A new programme is being rolled out across the country to teach people who are severely suicidal and who repeatedly self-harm that there is a less destructive way to manage their emotional pain.
Those who repeatedly self- harm are often diagnosed with borderline personality disorder (BPD), which is characterised by difficulties in managing emotions, in suicidality and continual self-harm.
Dr Marsha Linehan, a psychologist at the University of Washington, has led a crusade to find an effective treatment approach for BPD and has been credited internationally with developing the most effective treatment to date – dialectical behaviour therapy (DBT).
Linehan spent a week in Ireland at the start of the year training health practitioners in her techniques.
For people with BDP – which is also known as emotionally unstable personality disorder or emotional intensity disorder – standard DBT cuts suicide in half, cuts emergency department visits in half and cuts inpatient admission by 73 per cent when compared with other expert non-behavioural treatments.
Dialectical Behavior Therapy (DBT) reduced suicide attempts by half compared with other types of psychotherapy available in the community in patients with borderline personality disorder, an NIMH-funded study has found. DBT also excelled at reducing use of emergency room and inpatient services and more than halved therapy dropout rates compared to the mostly traditional approaches, report Marsha Linehan, Ph.D., University of Washington, and colleagues in the July 2006 issue ofArchives of General Psychiatry.
“All treatments are not equal for such suicidal patients,” said Linehan.
Borderline personality disorder is a difficult-to-treat mental illness affecting up to two percent of adults, 5.8-8.7 million Americans, mostly young women. People with this disorder of emotion regulation experience intense bouts of anger, depression, and anxiety that may last only hours, often in response to perceived rejection. They typically have tumultuous work and family life and may engage in risky, impulsive behaviors. Cutting, burning and other forms of self-harm are common, with up to 9% ultimately killing themselves. Although they account for at least 20 percent of psychiatric inpatient admissions, and frequently seek mental health services, patients with the disorder often fail to respond to commonly available treatments.
Hence, NIMH has supported the development and testing of DBT by Linehan and her colleagues over the past two decades. This variation on cognitive behavioral therapy specifically targets suicidal behavior, behaviors that interfere with treatment, and risky social behaviors. While previous controlled trials had demonstrated DBT’s usefulness, whether this was attributable to psychotherapy generally rather than to specific features of DBT remained unclear.
To help resolve this issue, the researchers created a more tightly-defined comparison condition. They treated for one year 101 female patients with borderline personality disorder, ages 18-45, in the Seattle area with either currently available “Treatment By Experts” (TBE) in the community, or therapists specifically trained in DBT.
The 52 patients randomly assigned to the DBT group received one hour of individual therapy and 2.5 hours of group skills training each week, in addition to phone consultations. DBT focused on improving patients’ coping skills and motivation by helping them reduce interfering emotions and thinking and reinforce functional behaviors. Their 16 DBT therapists also met weekly to enhance their motivation and skills.
Different patterns of brain activity in people with borderline personality disorder were associated with disruptions in the ability to recognize social norms or modify behaviors that likely result in distrust and broken relationships, according to an NIMH-funded study published online in the August 8, 2008 issue of Science.
Borderline personality disorder is a serious mental illness noted by unstable moods, behavior and relationships. Each year, 1.4 percent of adults in the United States have this disorder,1 which is widely viewed as being difficult to treat.
Using brain imaging and game theory, a mathematical approach to studying social interactions, the researchers offer a potential new way to define and describe this mental illness. They conclude that people with borderline personality disorder either have a distorted sense of generally accepted social norms, or that they may not sense these norms at all. This may lead them to behave in a way that disrupts trust and cooperation with others. By not responding in a way that would repair the relationship, people with borderline personality disorder also impair the ability of others to cooperate with them.
Brooks King-Casas, Ph.D., Baylor College of Medicine, and colleagues evaluated cooperation among pairs of participants playing an investment game. Each pair comprised a healthy “investor” and a “trustee,” who was either another healthy participant or a person with borderline personality disorder. In total, 55 people with borderline personality disorder participated. An additional 38 healthy trustees paired with healthy investors served as a control group. The investors and trustees interacted through linked computers, but did not meet or speak with each other at any point.
In each 10-round game, the investor started every round with 20 “dollars” and could invest any amount between 0–20. Clicking a button to send the investment offer automatically tripled the amount, at which point the trustee decided how much to return. If the amount returned was less than the amount invested, the investor was likely to offer smaller amounts in future rounds, signaling a breakdown in trust and cooperation in the relationship. Trustees could try to “coax” their investor partner by returning a large portion of the tripled investment, even when the offer was low—for example, returning all 15 dollars on a 5-dollar offer. Ultimately, coaxing resulted in generous payoffs in later rounds.
Compared with the control group, trust and cooperation faltered over time in pairs that included a person with borderline personality disorder. People with the illness tended to behave in ways that caused a breakdown in cooperation with their healthy partners. Moreover, they were half as likely as healthy trustees to try to repair the relationship through coaxing.
To determine whether a neural basis exists for this behavior, the researchers analyzed brain activity in the bilateral anterior insula. In addition to other functions, this region responds when we sense unfairness or violations of social norms.
Potential physiological marker for a severe mental disorder
• Science Update
Adults with borderline personality disorder (BPD) showed excessive emotional reactions when looking at words with unpleasant meanings compared to healthy people during an emotionally stimulating task, according to NIMH-funded researchers. They also found that people with more severe BPD showed a greater difference in emotional responding compared to people with less severe BPD. The study was published in the August 1, 2007, issue of Biological Psychiatry.
Borderline Personality Disorder is a serious mental illness characterized by intense fear of abandonment and/or rejection, problems controlling emotions, troubled relationships, impulsive or reckless behaviors, and other symptoms. The disorder affects roughly 1.4 percent of adults ages 18 and older in the United States.1
Erin Hazlett, Ph.D., of the Mount Sinai School of Medicine, and colleagues measured the startle eyeblink response, a measure of emotional reactivity, in 27 people with BPD and 21 healthy people. Past research shows that people are generally more startled during unpleasant situations than during emotionally neutral ones.2 During the study, each participant was shown a random series of words, some with neutral emotional meaning (such as “collect,” “regular,” “actually”) and some with unpleasant meanings, particularly for people with BPD (such as “hate,” “lonely,” “abandon”). The participants would hear a brief startling burst of static noise at unpredictable intervals—sometimes while a word was shown, sometimes between words, and sometimes not at all.
The researchers found that both groups of participants had similar startle reactions when viewing neutral words. But people with BPD were more startled than healthy adults by the static burst when looking at unpleasant words. Also, people with more BPD symptoms showed a greater difference in startle reaction when viewing unpleasant words vs. neutral words compared to people with less severe BPD. This finding suggests that unstable emotions and impulsiveness in people with BPD may be related to an exaggerated startle reflex. The researchers’ study presents an objective way to measure the problems with mood and emotional responses that are hallmark symptoms of BPD, suggesting a potentially useful adjunct to self-reported information when diagnosing and treating the disorder.
“Having the scarlet letter saying you had a mental health issue… that prevents you from purchasing a weapon, I’m not sure that’s a wise policy statement,” said Mark Pearlmutter, an emergency physician in Boston and an expert on mental health issues. “However, anyone who has history of violence, incarceration, borderline personality disorder, or unpredictability, I would personally support those patients not having access to weapons.”
Bon: I am NOT getting political here. I wanted to point out that I would never own a gun while living with a person with Borderline Personality Disorder. The impulsiveness + suicidal ideation + access to a gun = a very dangerous situation.
D.C. shift: Gun control to threat detection
By RACHAEL BADE | 4/3/14 8:16 PM EDT
After an Iraq War veteran took the lives of three other people at Fort Hood on Wednesday, President Barack Obama, Pentagon officials and others in Washington agreed more must be done to spot “insider threats” before they strike.
But what almost no one is saying: change gun laws.
The Fort Hood attack is the latest in a string of mass shootings, from the Navy Yard attack in September to a shooting at a Sikh temple in Wisconsin the year before, where the response from Washington has shifted from guns – to the shooters who wield them.
The push now is to identify those who might become violent before they act, especially when the military is involved — whether that’s a contractor who the police identified as unstable, like the Navy Yard shooter, or the gunman who had been treated by a psychologist at Fort Hood.
“We need to be honest with ourselves and with you and hold ourselves accountable,” Army Secretary John McHugh told the Senate Armed Services Committee on Thursday “If we identify new challenges, new threats that we hadn’t recognized before, we need to put into place new programs to respond.”