Borderline Personality Disorder - Assignment Example

RUNNING HEAD: BORDERLINE PERSONALITY DISORDER, PTSD Borderline Personality Disorder, Post Traumatic Stress Disorder And Substance Use Disorder Syndrome Name Class Date The research states that in sexual trauma there is a prevalence of consequent axis I and II disorders, especially Borderline Personality Disorder (BPD) as well as Post Traumatic Stress Disorder (PTSD) and Substance Use Disorder [SUDS] (Yen et al., 2002). This heavy correlation between PTSD, borderline personality disorder and substance abuse disorder, create complications in treatment (Ross, Dermatis, Levounis, and Galanter, 2003). Before proceeding in this paper, it is necessary to clarify the main theoretical concepts, such as BPD and PTSD. Speaking popularly, Post Traumatic Stress Disorder (PTSD) is “a normal response to an abnormal event” (Schiraldi, 2000, p. 3). The American Psychiatric Association(APA) in the DSM-IV Diagnostic and Statistical Manual of Mental Disorders (4th Edition) classifies PTSD as one of the anxiety disorders, typically caused by either or several of the three types of traumatic events: Intentional human causes, Unintentional human causes, or Acts of Nature. The presence of the stressor as part of the diagnosis differentiates PTSD from other disorders and makes it a uniquely complex phenomenon. (page number) Besides an exposure to the stressful event, the APA (1994, paraphrased in Schiraldi, 2000) lists four other critera for PTSD: persistent (more than one month) re-experiencing of the trauma (this category of symptoms is titled “intrusive memories” in Johnson, 2004), persistent (more than one month) avoidance of trauma-associated stimuli and suppression of general responsiveness (“avoidance behavior according to Johnson, 2004), persistent (more than one month) symptoms of hyperarousal (or, according to Johnson, 2004, “hyper-vigilance”), and disruption of psychological and functional equilibrium. Borderline Personality Disorder (BPD) is defined as “a highly prevalent, chronic, and debilitating psychiatric problem” associated with the following symptoms: “a pattern of chaotic and self-defeating interpersonal relationships, emotional labiality, poor impulse control, angry outbursts, frequent suicidality, and self-mutilation” (Levy, 2005, p. 259). Kernberg (2004), who considered the organization of the personality to be crucially determined by affective responses as displayed under conditions of peak affect states, adds to this definition: “identity diffusion and the … predominance of primitive defensive operations centering on splitting” among the key symptoms of this psychological dysfunction noting that they are accompanied by “the presence of good reality testing” (p. 99). The researcher meant that although the patient imagined himself living in the paranoid and distorted reality, he differentiated between the self and other objects. Many current researchers acknowledge the correlation between PTSD and BPD. Bremner (1999) conceptualized BPD as fitting into the psychiatric disorders associated with traumatic stress. From his perspective, an exposure to traumatic events and other stresses affected structural and functional aspects of the brain creating a stress-related psychiatric dysfunction. To specify, PTSD and BPD co-existed in almost a half of the sample. It was as though individuals created a shift in the brain to protect them when experiencing traumatic stress. This viewpoint was supported by McGlashan et al. (2000) who found a high rate of Axis I and II overlap. This observation came as a result of a study where they measured a clinical sample of four representative DSM-IV personality disorders. They called this "The Collaborative Longitudinal Personality Disorders Study" (CLPS) (page number). Yen et al. (2002) conducted a similar study to analyze the correlation of the aforementioned two disorders within the population of 668 individuals between the ages of 18 and 45 years. Twenty-five percent of those participants (N = 167) exhibited BPD symptoms. Furthermore, BPD participants more often suffered from lifetime PTSD than patients with any other form of personality disorder (51% of 191 individuals reported a history of traumatic exposure). Overall, Yen et al. (2002) hypothesized that BPD symptoms trigger a vulnerability for traumatic exposure which is the key characteristic of PTSD. Bolton, Mueser, and Rosenberg (2006) observed that between 25% and 56% of individuals with BPD exhibited symptoms of current PTSD as compared to approximately 10% of other patients. Their research involved two studies. One involved 275 mentally impaired inpatient and outpatient individuals with PTSD (30 patients with BPD among them), and the other involved 204 patients (20 people with BPD among them). The researchers stated that co-morbid diagnoses of BPD and PTSD were associated with higher rates of severe anxiety and depression. Ross, Dermatis, Levounis, and Galanter (2003) cited empirical evidence that co-morbid PDs being highly associated with Substance Use Disorder (SUDS) in approximately 50% of their samples. They also shared a viewpoint that stress-related dysfunctions predicted worse treatment outcomes, e.g. poorer psychosocial functioning, increase drug use, and lower retention rates. (page number) Patients with co-morbid disorders (dual and triple diagnoses) were more likely to abuse substance use. Consequently, such individuals had more inpatient admissions and more severe symptom profiles than those with a single diagnosis. The difference between people with the single-, dual- and triple diagnoses was extremely evident in after-hospitalization treatment. Ross et al. (2003) argued that co-morbidity of PDs as accompanied by SUDs should put the clinicians "on alert" as such individuals needed to be guided “at this critical junction” (p. 275). This transition from the in- to out-patient environments was critical to teach clients to be aware of what to do after-care, and what to do to comply with after-care therapy. In analyzing the implications of how failure to address these dynamics in reducing harm and treating co-occurring disturbances may further delay treatment and create relapse. The high rate of psychiatric co-morbidity demonstrated by numerous prevalence studies has lead to further investigations into the development of treatments which address the range of patients’ psychological and psychiatric problems. The aim of treating individuals’ substance abuse problems and co-existing personality disorders concurrently marks a departure from more traditional approaches to treatment where each problem was addressed separately. For example, chemical dependency treatment programs typically do not address co-occurring personality disorder, and many mental health providers, both clinics and private practitioners, do not treat a patient with a substance abuse problems, but will refer the patient to a chemical dependency program. This could be necessary if this type of treatment is beyond the scope of practice of the program or its therapists. However, the complex interaction of addictive disorders and additional personality disorder, however, suggests that there may be significant benefit to treating these problems simultaneously (Miller & Brown 2001; Ziedonis 1997;Najavits, 2002). In an outcome study by Najavits, Weiss, Shaw and Muenz (1998), it was found that “Clinically the combination of PTSD and substance abuse is marked by a more severe course than either disorder alone. In two studies in which substance abuse patients with current DSM-II-R PTSD were compared to substance abuse patients without PTSD, the former evidenced significantly greater impairment on a wide range of variables, including other Axis I disorder, psychiatric symptoms, compliance with aftercare, interpersonal and medical problems, and motivation for treatment.(page number). According to Najavits (2002), in her work with BPD, in out patient treatment, “Seeking Safety” was a method for reducing harm that addresses PTSD. Although she talks about Dialectical behavior therapy(DBT), she criticizes this practice because, it does not address PTSD directly. Instead, she feels that if patients are taught Seeking Safety, they will be better able to cope with their disorders, regardless of whether it is PTSD or BPD: “Indeed, in the pilot study on Seeking Safety, only 29% of patients met criteria for borderline personality disorder; paranoid personality disorder was more prevalent at 47%.” (page number) Trauma and substance abuse disorder (SUD) thus represent a natural pairing. One victim of childhood physical and sexual abuse said, ‘When I was twelve I had my first drink, and I knew immediately this was my answer. I felt relaxed for the first time in my life. I became an instant alcoholic.” (Najavits 2004 p. ) This is a common story for many who have suffered trauma. They find themselves in emotional states that do not coincide with the world they live in so they may have an inability to create good interpersonal relationships. When they add substance addiction or a general use of alcohol or other drugs to regulate their emotional anxiety, can cause other problems in treatment. Lineman (1993) suggests in their, “Behavioral Treatment of Borderline Personality Disorder” that the individual with BPD is emotionally vulnerable biologically and will automatically react in an exaggerated manner. Individuals may develope a way of “self-invalidation” where they either under express or dont express their feelings because their environment as a child couldn’t be trusted. This “invalidating environment” can be from extremes in the home and the child identifies with their own personality. As the client/patient invalidate themselves and begins vacillating in their problem solving behavior, in order to find acceptance through their reactions, they will choose not to respond emotionally or will find themselves over responding. Because communication is confusing for them, these non congruent reactions create a learned helplessness. At this point, because they cant trust their own communication, they look to others to solve their problems, which creates an unhealthy dependence on the other person. Once this happens, they slowly are unable to solve their own problems. When a patient has BPD and PTSD with triggers, the concept of staying safe is very important to their survival. Therapists must help clients manage their own emotions, in the present moment, and help them regulate these emotions on their own. However, this can be intense for the patient and takes time. For the therapist, it may take years of training. The goal is to create a method of acceptance for what is right here, right now. This method doesn’t address the PTSD. Najavits (2002) uses coping skills in “Seeking Safety,” by using red and green flags which “(1) identify signs of danger and safety for PTSD and substance abuse, and (2) create a safety plan." (page number) PTSD worsens as the individual withdraws from the effects of substance abuse, which can uncover extreme emotional pain that they numbed while using. As patients learn about their PTSD and are able to look at their addiction they tend to feel “less crazy” and more understanding of themselves. Najavits also suggests tht compassion is needed. Here is one way she suggests: Scene: A child sees their parent or other adult using drugs. Adult Responses The adult responds by self talk which is very negative. “I don’t deserve to live,” “I have always been a bad person and now my child can see that.” They create safety by saying to themselves “I said to myself, I must be feeling really upset and deprived if I used in front of her. The adult responds to self, "How do I need to take care of myself better so that this won’t happen again?” (Responses from Najavits 2004) Without this type of careful treatment and attention, this individual may relapse due to feeling an inability to cope or to handle their shame in using and being seen by their child. These are simple elements of coping that may really help change whether or not this person relapses. This researcher’s experience is that many of the patients/clients cannot always identify what they are feeling. In this instance, using DBT is imperative because it helps the patient/client sort out their emotions, using this technique. In other words, DBT is a nonthreatening way to help them find the right emotional response and understand what they are feeling, in the moment. They may have many emotions, but the point is to address them one at a time, to find what is most effective and positive at the moment. If they dont have a positive and healthy way to express these emotions, some may turn to destructive self behaviors like cutting themselves. DPT offers many techniques that people can use to express their emotions in the present moment. Another example is to think about emotions while they are washing dishes. They are taught to squeeze the rag and let their frustration out, by slowly feel one emotion at a time as it is released. Sometimes this helps to slow down triggers or identify a PTSD response or lessen the severity of emotional agitation. The DBT trains individuals to have a way to prep for emotional overload that sometimes happens before the logic of the inner voice. Breathing for a few minutes to sort out the feelings of being overwhelmed and then addressing one emotion at a time is also a technique. Foa, Keane and Friedman, (2000) add: While the treatment guidelines for any given approach indicate the degree of empirical support available for the treatment, empirical data on combination treatments in PTSD are extremely rare and mostly descriptive. …At present, therefore, the integration of treatment techniques remains the art of the clinician…Not all clinicians are skilled in providing different techniques…(page number) Group therapy is also used in this process and when the topic of safety is introduced, many triggers surface in the session. The therapist can helps by teaching techniques like grounding and exposure interventions. They also must assist in the de-sensitization of the trauma or events around that trigger the patient. This researcher works in a treatment program that works with American Indian Veterans who have SUDS, PTSD or a combination. The rates of suicide are extremely high, and we can attest to the need for more treatment options. Although our eclectic program is preferred by many American Indians who are in our service area, we see the same problems as listed here: In 2000, 29,350 persons died by suicide in the United States. Suicide deaths outnumbered homicide deaths by 5 to 3. Suicide was the third leading cause of death for 10-24 year olds, and the eighth leading cause of death for males. Vital statistics indicate that suicide rates vary dramatically by demographic characteristics. Males die by suicide more frequently than females by a ratio of 4 to 1. Older white males have the highest suicide rate, followed by young American Indian and Native Alaska males. In contrast, older African American females have one of the lowest rates. Married persons have lower rates than unmarried persons. Rural suicide rates exceed those in urban areas, and state rates vary by region, with Western mountain states having the highest suicide rates in the Nation. The health conditions most consistently associated with suicide are mental illness, SUDs and AUDs, affecting up to 90% of all people who die by suicide. The lifetime risk for suicide death among alcohol-dependent individuals has been estimated to be 7 to 10%, and among persons with affective disorders, 2 to 7%. (National Institute of Mental Health 2003). Although DBT and CBT are used in treatment, the non-traditional treatments used in our facility reflect the culture of the American Indian, who comprises a very large sector of the National Guard. PTSD once diagnosed repeats itself due to untreated disorders, instability, hyper-arousal, grief, relationship and life changes and childhood abuse. With treatment, these issues can be managed and lead to better outcomes. Clients find stability in relationships, inner peace, re-participation in career, education and general belonging in society. When comparing the non-traditional treatments currently used like psycho-drama, recreational therapy, spiritual healing through drumming, sweats and meditation, we are tackling PTSD with creative insight and helping our clients connect with their culture in a more positive way. We are in the process of documenting our success. We use DBT and CBT with the non-traditional treatment. These types of non-traditional treatment centers are becoming more popular as they have high client satisfaction and a better chance for recovery. This concluding section is dedicated to the analysis of the two innovative and effective therapeutic approaches to treating PDs as combined with SUDs: the Dialectical Behavioural Therapy developed by Lineham (1993) and, the Integrative Treatment Approach suggested by Najavits (2002). The Dialectical Behavioural Therapy developed by Lineham (1993) fits into the problem-solving therapeutic paradigm which that allows a wide amplification and is clinically effective. Its core assumption is that antisocial and inadequate behavioral patterns are explained by the scarcity of patients’ psychological resources to cope with their problems in an alternative acceptable manner. Lineham’s Dialectical Behavioural Therapy differentiates from other problem-solving alternatives in its particular attention to the effect of a specific diagnosis on the course of treatment and its extensive preventive measures against poor attendance. Linehan compared her outcomes to the outcomes of standard outpatient-care methods to find the ratio of patients who continued treatment. She found that with the assistance of a single therapist, the number of patients who continued their treatments rose from 42 to 83 percent. The approach utilizes a range of cognitive-behavioural therapeutic techniques as based on a dialectic philosophy. The patient is helped to value his/her self as a precious and integrative phenomenon by eliminating the feelings of guilt, self-abomination and neglect. The therapist assists an individual with multiple disorders in finding stimuli for change. (Linehan 1993, p. ) The core concept of the approach is the “skill” which is defined as “cognitive, emotional, and overt behavioral (or action) response repertoires together with their integration, which is necessary for effective performance” (Linehan, 1993, p. 329). The scholar described the four broad modules of skills: (1) mindfulness, (2) interpersonal effectiveness, (3) emotion regulation, and (4) distress tolerance. To proceed, the pioneer of this method listed three categories of skills training procedures: (1) skills acquisition, (2) skill strengthening, and (3) skill generalization. An introduction of new skills occurs at the first stage. At the further stages, a patient learns to manage the freshly acquired skills and project them onto the everyday environment. It is clear to this researcher that this method is important to treatment because clients need to understand that they can live life on their own. Often, with PTSD, clients lives are disrupted and after awhile, its difficult for them to understand that they can move on after theyve had an episode. They must learn to control their emotions so they can develop as a full person. Since DBT is geared to deal with clients who are exhibiting destructive behavior, it makes sense that individuals learning the techniques would eventually understand how to circumvent the destructive behavior by learning and following the techniques learned. The one thing that I disagreed with somewhat is the fact that this method uses phone counseling. I think it is difficult to assume that a client with PTSD or BPD would understand the boundaries imposed with talking to a counselor by phone, one on one. Since people with BPD already have challenges with boundaries, it seems that this would be a trigger for behavior that might lead them back to a relapse. Also, since the goal of this therapy is to reduce or eliminate the behaviors that are life threatening, it would seem that there may also be problems with the feelings of abandonment that these clients feel. Im not sure that I would be totally comfortable using this therapy as the only method available. The Integrative Treatment Approach suggested by Najavits (2002) was designed specifically for treating PTSD and substance abuse and therefore it is valuable for helping other patients with multiple diagnoses. This therapeutic technique is a present-focused one so far as it helps patients to free themselves from past traumatic experiences and enables them to practice in acquiring safety from trauma/PTSD and substance abuse. Being equally effective for single patients and groups of various backgrounds, Najavits’ methodology relies on five principles: 1. individuals with multiple disorders are stimulated to value safety as the main life goal in regard to relationships, thinking, behavior, and emotions. 2. they are guided into the integrated course of treatment, during which several dysfunctions are seen to at once. 3. individuals are helped in designing ideals to balance against the loss of ideals resulting in PTSD and substance abuse. 4. a range of exercises includes cognitive, behavioral, interpersonal, case management practice. 5. the method heavily relies on clinicians’ activities. (page number) This treatment seems to be a better model because it works to empower the individual in what seems like the shortest amount of time. Another thing that this approach seems to do is motivate clients to want to take action. When clients are allowed to sit and bemoan the past in their minds, it is difficult for them to get a handle on the present. It is also difficult for them to see that they can live a productive life. One of the things that most people notice about clients who use alcohol and present other diagnoses is that they are generally feeling out of control physically and emotionally. When a client is allowed to stay within the framework of the negative emotions, they do begin to believe that whatever they are telling themselves, is true, and one thought leads to another and can send them into a space that feels unsafe. The Seeking Safety program will assist the client (if they use the techniques) to stop themselves before they go into a full episode. 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Living with Drink: Women who live with problem drinkers. London: Harwood. Velleman, R., and Orford, J. (1990). Young adult offspring of parents with drinking problems: Recollections of parents’ drinking and its immediate effects. British Journal of Clinical Psychology, 29, 297-317. Whalen, M., Fowler-Lese, K. P., Barber, J. S., Williams, E. N., Judge, A. B., Nilsson, J. E., et al. (2004). Counseling practice with feminist-multicultural perspectives. Journal of Multicultural Counseling & Development, 32, 379-389. Yen, S., Shea, T. M., Battle, C. L. Johnson, D. M. et al. (2002). Traumatic exposure and posttraumatic stress disorder in borderline, schizotypal, avoidant, and obsessive- compulsive personality disorders: Findings from the collaborative longitudinal personality disorders study. The Journal of Nervous and Mental Disease, 190 (8), 510- 518. My Comments Okay, here are my comments on this one, in no particular order. I wrote them as I was going through the paper: 1. You dont need to spell out all of the details on a study. Instead, summarize it then a) state their findings b)state your point as to how it relates to the questions asked. 2. Always have your work edited. Most colleges have writing labs where you can get this done or there are online resources. However you have to give yourself enough time between writing the paper, having it edited, then handing it in. 3. I wasnt sure where the quote from Najavits, Neiss, Shaw and Muenz (1998) stopped. I put quotes where I thought it might end, but wherever it does, it needs a page number. 4. A couple of places need page numbers. I highlighted these in yellow. Put in the page number and then go up to the "ab" if you are in WORD, and click the down arrow. Choose "no color" and that will erase the yellow. 5. Seeking Safety -- its not clear what that has to do with DTB. Somethings missing from the paragraph to tie these together. 6. Next paragraph -- WHY do trauma and substance abuse represent a natural paring? Spell that out a bit. Does this relate to DBT in some way? Then say so. 7. The paragraph starting with, "because communication is confusing…" --read it and see if it make sense. 8. Be brave! Say what you have to say! Dont use "very" (cuz he hates it and its really subjective). I changed the sentence to make it clearer and easier to read. 9. Again, I moved things around, cleaned things up and rearranged other things. I took out anything that either didnt make sense or interrupted the flow of the paper. 10. American Indian treatment program -- read this and make sure what I wrote is correct. 11. Your professor speaks to a page and a half of quotes. I found it and shortened it. You quoted WAY too much. Why is this information important to what you were saying before you began the quote? Thats what is important to say and ONLY that much. 12. Here are a couple of things that send up a red flag for professors when they see it: a) this long quote looks like you "cut and pasted" exactly from the text. Technically, this is plagiarism. You can only use "fair use" in papers and such. Note: If youre going to "cut and paste" references, make sure you highlight them in your paper and make them match the color and the font inside your paper. b) Professors want to know what you know, and they want you to say it in your own words. That is why your professor said it didn’t show mastery on your pare. You can support what you know with quotes, but only in VERY SHORT ones. You might want to put something else in that area or paraphrase what you put there and put some of it back in. 13. you had several places where the font changed…I wasnt sure why…but you might experience it at your end. I changed everything to Times New Roman 12 point. REMEMBER, you need page numbers at the end of every quote, so you may have to go back and put them in. 14. On page 6, I tried to make sense of the Najavits study--not sure its what you want to say, so check it. 15. Check question 3 to make sure it reads correctly (inside your paper, the last part). 16. I added some "fluff" to the end of the paper, trying to stretch it out to 15 pages. If you need 15 exactly, you might want to put a little more in…like a summary. 17. I didnt change the reference this time; its your turn to do it! Okay, thats it for now! I hope it helps and if you need me again, let me know! Read More