The application of dialectical behavior therapy for patients with borderline personality disorder on inpatient units.

Inpatient treatment of individuals with borderline personality disorder (BPD) is typically fraught with difficulty and failure. Patients and staff often become entangled in intense negative therapeutic spirals that obliterate the potential for focused, realistic, and effective treatment interventions. We describe an inpatient treatment approach to BPD patients which is an application of Dialectical Behavior Therapy (DBT), a cognitive-behavioral therapy for patients with BPD which has been shown to be effective in reducing suicidal behavior, hospitalization, and treatment dropout and improving interpersonal functioning and anger management. The inpatient DBT staff creates a validating treatment milieu and focuses on orienting and educating new patients and identifying and prioritizing their treatment targets. Inpatient DBT treatment techniques include contingency management procedures, skills training and coaching, behavioral analysis, structured response protocols to suicidal and egregious behaviors on the unit, and consultation team meetings for DBT staff.

Characteristics of borderline personality disorder associated with suicidal behavior.

OBJECTIVE: This study examined the relationship between characteristics of borderline personality disorder and suicidal behavior. The authors hypothesized that a specific feature of borderline personality disorder, impulsivity, and childhood trauma, a possible etiological factor in the development of impulsivity, would be associated with suicidal behavior. METHOD: Information on lifetime history of suicidal behavior was obtained from 214 inpatients diagnosed with borderline personality disorder by structured clinical interview. The authors examined the relationship between DSM-III-R criteria met and the following measures of suicidal behavior: presence or absence of a previous suicide attempt, number of previous attempts, and lethality and intent to die associated with the most lethal lifetime attempt. RESULTS: Impulsivity was the only characteristic of borderline personality disorder (excluding the self-destructive criterion) that was associated with a higher number of previous suicide attempts after control for lifetime diagnoses of depression and substance abuse. Global severity of pathology of borderline personality disorder was not associated with suicidal behavior. History of childhood abuse correlated significantly with number of lifetime suicide attempts. CONCLUSIONS: The trait of impulsivity is associated with number of lifetime suicide attempts and may therefore be a putative risk factor for a future suicide attempt. If so, impulsivity is a potential target therapeutically for prevention of future suicide attempts. The association between childhood abuse and number of lifetime suicide attempts is consistent with the hypothesis that childhood abuse is an etiological factor in the development of self-destructive behaviors.

Relationship of dissociation to self-mutilation and childhood abuse in borderline personality disorder.

OBJECTIVE: This study sought to document the prevalence of dissociative experiences in adult female inpatients with borderline personality disorder and to explore the relationship between dissociation, self-mutilation, and childhood abuse history. METHOD: A treatment history interview, the Dissociative Experiences Scale, the Sexual Experiences Questionnaire, and the Hamilton Depression Rating Scale were administered to 60 consecutively admitted female inpatients with borderline personality disorder as diagnosed by the Structured Clinical Interview for DSM-III-R Personality Disorders. RESULTS: Fifty percent of the subjects had a score of 15 or more on the Dissociative Experiences Scale, indicating pathological levels of dissociation. Fifty-two percent reported a history of self-mutilation, and 60% reported a history of childhood physical and/or sexual abuse. The subjects who dissociated were more likely than those who did not to self-mutilate and to report childhood abuse. They also had higher levels of current depressive symptoms and psychiatric treatment. Multiple regression analysis demonstrated that each of these variables predicted dissociation when each of the others was controlled for, and that self-mutilation was the most powerful predictor of dissociation. CONCLUSIONS: Female inpatients with borderline personality disorder who dissociate may represent a sizable subgroup of patients with the disorder who are at especially high risk for self-mutilation, childhood abuse, depression, and utilization of psychiatric treatment. The strong correlation between dissociation and self-mutilation independent of childhood abuse history should alert clinicians to address these symptoms first while exercising caution in attributing them to a history of abuse.

The family, family therapy, and borderline personality disorder.

The authors review recent controlled studies on the interrelationship of the family and its members with borderline disorder and propose a new model for understanding and managing this relationship. The focus of the model is on psychopathology, evaluation, and treatment of patient and family as they influence each other. In the authors' view this illness originates in cerebral dysfunction, in the patient in combination with impaired relationships among family members. When the family is available, we believe that the treatment of choice is a multimodal approach involving family psychoeducation and family systems or dynamic intervention where possible, in combination with medications, individual psychotherapy, or both.

Clinical correlates of self-mutilation in borderline personality disorder.

OBJECTIVE: This exploratory study sought demographic and clinical correlates of self-mutilation (self-injury without suicidal intent) in borderline personality disorder. METHOD: Among 124 consecutively admitted inpatients with borderline personality disorder, there were 62 who did not mutilate themselves, 23 who mutilated themselves infrequently (fewer than five lifetime events), and 39 who mutilated themselves frequently (five or more lifetime events); each received ratings on numerous measures of psychopathology. RESULTS: Compared to nonmutilators, frequent mutilators were significantly more likely to be in outpatient treatment at the time of admission and had more weeks of prior outpatient and inpatient treatment; they were also more likely to receive comorbid diagnoses of current major depression, anorexia nervosa, and bulimia nervosa. Frequent mutilators had significantly higher group means on the Beck Scale for Suicidal Ideation, were more likely to have attempted suicide, and were more likely to have attempted suicide more often than both infrequent mutilators and nonmutilators. The adjusted odds ratios from logistic regression analyses demonstrated that major depression, bulimia nervosa, number of prior suicide attempts, and acute suicidal ideation were each associated with greater risk of frequent mutilation. CONCLUSIONS: Borderline patients who frequently mutilate themselves may represent a subgroup of especially high utilizers of psychiatric treatment who are at particularly high risk for suicidal behavior and for comorbid major depression and eating disorders. Clinicians should consider aggressive treatment of comorbid axis I disorders and careful assessment of suicide risk in these patients.

Substance use in borderline personality disorder.

The authors investigated the prevalence of substance abuse in 137 inpatients with DSM-III borderline personality disorder. Ninety-two (67%) of these patients were given DSM-III substance use disorder diagnosis. The most frequently used substances were alcohol and sedative-hypnotics. When substance abuse was not used as a diagnostic criterion for borderline personality disorder, 32 (23%) of the 137 patients no longer met borderline criteria. These patients differed significantly from the rest of the patients in severity and course of illness. These data suggest that there might be a subgroup of borderline patients for whom substance use plays a primary role in the development of borderline psychopathology.

The problem of alcohol in the medical/surgical patient.

The authors report the results of a computerized data-based study of 845 general hospital patients seen by a consultation-liaison psychiatry service in a major urban hospital. The findings indicate that only 5.2% of the referrals were for the problem of alcohol. Furthermore, the detection rate of an alcohol problem by both the referring physicians and the psychiatric consultants was low (8.3%) as compared with the literature's reported prevalence rate of alcoholism in the general hospital (8.7%-55%). The problem of recognition of an alcohol problem in the medical/surgical patient is explored with particular emphasis on the obstacles to diagnosis--masking of alcoholism by other major psychiatric disease, the categorization of patients by symptom rather than underlying causation, and the lack of sufficient employment of useful diagnostic screening devices.