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A Case Study of Dialectical Behavior Therapy for Borderline Personality Disorder

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Joyce P. Yang and Marsha M. Linehan

F60.3 Borderline

Personality Disorder I

•

B orderline personality disorder (BPD) is a serious disorder characterized by a pervasive pattern of dysregulation and instability across all domains of functioning. Individuals with BPD have difficulty with emotion regu- lation and often exhibit suicidal and nonsuicidal self-injurious (NS SI)

•behaviors. Approximately 10% of individuals with BPD commit suicide (Linehan, Rizvi, Welch, & Page, 2000). The prevalence of BPD in the gen- eral population is estimated to be around 1% to 2%, indicating that it is one of the more common personality disorders (Lenzenweger, Lane, Loranger, & Kessler, 2007; Torgersen, Kringlen, & Cramer, 2001). At the same time, clini- cians often hesitate to treat clients diagnosed with BPD due to the challenging interpersonal behaviors, as well as potential increased risk.

The Case

As a therapist on a dialectical behavioral therapy (DBT) team, you have been referred a 20-year-old, Asian American woman, recently discharged from an inpatient psychiatry unit following a suicide attempt by lithium over- dose. The client, Jenny, describes her attempt as occurring during a period of many stressois, especially final exams at her technical college and her

http://dx.doi.org/10.1037/0000069-016 An ICD-10-CM Casebook and Workbook for Students: Psychological andBehavioral Conditions, J. B. Schaffer and E. Rodolfa (Editors) Copyright 2018 by the American Psychological Association. All rights reserved.

192 1 YANG AND LINEHAN

father's recent serious cancer diagnosis. She reports that on the day of her attempt, she felt a sense of chaotic agitation and an intense urge to do something to get out of the pain she was experiencing. She consumed a large quantity of alcohol (she is typically a nondrinker) and took all of the psychotropic niedication she had on hand (a potentially lethal dose of lithium). She says she had not planned this act ahead of time. Rather, she acted impulsively in an attempt to do anything possible to reduce her distress. Her roommate found her in the bathroom and called 911. After receiv- ing care in the hospital emergency department, she stayed in an inpatient psychiatric ward for 2 weeks, until she was discharged upon stabilization. Jenny presents to treatment indicating that she ultimately wanted to live but was experiencing suicidal and self-harm urges daily, as well as a great deal of emotional misery (which indudes feelings such as shame, sadness, and hopelessness that she finds difficult to tolerate). She describes two previous suicide attempts during high school and technical college, both drug overdoses. She had experienced ambivalence both times, indicating the desire to escape, although not necessarily the urge to die; in her words, "If I ended up dead, in order to not feel the distress any more, that's okay." She contends that her thoughts about suicide were not as much about wanting to die, but more about want- ing to escape the current pain she was feeling. She also had a long history of NSSL including cutting along her arms and thighs. Upon entering treatment, Jenny commits to attempting to stay alive fcT 1 month in order to try the therapy.

In monitoring Jenny's suiddality (see also Chapter 6 in this casebook), it would be critical to assess lethality, which is the degree to which her chosen means have the capacity to lead to death (e.g., a gun would be high lethality; taking five Tylenol would likely be low lethality). Another important factor is imminence, the degree of immediacy of the patient's plan (e.g., "I am going to do this as soon as I leave this therapy session" would be high imminence, whereas "One day I might take action" would be lower imminence). Further, assessing access to means is helpful to have some understanding of whether a patient is able to carry out the suicide plan. For example, if a patient's plan is to overdose on prescription medication, but she has no prescriptions and does not know anybody who has any, then there is no access to preferred means. However, if the plan involves hanging using a belt and she has a doset full of belts at home, then ready access to means would be available. In addition, understanding whether the patient's desire is to die, to escape, to cry for help, or to access specific types of support (e.g., hospitali7ation) is useful in conceptualizing the function of the attempt.

When Jenny was approximately five years old, she had about three experiences involving an aunt roughly handling and deaning her sexual organs, engaging in phys- ical punishment, and verbally berating her in the process. She currently has flashbacks and memories of these events, which are associated with intense emotional misery, as well as increased suicide and self-harm urges. Jenny reported that she told her mother about the incidents, but her mother did not take them seriously, nor did she engage in any actions as a result. She described her relationship with her parents as inconsistent—her basic needs were met, but she experienced consistent invalidation of her emotions, with her mother in particular telling her to "just handle it" or that she was being "too sensitive" whenever she experienced negative emotions.

Jenny has dispositional anxiety and possibly biological sensitivity to negative emo- tion. Particularly when vuln erable (e.g., during periods of menstrual pain or high

Borderline Personality Disorder 193

)f her attempt, -ring to get out alcohol (she is e had on hand as act ahead of sible to reduce L . After receiv- ent psychiatric fly presents to encing suicidal vvhich includes ilt to tolerate). :hnical college, indicating the

, "If I ended up rtends that her re about want- istory of NSSL Jenny commits

iook), it would aeans have the Tylenol would

e of immediacy rerapy session" vould be lower rderstanding of a patient's plan is and does not us. However, if at home, then

Lg whether the ypes of support Mempt. .ee experiences gaging in phys- has flashbacks

otional misery, at she told her sly, nor did she her parents as nt invalidation ndle it" or that otions. negative emo-

al pain or high

stress), she has difficulty tolerating emotions of shame, anger at sell, or sadness, and she engages in maladaptive behavior such as suicide/self-harm planning and binging/ purging. She has struggled with alternately restricting and binging and purging behav- iors for many years. She typically binges and purges impulsiVely when emotionally distressed, which leads to additional feelings of guilt and shame, as well as subsequent food restriction the following day in an attempt to "make up" for the binging and purg- ing. A day of restriction is then often followed by waking up in the middle of the night to binge, which she reports occurs in a "dreamlike" or unaware state.

Jenny currently spends a• great deal of time thinking about suicide, including making plans for ways to die, thinking about means and how to procure lethal methods, and ruminating on what being dead would be like. Her thinking about self- harm follows a similar pattern.

Jenny reports that while she does care for her parents a great deal, and feels bound to and responsible for them, she also wishes that her relationship with them could be more consistent. She describes typically feeling like she shifts between being disconnected and connected to them, as she alternates between thinking they should have protected her from the traumatic experiences with her aunt to thinking that it was her own fault, not her parents'. She experiences a similar back and forth shift in connection with her friends, as she alternates between feeling let down by them and accepting that all people are fallible. She finds herself wanting to avoid getting too close to people due to fear of being abandoned by them, yet experiencing strong desires to be intimately connected to people around her. These contradictory thoughts and the subsequent inconsistency in her desires and identity affect many aspects of her life. As a result of the unstable values, she reports chronically feeling empty inside and emotionally dysregulated.

During your intake interview with Jenny, you view her as highly compliant. She is agreeable and forthcoming and expresses a genuine desire and hope to build a life she experiences as worth living. She seems motivated to put effort into her treatment and is willing to complete any homework you assign to her. Nevertheless, you are worried that Jenny is losing hope, as her emotional misery and suicide and sell-harm urges continue to remain very high.

Assessment Using the ICD-10—CM

ACTIVITY 15.1:

What other assessment would you would want to conduct to gain a more complete understanding of Jenny? Which of her behaviors and attitudes would you prioritize in your initial assessment?

Thorough and accurate assessment is critical for successful treatment. Indeed, the majority of therapeutic errors or failures in therapy can be conceptualized as errors in assessment. You recognize, given the complexity of Jenny's case, that assessment will be an ongoing process that overlaps with the begirming of treatment. To understand fully her intense emotional misery and suicide and self-harm urges, clear and detailed

194 YANG AND LINEHAN

behavioral chain analyses are necessary. Behavioral chain analyses involve defining

the target (undesired) behavior and understanding all of the links leading up to the

engagement in the behavior, beginning with the prompting event. Because Jenny

has not acted on her suicide and self-harm urges for a number of weeks, the primary '

target behavior you are interested in understanding is thinking about and planning

for suicide and self-harm. The chain analyses revealed the following links:

1. Her proximal vulnerability factors, which are factors in the immediate past,

such as situations that happened during the day that make her vulnerable

to intense emotions, include physical, especially menstrual, pain. Her distal

vulnerability factors, which are factors in the more distant past that make her

vulnerable, include biological sensitivity to emotion and periods of higher

stress (e.g., final exams). 2. The prompting events include all precipitants that elicit intense emotions of

shame, anger, and sadness, encompassing any sex-related stimuli (ranging

from male friends making physical contact with her to hearing the words and

content related to sex or sexual abuse), stressors such as academic assign-

ments or exams, and binging/purging behaviors. 3. The links in the chain after the prompting event are (a) feeling intense, typically

co-occurring emotions of shame, anger, and sadness; (b) thoughts of worthless-

ness, being bad and disgusting; (c) additional thoughts that are either "I should

punish myself" or "I just need this to stop." – 4. These lead to the target behavior of thinking and ruminating on self-harm or

suicide ideations in order to escape the situation or punish herself.

5. The maintaining consequences of the target behavior are that Jenny experi-

ences short-term relief from negative emotion because suicide/self-harm plan-

ning serves an escape function. This brief respite from the aversive experience

of negative emotion means that her target behavior is negatively reinforced,

that is, the aversive stimulus is eliminated and the relief causes her target behav-

ior to be more likely to occur over time. (For further information on this

process, see Mowrer, 1947.) 6. Although the target behavior of suicide/self-harm planning is reinforced in

the short term, it leads to emotional misery shortly thereafter, as she experi-

ences even more negative emotions as a result of thinking about suicide and

sell-harm, thereby perpetuating a vicious cycle.

ICD-10-CM Diagnosis

ACTIVITY 15.2:

What are the possible ICD-10–CM diagnoses for Jenny, including her primary diag-

nosis and any comorbid diagnoses (i.e., disorders that co-occur)? Considering the

number of symptoms that Jenny reports and that they could point to a wide array

of potential diagnoses, why would you select one diagnosis over another?

From the case des, psychological sym; chological symptoi dysregulation, whe worry/anxiety, and with, and which p planning; (c) chron with family and frie purging behaviors.

The Blue Book, diagnostic guidelin, and Behavioural Disc the diagnosis that r resulted in a patier describes a patient debate between ME sistent with her em emotion-related syr would point in the ,

One could start as well as suicide ar disorder, recurrent symptoms that are b diagnosis, such as ir unstable and inconsi desires. Given the pc symptom of Major d on the length of time symptoms), her syn Borderline personab problematic behavio ating strong negative she feels like she can and therefore engag4 a central feature of J disorder (F60.3). Kee of Borderline person diagnoses and proble lation of individuals or anxiety disorder (

Restricting, bing ficult to differentiate as restriction, bingin as Jenny is of normE restriction follow he

Borderline Personality Disorder 195

lye defining ng up to the cause Jenny the primary nd planning cs:

lediate past, r vulnerable n. Her distal tat make her ds of higher

emotions of uli (ranging e words and mic assign-

ase, typically Df worthless- ler "I should

self-harm or If. mny experi- [-harm plan- e experience 7 reinforced, arget behav- tion on this

einforced in ; she experi- suicide and

lary diag- -ing the ide array

From the case description so far, it is clear that Jenny experiences many distressing psychological symptoms and may meet criteria for several disorders. The main psy- chological symptoms Jenny has reported are (a) pervasive and increasing emotional dysregulation, where she experiences strong emotions ranging from sadness to shame, worry/anxiety, and anger that she has difficulty understanding, tolerating, and coping with, and which permeate all areas of her life; (b) persistent suicide and self-harm planning; (c) chronic feelings of emptiness; (d) unstable and inconsistent relationships with family and friends; (e) unclear values and desires; and (f) restricting, binging, and purging behaviors.

The Blue Book, the accompanying manual concerning clinical descriptions and diagnostic guidelines for mental health disorders for the ICD-10 Classification of Mental and Behavioural Disorders (WHO, 1993), states that precedence can be given either to the diagnosis that necessitates the current admission to care (i.e., the symptoms that resulted in a patient's current treatment) or a "lifetime" diagnosis (one that better describes a patient's problems in living across the board; p. 12). Thus, one might debate between Major depressive disorder, recurrent (F33.x), which would be con- sistent with her emotion-related symptoms (symptoms a—e above), or focus on her emotion-related symptoms using a conceptualization of a "lifetime" diagnosis, which would point in the direction of a personality disorder.

One could start with a consideration of her strong emotions of sadness and shame, as well as suicide and self-harm planning, which are in line with a Major depressive disorder, recurrent (F33.x) diagnosis. At the same time, however, she has other symptoms that are better encompassed by the Borderline personality disorder (P60.3) diagnosis, such as intense negative emotions of anger, chronic feelings of emptiness, unstable and inconsistent relationships with family and friends, and unclear values and desires. Given the pervasive nature of her emotion dysregulation, which is not a typical symptom of Major depressive disorder, recurrent (F33.x; a diagnosis that focuses more on the length of time symptoms have been present than on the pervasiveness of those symptoms), her symptoms may be better accounted for by a "lifetime" diagnosis of Borderline personality disorder (F60.3). The underlying problem for many of Jenny's problematic behaviors, such as suicide and self-harm planning, is her difficulty in toler- ating strong negative emotions. As she experiences intense negative emotions, because she feels like she cannot control or tolerate them, she has a strong urge to escape them, and therefore engages in destructive behaviors. This emotion dysregulation, which is a central feature of Jenny's presentation, is the core problem of Borderline personality disorder (P60.3). Keep in mind that the pervasive nature of the emotion dysregulation of Borderline personality disorder (F60.3) means that other comorbid (co-occurring) diagnoses and problems in living are very common. Studies report that among a popu- lation of individuals with BPD, between 60% and 96% also met criteria for a mood or anxiety disorder (Grant et al., 2008; Zanarini et al., 1998).

Restricting, binging, and purging are disordered eating behaviors. It may be dif- ficult to differentiate between F50.0x Anorexia nervosa and F50.2 Bulimia nervosa, as restriction, binging, and purging can be components of both disorders. However, as Jenny is of normal height and weight, without amenorrhea, and her periods of restriction follow her binge and purge episodes, F50.2 Bulimia nervosa is likely the

more appropriate secondary diagnosis. Hence, you diagnose Jenny has having F60.3 Borderline personality disorder as the primary diagnosis and F50.2 Bulimia nervosa, as a secondary diagnosis.

Ethical Considerations—

Protecting Your Patient

ACTIVITY 15.3:

What are the specific ethical concerns with a person who presents with intense emotional distress and a history of self-harm? Given the complexity of this case, what could you do if you are unsure of how best to meet Jenny's needs?

196 YANG AND LINEHAN

In order to best protect the patient, therapist competence is highly important (Ethical Principles of Psychologists and Code of Conduct [APA Ethics Code], Standard 2.01, Bound- aries of Competence; APA, 2017). Therapist competence is often defined in part by the extent to which a therapist is able to deliver a treatment to a specific standard (Fairbum & Cooper, 2011). Additionally, a key component of protecting the patient is the delivery of an empirically supported treatment (APA Ethics Code, Standard 2.04, Bases for Sci- entific and Professional Judgments), given that only empirically supported treatments by definition have scientific evidence indicating their effectiveness and efficacy. DBT has the most empirical support of all treatments for BPD, and at present is considered the frontline treatment for the disorder (Neacsiu & Linehan, 2014).

One of the major considerations leading mental health professionals to hesitate to treat individuals with BPD is fear of inability to adequately manage suicide risk (Neacsiu & Linehan, 2014). Should a provider be competent in treating suicide but choose not to do so due to the potential complications or risk associated with suicidal patients, it may be useful to consider the fundamental principle of justice in the APA Ethics Code (Principle D). Specifically, as Principle D: Justice highlights the importance of fairness in entitling all individuals access to and benefit from the contributions of psychology, an examination of whether psychologists are biased against suicidal patients, and how that intersects with the ethical principles guiding our field, may be warranted Similarly, should it become reasonably clear that the patient is no longer benefiting from the treatment, according to the APA Ethics Code, Standard 10.10, Terminating Therapy, alternatives should be considered, as is the case with all psy- chological therapies.

One unique component of DBT is the consultation team, which comprises all clinicians who work together in the clinic to provide treatment. Consultation teams include the primary therapists as well as skills group leaders, who provide support to each other to maintain motivation for delivering effective treatment and enhance each other's clinical skills. Full DBT applied to fidelity involves this "therapy for the

therapists" 0 ence to the t obtained frot tiality extend is useful for accountable i mation about

Risk Mi. Protecti

ACTIVITY 15

What specifi yourself and

Similar to the mary protectiv (APA Ethics Co therapist, in cat to date. Utilizir sound, as well a that therapists guidance for th very stressful a The consultatio turn to help the

Another cri tion of the then used for what ai (e.g., Linehan, therapy record. most important

A final cons aries (APA Ethic in order to decr sional ethics. Th sideration in DB interfere with y tions thoroughly the ultimate proi

1 intense :his case,

; having F60.3 limia nervosa,

ortant (Ethical 2.01, Bound-

1 in part by the 3ard (Fairbum is the delivery Bases for Sci-

ted treatments efficacy. DBT

t is considered

als to hesitate g-e suicide risk ng suicide but I with suicidal ice in the APA he importance contributions gainst suicidal r field, may be at is no longer andard 10.10, with all psy-

comprises all iltation teams ovide support t and enhance herapy for the

•;61'

Borderline Personality Disorder 197

therapists" (Linehan, 1993, 2014) component in order to increase therapist adher- ence to the treatment and reduce burnout. Importantly, informed consent must be obtained from patients prior to participating in DBT, acknowledging that confiden- tiality extends to the team level, beyond the individual therapist. This clarification is useful for both increasing confidence that the clinician will be well supported and accountable in treatment delivery, as well as providing the patient with critical infor- mation about the treatment being initiated.

Risk Management—Protecting Your Patient, Protecting Yourself

ACTIVITY 15.4:

What specific risks do you foresee in working with Jenny? How can you protect yourself and your client if you become anxious and overwhelmed?

Similar to the discussion above about the ethics of protecting the patient, the pri- mary protective factor for a therapist is providing evidence-based practice to fidelity (APA Ethics Code, Principle B: Fidelity and Responsibility). A competent DBT-trained therapist, in conjunction with a consultation team, is armed with the best known tools to date. Utilizing the most empirically supported treatment is the most scientifically sound, as well as self-protective, method to address the client's diagnosis. DBT requires that therapists are part of a DBT consultation team, which functions as support and guidance for the therapist, given the recognition that effective treatment of BPD is very stressful and adhering to the DBT therapeutic framework can be challenging. The consultation team exists to increase therapist adherence to DBT principles and in turn to help the therapist provide the best treatment possible.

Another critical component of risk management is diligent written documenta- tion of the therapeutic process, including noting which evidence-based strategy was used for what and why. Each time it is warranted, a thorough suicide risk assessment (e.g., Linehan, 2009) should be conducted and adequately documented as part of the therapy record. Clear and thorough documentation of clinical contact is one of the most important ways of protecting yourself.

A final consideration for your protection is careful adherence to your own bound- aries (APA Ethics Code, Standard 2.06, Personal Problems and Conflicts) in therapy in order to decrease the likelihood of therapist burnout—and violation of profes- sional ethics. Therapy-interfering behaviors of the therapist are also targets for con- sideration in DBT. These include your own anxiety or emotional responses that may interfere with your ability to act in the client's best interest; addressing these emo- tions thoroughly will ensure the best provision of treatment possible, which in turn is the ultimate protection for you and your client. Another critical function of the DBT

198 YANG AND LINEHAN

team is to help DBT therapists manage burnout with teamwork, group supervision, and opportunities to practice mindfulness skills (Perseius, Kaver

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