana, the MI intervention was statistically significant at all three intervals: 1 month, 3 months, and 6 months (de Dios et al., 2011, p. 57). They emphasize the aforementioned caveat to demonstrate that MI is potentially most effective in circumstances where individuals already hold some desire to stop using. This finding is important for clinicians seeking to develop the most effective treatment approaches for individual clients.
Alternative Coping Skills for Anxiety
It was noted that many of the study’s participants reported using marijuana as a self-treatment for anxiety. The researchers therefore introduced mindfulness exercises as a supplement to MI interventions (de Dios et al., 2011). The mindfulness exercises and meditation were used in conjunction with MI in an attempt to teach participants alternative coping skills to deal with reported anxiety. Based on participants’ reports, the women in the study group were half as likely to use marijuana on days when they had meditated (de Dios et al., 2011, p. 62). Due to the study’s limitations, however, no broad significant conclusions can be drawn on the use of mindfulness exercises and marijuana use.
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