DBT Skills Training

DBT Skills Training

Dialectical Behavior Therapy Toolbox to Treat Borderline Personality Disorder, Mood Swings, and ADHD. Techniques of Mindfulness for the Treatment of Anxiety and Depression (2022)

Tammy Payne

TABLE OF CONTENTS

INTRODUCTION

CHAPTER 1:

BIPOLAR DISEASE

CHAPTER 2:

BDNF

MAGNETIC TRANSCRANIAL STIMULATION

THERAPY FOR DIALECTICAL AND COGNITIVE BEHAVIOR

INVITATION TO THE SUBJECT

BIPOLAR DISORDER TYPES (TYPE I AND TYPE II)

PROGNOSIS AND COURSE

CHAPTER 3:

THE COGNITIVE-BEHAVIORAL APPROACH INTRODUCTION

Proessional practice recommendations

CHAPTER 4

MUSIC THERAPY AND STRESS: ALTERNATIVE MOOD REGULATORS

THE INDIVIDUAL'S CONSTITUTION ACCORDING TO CHINESE MEDICINE

TREATMENT FOR METAMORPHIC DISORDERS

CHAPTER 5:

THE PERFECT MINDFULNESS

CHAPTER 6:

STRESS AND BREATHING IN THE DBT TECHNIQUE

CONCLUSIONS

INTRODUCTION

The dialectical behavioral therapy treatment approach, often known as Dialectical Behavior Therapy (D.B.T.) in English, is a cognitive behavioral treatment created particularly for borderline personality disorder. Several controlled clinical trials and even more recent investigations have established dialectical behavioral therapy as the first proved effective treatment for borderline personality disorder, including and particularly in its most extreme manifestations of self-harm and parasuicide, dating back to the 1990s. The therapeutic format that has been shown to be effective in this regard entails co-therapy, i.e. a strong interaction between individual psychotherapy and a sort of skills training (which is commonly done in groups).

Dialectical behavioral therapy (DBT) is based on a dialectical worldview. Different elements of the nature of reality and human behavior are supported by the dialectical approach. The dialectic supports the fundamental interrelationship and unity of reality as its first aspect, implying that the analysis of single parts of a system is limited if they are not inserted in the specific contingent contexts in which the behavior of individuals and individuals in groups is expressed.

A second feature is that reality is not viewed of as static, but as a collection of conflicting internal forces (thesis and antithesis) in flux, the synthesis of which produces new tensions between opposing forces. In this perspective, borderline patients' dichotomous and severe patterns of dysfunctional thought and behavior are seen as dialectical failures: the individual is trapped on extreme polarities and striving to move dynamically towards a synthesis.

The third characteristic that distinguishes the dialectical perspective is the premise that the nature of reality is built on change and process, and that both the person and the environment are continually changing.

As a result, the therapy's goal is to enhance the capacity to handle change rather than to maintain a stable condition in a stable and constant environment.

DBT conceptualizes borderline personality disorder in light of biosocial theory. Emotional dysregulation is the cornerstone of borderline personality disorder, according to biosocial theory. The idea contends that with borderline disorder, there is a significant problem in regulating emotions, which is referred to as emotional dysregulation. Emotional dysregulation is the outcome of the combination of a biological predisposition, an environmental setting, and the reciprocal impacts and transactions between these two variables throughout the course of a person's life. According to DBT, dysfunction in a part of the human being's complex emotional regulation system can provide the biological basis (though not necessarily genetic) for emotional vulnerability and subsequent difficulties in emotional regulation, though it is currently difficult to identify a specific biological anomaly of the emotional regulation system for the borderline disorder.

Marsha Linehan describes emotional vulnerability as three distinct elements: a) very high sensitivity to emotional stimuli; b) very strong responsiveness to emotional stimuli; and c) a sluggish return to the fundamental emotional state after emotional activation has occurred. A borderline personality disorder is characterized by a hypersensitive and hyperreactive reaction system, as well as a weakness in controlling emotions and the accompanying actions. Maladaptive and ineffective emotional control mechanisms are used in particular.

The so-called disabling environment, in addition to emotional vulnerability, is an environmental and contextual aspect that interacts with it for the creation of emotional dysregulation. The propensity of the subject's emotional and cognitive experiences (e.g., emotions, ideas, and beliefs) to be dysfunctional and inappropriate is a feature of the debilitating environment. Parental reactions that are out of sync with and detrimental to the child's cognitive-emotional environment, for example, are prevalent, impeding the development of emotional regulating abilities.

The debilitating environment reacts dystonically to the child's emotional and cognitive expressions, invalidating their experiences with a lack of reaction or with severe and dysfunctional responses. To put it another way, we do not perceive the emotional and cognitive experience on its whole.

The expression of unpleasant emotions and affectivity is often invalidated, with bad feelings and painful experiences being trivialized, punished, disregarded, or ascribed to stable personality qualities or a lack of goodwill.

The disabling environment favors emotional dysregulation by interacting with aspects of emotional vulnerability because it does not support the child in appropriating emotional regulatory skills; conversely, the disabling environment teaches the child to disabuse their emotional and cognitive experiences (for example, believing that their emotions and beliefs are incorrect and looking to others for clues on how to think and what to feel).

According to the dialectical behavioral theory model, the basis for the onset and maintenance of emotional dysregulation and many dysfunctional behaviors associated with a borderline personality disorder is found during the course of life in the interaction and transactional relationship that is created between emotional vulnerability (biological aspect) and disabling environment (environmental aspect).

The capacity to control emotions is important because its absence or inadequacy may lead to behavioral dysregulation; according to the DBT paradigm, borderline individuals' impulsive and dysfunctional behaviors are a result of emotional dysregulation. However, emotional dysregulation has an influence not only on behavioral elements but also on the development and maintenance of a stable sense of identity.

Emotional dysregulation and affectivity inhibition result in unpredictable behavior, cognitive inconsistency, and identity lability.

At this stage, we see relationship instability accompanying emotional, behavioral, and identity dysregulation: unstable interpersonal connections, understood and chaotic, controlled impulsively and dysfunctionally, are only the product of emotional, cognitive, behavioral, and identity dysregulation. In general, DBT, as well as the diagnostic criteria in the literature, demonstrate a pattern of dysregulation and instability at the emotional, cognitive, behavioral, relational, and identity levels in borderline personality disorder.

DBT focuses on the collection of dysfunctional behaviors that disrupt the life of a person with a borderline personality disorder at many levels, ranging from suicidal and parasuicidal behaviors to impulsive and dysfunctional behaviors that manifest in several settings and circumstances. Among them include, for example, self-hostility, promiscuous sexuality, drug addiction or alcohol misuse, dysregulation of eating behavior, unsafe activity in their life, rage excesses, and violent actions in relationships with others. And a variety of other impulsive actions that are damaging to the person in the medium and long run. In this view, the goal is to develop and disseminate a different repertoire of emotional, cognitive, and behavioral responses to diminish behavioral decontrols.

However, the goal of DBT is not limited to this; it aims to enhance the management of such highly dysfunctional behaviors, emotional regulation, and the validation of the immense pain that often accompanies persons with borderline disorder. The ultimate objective is to enhance the patient's quality of life so that, as stated by Marsha Linehan, the model's originator, we can create a life experience worth living.

DBT, like traditional cognitive-behavioral therapy treatment procedures, is focused on the patient's shared formulation of particular treatment aims, to establish a collaborative partnership and mutual commitment to accomplishing the therapy's objectives. The whole therapy focuses on the development and maintenance of a connection between the patient and the therapist, in which the validation of the patient's ideas, feelings, emotions, and actions is critical.

The therapy consists of coterapia, in which many therapeutic actors collaborate to achieve a shared aim. The individual therapist, the group skills training leaders, and sometimes even the psychiatrist form a network of Cath therapy so that the patient becomes acquainted with several reference persons who perform certain duties within the treatment system. Typically, the approach calls for a 50-minute session of psychotherapy every week, followed by an hour and a half or two hours of group skills training. There may also be exceptions to this approach, such as if you wish to do particular skills training for specific therapeutic reasons.

Many components of cognitive-behavioral therapy are used in the dialectical behavioral therapy approach, such as contingency management, exposure, behavioral analysis, problem-solving, and many aspects of skills training.

Similarly, there are components of the treatment that differ from normal cognitive-behavioral therapy. To begin with, mindfulness skills are given special emphasis, and DBT is referred to be a third wave treatment for this reason. Second, as the name implies, a greater emphasis is placed on dialectical aspects: beyond the change, a quota of acceptance and validation of contingent behavior is fundamental - even if dysfunctional - in a difficult game of balancing change and acceptance, which is also reflected in the use of therapeutic techniques and strategies. Third, behavioral dialectic therapy entails systematic attention to what are described as interfering behaviors with treatment and allows for priority treatment in session - second only to suicidal behaviors and impulses.

Subjects with borderline personality disorder, according to the model, lack self-regulating abilities of emotions, actions, and interpersonal connections, or have difficulty adapting these skills to varied experience situations, hence skill training is critical in dialectical behavioral treatment.

As previously stated, this would result in dysregulation and instability on several levels, including emotional, cognitive, behavioral, relational, and identity levels.

Skills training as conceived by dialectical-behavioral therapy involves the organization of four modules of learning and appropriation of specific skills that target the improvement of aspects of emotional, cognitive, behavioral, relational, and identity disorders typical of the borderline. The first module refers to nuclear mindfulness skills. These skills are the basis of the possibility of consciously observing oneself and others around one another in the present moment, suspending judgment. Mindfulness skills are divided into three content skills that refer to the object of mental activity (observing, describing, participating) and three formal skills, related instead to the way in which these mental processes take shape (taking a non-judgmental attitude, focusing on one thing at a time, being effective). A second module deals with emotional regulation skills, which are fundamental in the context of borderline functioning. As already mentioned above, borderline subjects experience intense dysregulation and emotional lability, with high levels of reactivity and a slow return to the basic emotional state. Starting from the skills of recognition of emotions in their different components, the module takes place focusing on the appropriation, improvement, and generalization of the skills of regulation of emotions. A third module deals with interpersonal effectiveness skills focusing on learning effective strategies for managing interpersonal relationships.

The meetings cover different areas, from the ability to analyze interpersonal situations and clarify one's objectives, to the skills to be used to achieve one's objectives while maintaining respect for oneself and not deteriorating the relationship in a maladaptive way. In this sense, this module is similar to programs on assertiveness and problem-solving interpersonal. A fourth module refers to the tolerance skills of mental suffering and anguish, useful when the subject is in a state of dysregulation not only emotional but also behavioral. The intensity of the emotions, in this case, is very high, and it is in this phase that the subject can act and conduct highly dysfunctional and self-injuring. The skills that characterize this module are intended to manage and tolerate more adaptively anxiety and intense emotional activation in order to prevent dysfunctional behavior. Generally, the meetings take place in groups of about 6-10 participants, with the presence of two therapists (one with the main role of conductor, the other with the role of co-conductor, and each having specific roles and functions). The skills training consists of 4 modules, for each of which there are about 8 meetings; the modules can be repeated cyclically because the nature of the skills training is experiential and not merely didactic. It is essential to stress that dialectical behavioral therapy, in its proven effectiveness for the borderline disorder, is such when it involves the association between individual therapy and group skills training therapy, to the point that it is not possible - according to the model - to attend a group skills training without also following individual psychotherapy of the same orientation.

CHAPTER 1:

BIPOLAR DISEASE

Bipolar disorder is a mood condition defined by an oscillation between the two opposed poles that are typically recognized in joy (positive pole) and despair (negative pole) (negative pole).

NOTES ON HISTORY

The Ode of Despair, penned by an anonymous Egyptian scribe some four thousand years ago, is the oldest evidence of mood disorders in the West. Some various papyri and hieroglyphics attest to the high rate of suicides in the Nile Valley.

In the Old Testament, we discover Jeremiah's afflictions, from whence the name geremiad arises, a protracted and plaintive lamentation that also conveys King Saul's anguish, remorse, and helplessness.

Homer's Iliad relates the tale of Bellerophon, who alone and overcome with melancholy went unhappily across the field of Aleio and the tracks of the living depart in Greek culture.

Plutarch expresses the idea of a common mood disorder of his day, filled with magic and religion: He sits outside, draped in sackcloth and filthy rags. Now and again, he rolls in the dirt, expressing shame for taking a path that the heavenly Being did not approve of. But it was in Greece, in the 4th century BC, that Hippocrates attempted to give an etiological explanation to diseases with the theory of moods (yugrrs: wet, humid), based on the foundations laid by Pythagoras and Empedocles and empirical observation of emerging medicine in the western world, and overcoming the magical and religious conception, according to which the human organism is in a balance between four fluids: phlegm enclosed The same hypothesis would have explained, in addition to sadness (overabundance of black bile) and mania (excess of yellow bile), the seasonal course of which Hippocrates observed, the personalities: sanguine, phlegmatic, melancholy, choleric

In the first century AD, Areteo di Cappadocia systematically examined depression and mania, observing how they followed one another in some patients: he hypothesized a close link between the two disorders, emphasizing their cyclical nature and recommending psychotherapy to clarify the causes for some reactive forms.

Galen (131- 201) later confirmed the humoral idea, pointing out that the cause of sadness is a basic brain change.

In the Roman civilization, there existed a living evil known as tedium vitae, and Seneca noted how disdain for life was the reason for many suicides, regardless of social status, and therefore justified suicide: He who dies from suffering is weak and scared, but he who lives to suffer is stupid.

Medieval society retreated from the Greco-Roman view, and under the influence of the Arab school of Avicenna (980-1037), the magical-religious concept of mental diseases as a result of demonic possession resurfaced.

The melancholy, previously studied in humoral theory, was ethically judged as guilt, a sin, and no longer a disease, as represented by Dante Alighieri himself, who places the accidies alongside the braconid in the swamp Stygia and describes them in the VII Song of Hell: We were in the sweet air that comes from the sun, bringing in a sticky smoke.

With the Enlightenment in the seventeenth and eighteenth centuries, there was a return to naturalistic investigations, and depression and mania were separated nosologically based on basic clinical criteria.

In 1854, Falret, with La folie circulares, and Baillargeon, with La folie a double form, reported an illness marked by a continuous and regular alternating of sadness and mania, which were interpreted as two distinct manifestations of the same sickness.

Emil Kraepelin, in his 1896 book on psychiatry, recognized two nosologically distinct entities in the sphere of mental disorders: manic-depressive psychosis and early dementia, characterized by age of start, familiarity, course, and prognosis. Given the commonality, the periodic course, the better prognosis than early dementia, and the possibility of presentation in the same patient but at different times, Kraepelin combined mania, depression, and circular and periodic madness in the diagnosis of manic-depressive psychosis; later, he also included mixed states (1904) and, finally, evolutive depression (1913), previously excluded from manic-depressive psychosis due to its unfavorable prognosis.

The Kraepelin vision influenced psychiatrists all over the globe until 1957 when Leonhard offered a differentiation between unipolar depressed forms, unipolar manic forms, and bipolar forms, in which depressive, manic, hypomaniacal, and mixed episodes alternated.

Taylor and Abrams thought that unipolar and bipolar disorder were continuous in 1980 based on genetic/family investigations.

The diagnostic-statistical handbook DSM-III (1980) and the interview system ICD-10, on the other hand, reaffirmed the distinction between depressive and bipolar illnesses (1992).

Recently, a unitary model for mood disorders has been proposed, in which the various psychopathological entities are arranged along a continuum (spectrum of mood), which begins with affective temperaments (hyperthymia, cyclothymia, dysthymia) and progresses through mild or subthreshold forms to the most serious and acclaimed pictures. The mood spectrum model enables more exact diagnoses, which are beneficial for pharmaceutical choices for specific patients.

FACTORS OF RISK AND EPIDEMIOLOGY

One of the most frequent types of mental disease is bipolar disorder.

He is also accountable for a Disability-adjusted life year (DALY) that is worse than any type of cancer or the most severe neurological disorders such as epilepsy or Alzheimer's disease, owing to its early start and chronic course.

EPIDEMIOLOGY

Merikangas et al. (2011) discovered a lifetime prevalence of 0.6 percent for bipolar disorder I (BP-I), 0.4 percent for bipolar disorder II (BP-II), and 1.4 percent for subthreshold forms (BPS) in a survey of 61392 individuals from 11 countries in America, Europe, and Asia.

The overall prevalence of all bipolar spectrum disorders in the general population is 2.4 percent.

Furthermore, the 12-month prevalence of BP-I is 0.4 percent, 0.3 percent for BP-II, and 0.8 percent for BPS.

Males had greater lifetime rates of BP-I and BPS than females (approximately 1.1:1), but the ratio was inverted for BP-II. Approximately half of the participants with BP-I and BPS began before the age of 25, whereas those with BP-II began somewhat later. The average age of onset for BP-I is 18.4 years, for BP-II it is 20 years, and for BPS it is 21.9 years.

COMORBIDITY

It is difficult to find a disorder that presents itself in its pure state in all the psychiatry; in the majority of cases, there are complex clinical pictures within which there are elements characteristic of several psychiatric disorders together: in a study conducted on patients hospitalized and affected by DB, the psychiatric comorbidities were about 40%, while the general medical ones were 20%, with a higher frequency in the female sex.

Comorbidity is quite prevalent, particularly with illnesses of the anxious domain, to the point that we may talk of true clusters of particularly common comorbidities in certain circumstances.

Panic disorder is present in 50% of comorbidity, conduct disorders in 44.8 percent, drug addiction disorders in 36.6 percent, and phobias in 30%.

Subjects with bipolar illness are often affected by metabolic disorders: McElroy identified a prevalence of obesity of 25%, Fagiolini et al. of 35%, and 45 percent in the following research. The authors also emphasized the worrying frequency of metabolic syndrome (MS) (30-40 percent ). Recently, epidemiological and clinical data have shown a relationship between bipolar illness and cardiovascular disease, which is probably connected to metabolic syndrome.

Comorbid disorders are more common in individuals with BP-I (88.2 percent) and BP-II (83.1 percent) than in those with BPS (69.1 percent ).

After considering the comorbidities, related disorders, and functional repercussions of a patient with bipolar disorder, we may conclude that patients suffering from depression have a more functional impairment (70.4 percent) than those in the manic phase (50.9 percent ).

Attempts on suicide

People with bipolar illness have a 15-fold greater lifetime suicide risk than the general population (DSM-V).

It is anticipated that 25 to 50 percent of people with bipolar illness will try suicide at least once in their lives, with 8 to 19 percent succeeding. Suicide risk rises in direct proportion to the severity of bipolar illness. Anti-conservative efforts affect around one-quarter of those with BP-I, one-fifth of those with BP-II, and one-tenth of those with BPS.

FACTORS OF RISK

Although the precise route of genetic transmission is unknown, multiple investigations have shown substantial evidence of familiarity with mental disorders. According to the DSM-V, family members of persons with mood disorders have a 10 times higher chance of being sick than the general population, and within the same family, unipolar and bipolar forms often overlap, indicating the continuity previously noted among these illnesses.

Gender: BP-I is somewhat more prevalent in males, whereas BP-II is more prevalent in women (CvetkovicBosnjak, 1998; Hendrick et al., 2000).

A new study found gender disparities in bipolar illness (Miller et al., 2014). The female gender is associated with more depressive symptoms and various comorbidities than the male gender, and women with the condition are at a higher risk of relapses following pregnancy and menopause. Women are more likely to have metabolic syndrome, weight gain, and cardiovascular risk due to hormonal variables, as well as a higher chance of sexually transmitted infections and unexpected births.

Manic episodes and comorbidity with substance-related and behavioral problems are more common in people.

Age: Major depression arises most commonly between the ages of 20 and 50 (average age of about 40), with a peak in 10% of cases occurring beyond the age of 60. The age of onset has decreased in recent generations (under 20 years), most likely owing to the increased prevalence of drug addiction among young people. Bipolar disorders are most common between the ages of 15 and 50. (average age around 30). Cyclothymia and dysthymia develop sooner than other disorders, often in childhood and adolescence, or at most in very early adulthood (between 15 and 30 years).

Marital status: Bipolar disorders are more common among single, single, and separated people. The reasons might be the early age of onset, the severe impact that the symptomatology of these conditions has on the couple's connection, or the significant stress that separation from the spouse creates in susceptible patients.

People with mental disorders are more likely to be from the upper classes, but not exclusively; they are more common in high-income nations than in low-income ones (1.4 versus 0.7 percent ).

According to certain authors, extended but moderate hypomaniacal phases or hyperthymic temperamental qualities that boost work abilities support social advancement. Others argue that it is the stress of overcoming and maintaining more comfortable settings that cause mood problems.

ETIOLOGY

Since Hippocrates' notion in the 4th century B.C., mood disorders have been regarded as an organic illnesses in all aspects, since they exhibit features such as familiarity, cyclicality, remissions, and relapses, which are consistent with the traditional idea of disease. Various etiopathogenetic theories were developed throughout the twentieth century, some of which were biological in nature, while others were cognitive and psychodynamic in nature.

GENETICS.

Numerous research on families that adopted children, and twins have underlined the impact of inheritance on bipolar disorder: concordance between homozygous twins varies from 40 to 70 percent, with current work estimating an inheritance of up to 90 percent.

Numerous studies have indicated that the chance of being sick for a first-degree relative of a patient with severe depression is 2-10%, and the risk of becoming ill for a first-degree family of a patient with bipolar disorder is 8-18%. Furthermore, the probability of becoming ill for a twin of a patient with serious depression is 50% if he is a merozygote and 10% to 25% if he is a zygote. In the case of a bipolar illness patient's twin, these percentages grow to 33-90 percent and 10-25 percent, respectively.

Temperament, which characterizes the underlying tone of mood,