Discussion: Treatment of Personality Disorders

Discussion: Treatment of Personality Disorders

Treatment of Personality Disorders Debate Example Paper

Personality disorders are, more often than not, especially challenging to manage, partially for the reason that they are, by classification, quite persistent, prevailing, combined with  uncompromising patterns of behavior in addition to intrinsic episodes. Furthermore, several unique objectives or aspirations of treatment of personality disorders can be put together, and a variety of these treatment options are more strenuous to undertake than others. Some of the objectives in treatment for personality disorders may perhaps consist of lessening subjective distress, modifying particular dysfunctional actions/behaviors, accompanied by altering entire precedents of behavior or the full established perception of the personality, traits, as well as their “assumed role” (Butcher, Hooley, & Mineka, 2014, Chapter 10: Personality Disorders). In this debate, we will discuss the pros and cons of both treatment option for borderline personality disorders and theoretical models based on current research. Our selected treatment options for Borderline Personality Disorder are: Medication Therapy and Dialectical Behavior Therapy. Discussion: Treatment of Personality Disorders

ORDER Discussion: Treatment of Personality Disorders

The Need for Medication Therapy

The brain and BPD: Pro-Medication Therapy

Using real-time brain imaging, a team of researchers have discovered that patients with Borderline Personality Disorder (BPD) are physically unable to regulate emotion. The Research team at Mount Sinai Medical Center  found that when people with BPD attempted to control and reduce their reactions to disturbing emotional scenes, the anterior cingulate cortex and intraparetical sulci areas of the brain that are active in healthy people under the same conditions remained inactive in the BPD patients (Nauert, 2019).

FMRI Revelation: Pro-Medication Therapy

The past 20 years have produced some biological findings due to the technological advancements in the neurological world of science.  Functional Magnetic Resonance Imaging (FMRI)  can measure the response of high frequency radio waves when placed in a strong magnetic field thus, producing images of blood flow that occurs during brain activity in specific regions of the brain. These images of the brain are revealing the specific systems in the brain that are overactive and underactive in those who have been diagnosed with Borderline Personality Disorder (BPD)

The portions of the brain involved in processing emotions are the amygdala, insula, posterior cingulate, hippocampus, and anterior cingulate cortex, as well as, the prefrontal regulatory regions of the brain. (Pier, 2016). FMRI has revealed heightened activation during processing of negative emotional stimuli in the left amygdala, left hippocampus, and posterior cingulate cortex as well as diminished activation in prefrontal regions. Another meta-analysis showed heightened activity in the insula and less activation in the subgenual anterior cingulate cortex in persons with BPD but did not find amygdala hyperactivity. FMRI research analysis revealed changes in the amygdala were produced from the medication status within the brains of research participants, revealing psychoactive drugs reduced the negative effect of limbic activity. Pharmacologic molecular proteins have also shown decreased metabolic activity in the anterior cingulate cortex and orbital frontal cortex in response to serotonergic challenges in impulsive-aggressive and affectively unstable BPD populations. Additionally, there was a resting metabolism between the orbital frontal cortex and the ventral anterior cingulate cortex. These brain revelations show changes in the brain due to medications that effect serotonin levels which can have a positive effect on an individual’s ability to manage their negative emotions with medication therapy (Pier, 2016).

Emotions and SSRI’s: Pro-Medication Therapy

The dysregulation of Serotonin can be the cause of psychopathological disorders, to name, Borderline Personality Disorder. Serotonin and oxytocin are two neuromodulators involved in human affect and personality disorders. These chemicals interact in emotional based behavior. Changes in these neuromodulators affect the regions of the brain responsible for mood, stress and emotional regulation. Medications that have proved positive in these dysregulations of the brain are (SSRI) serotonin re-uptake inhibitors (Zak, 2008). Discussion: Treatment of Personality Disorders

Oxytocin decreases cortisol (stress hormone) and anxiety responses to social stress.  Serotonin Re-uptake inhibitors (SSRI’s), assist the brain production of oxytocin by working together with serotonin neurotransmitters. This combination can be regulated by taking Prozac or Paxil, or other antidepressants available on the market today that are called SSRI’s (Zak, 2008).

Conclusion: Pro-Medication Therapy

Borderline Personality Disorder behaviors manifest as a need for closeness and attention coupled with a fear of rejection and abandonment and can create dissociation and social impairment in an individual diagnosed with BPD. Oxytocin and Serotonin are known for their capacity to facilitate social bonding and reduce anxiety and minimize stress.  If, science can circumvent an individual’s oxytocin system and Serotonin Neurotransmissions that are irregular, and stabilize the systems in the brain responsible for emotions, wouldn’t this have a positive impact on an individual’s biological, psychological, and social interaction?

Research clearly demonstrates that BPD evolves from anatomical factors.  However, it is important to note that there are many risk factors; social, genetic and emotional, each one serving to enforce the other. Therefore,  it seems only appropriate  that the community, science and therapy come together  to strengthen the resolve  by addressing;  the biological, psychological and social aspects of this disorder through Medication Therapy, Dialectical Behavioral Therapy as well as, Group Therapy.

Medication Therapy Cons:

Currently, the US Food and Drug Administration (FDA) has not approved any medications to treat Borderline Personality Disorder.  There are only medications to treat the symptoms of BPD.  These medications are usually only used to treat the patients’ most severe symptoms.  Sometimes, medications are only used during crises (Ripoll, 2013).

Amitriptyline, a tricyclic antidepressant has had a positive effect on BPD, but the use of it is limited of there is a high toxicity in overdose (Olabi and Hall, 2010).  Another antidepressant that has minimal effect on BPD are selective serotonin reuptake inhibitors (SSRIs).  They do not help with impulsive aggression.  SSRIs have been found to have positive effects on anxiety or depression.  These are considered symptoms of BPD; therefore, it is not directly having an effect on the disorder itself.

Mood stabilizers have also been researched regarding the treatment of BPD.  These medications are used to decrease a patient’s suicidal behavior.  Some researchers did a placebo-controlled trials of lithium treatment and found that it did show an improvement in the patient’s mood.  This being said, a patient’s mood is a symptom of BPD.  The lithium will not improve BPD as a whole.  Also, lithium also has a high risk of overdosing.  In a recent trial, carbamazepine, another mood stabilizer, has shown no positive affect on BPD or any of its symptoms (Olabi and Hall, 2010).

Some antipsychotic medications have been shown to have positive effects on cognitive-perceptual symptoms of BPD.  Antipsychotic medications are preferably and primarily used when a patient has a relapse. An example of an antipsychotic medication that has been studied in patients with BPD is olanzapine.  This medication has been found to reduce some symptoms of BPD but has not treated BPD as a whole.  One of the disadvantages of olanzapine is that “it is associated with metabolic side effects, which may limit its tolerability” (Olabi and Hall, 2010, para. 11).  Discussion: Treatment of Personality Disorders

Dialectical Behavior Therapy

In the early 1980s, Dr. Marsha Linehan was utilizing cognitive behavior therapy (CBT) with patients who presented with borderline personality disorder.  She found that this treatment alone was not working.  According to Shimelpfening (2020), using the foundation of behavior therapy, Dr. Linehan introduced the philosophical idea of dialectics.  Dialectics is based on the principle that everything is composed of opposites—all things are interconnected, change is constant, and opposites can be integrated to form a closer approximation of the truth.  Partnering this philosophy with the foundation of behavior therapy, Dialectical Behavior Therapy was established.

Dialectical Behavior Therapy, or DBT, is made up of four modules: core mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. These modules are designed to assist individuals with better managing thoughts, emotions, and behaviors. They are implemented through both individual and group weekly sessions.  Individual sessions focus on problem solving, starting first with self-injurious behaviors. Group sessions are focused on life skills encompassing the above modules.  Working through DBT with the four modules is designed as either a 6-month intensive or full year program.

Dialectical Behavior Therapy Pros:

Dialectical Behavior Therapy (DBT) is the primary treatment for borderline personality disorder (BPD). It originated as a treatment specifically geared to BPD. Borderline personality disorder is comprised of persistent instability of emotion and thought.  According to the Mayo Clinic, symptoms of BPD include an intense fear of abandonment, pattern of unstable intense relationships, rapid changes in self-identity, periods of stress related paranoia, impulsive and risky behaviors, suicidal behavior, mood swings, feelings of emptiness or intense anger. Initially, cognitive behavioral therapy (CBT) was used to assist in treating BPD.  CBT assists people in reframing their own thoughts differently.  It focuses on empowering individuals to make healthy choices.  But, because BPD can be cause extreme friction with mood and self-harm, as well as significant challenges with the external world, cognitive behavioral therapy was modified to include balance a balanced between the two.

DBT focuses not only on the internal recalibrating of thoughts and thought patterns, but also on the ability to change behavior patterns in a realistic way.  It focuses on mindfulness and how to manage relationships.   DBT has been expanded to additionally focus on the treatment of numerous psychological symptoms regardless of BPD, including persistent suicidal thoughts, mood disorders, and eating disorders. Many people with BPD struggle with impulsive behaviors, including self-injury, eating disorders, and substance abuse. The skills taught in DBT—distress tolerance, emotion regulation, mindfulness, and interpersonal effectiveness—can be helpful for people with borderline personality disorder. The distress tolerance and emotion regulation skills taught in DBT can help people regain control and decrease these harmful behaviors.

Borderline personality disorder changes may occur only in long-term treatments. It is standard that twelve months12 of DBT was effective in reducing borderline symptoms.  DBT for borderline personality disorder is often lengthy, expensive, and resource intensive. However, the current length of outpatient treatments is arbitrary and based on traits that never tested if the treatment intensity could be reduced.

There is currently a study examining examine the clinical and cost-effectiveness of 6 versus 12 months of DBT for chronically suicidal individuals with BPD. “This is the first study to directly examine the dose-effect of psychotherapy for chronically suicidal individuals diagnosed with BPD. Examining both clinical and cost effectiveness in 6 versus 12 months of DBT will produce answers to the question of how much treatment is good enough.”  (McCain et al. 2018) Results are anticipated in 2020, however no updates have been made.  This could change the trajectory of DBT.  However, at this time there is insufficient evidence to support short-term psychotherapy for borderline personality disorder.  Long term DBT remains the most successfully researched and peer reviewed route for borderline personality disorder treatment.Discussion: Treatment of Personality Disorders

ORDER Discussion: Treatment of Personality Disorders

Dialectical Behavior Therapy Cons:

While Dialectical Behavior Therapy (DBT) has shown a high level of efficacy, I’d like to argue that there are still a number of shortcomings.   The primary challenges with DBT revolve around the original intent of DBT, intensity of treatment, cost, current research limitations.

I’d first like to discuss core intent of DBT.  DBT was developed throughout the 1970s as a method for individuals who repeatedly attempt suicide.  At its center, DBT worked to focus on affecting real change in the individual’s life and thinking.  The thought was, if one could change the trajectory of thinking, suicidal urges could be reduced.  DBT has shown remarkable efficacy with self-injurious behavior and suicidal ideology.

As suicidal behavior is found to be very common in individuals living with borderline personality disorder, it makes sense that DBT would lend itself well to treatment options.  However, if we consider that the origin of DBT is measured on reduction of self-harm behaviors, does the treatment extend itself well enough to combat the additional core features of borderline personality disorder? Some argue that while DBT may be useful as an initial guide to treatment, we should remain open to the idea of moving into additional therapeutic measures once certain guideposts are reached.

A second shortcoming to DBT lies in the level of commitment and time needed in order to effectively run through its course.  As noted earlier, DBT has multiple steps and includes a number of weekly obligations in order to carry forward. According to an article posted by the US National Library of Medicine,  “A patient has to attend two separate sessions which include 1 hour of individual therapy and 2 hours of group skills training every week along with regular homework assignments over at least 1 year of treatment. Therapist has to be available 24/7 for providing emergency behavioral coaching, however rules can be laid down in this to protect the therapist from burnout.”  (Reddy, 2017) To add to the idea of time commitment, the cost runs parallel.  Many insurances do not recognize DBT as a billable practice and may only cover some costs of individualized therapy, leaving the remainder to the individual. This intensive type of therapy can be brutally expensive and remains out of reach for some.

And finally, I would like to bring in an overview of research limitations on DBT for Borderline Personality Disorder.  Many studies that have been completed on DBT run their course through a year.  This is, as noted earlier, the general time frame for DBT in terms of managing self-harming and suicidal behaviors.  This does not, however, give us measurable data to focus beyond that and specifically to the additional components in BPD.  In fact, much of the research completed leans into the improvement of patients specific to suicidal ideology and risky behavior.  In addition to this, the coupling of medication has yet to be explored. An article on the empirical reality of DBT for BPD states, “Although a Cochrane review concludes that psychotherapies, in general, are effective in the management of borderline personality,[5] it is not altogether clear as to the role of medication in the management and there are no rigorous or adequately powered studies comparing medication and psychotherapy.” (Reddy, 2017)

In conclusion, I would like to put forward that DBT has shown itself to be effective in managing components of borderline personality disorder.  However, without measured research specific to the efficacy with a focus on long term treatment of all BPD components, I cannot conclude that it is a finalized option.  Rather, can. Be built on as a component of a much larger plan that looks to the well-rounded treatment of all features of borderline personality disorder.

Conclusion

Every treatment possesses its own unique and specific advantages as well as setbacks/ impediments, as soon as they have opted for a treatment, it is vastly imperative that an individual makes inquiries in regards to every single offered treatment options in addition to making sure, without a shadow of a doubt, that they comprehend the guiding principles, processes along with the risks encompassed in every single offered treatment option. A person ought to take into consideration the well-founded reasons provided as to what constitutes a particular treatment most right and proper or apt for them as an individual for the reason that, a number of treatments may perhaps generate beneficial, reliable, and effective effects for some more than others whom have experienced negative results from particular treatments.Discussion: Treatment of Personality Disorders

References:

Butcher, J. N., Hooley, J. M., & Mineka, S. (2014). Abnormal Psychology (16th ed.). Retrieved from The University of Phoenix eBook Collection.

Kim, S. (2019). Psycom: Remedy Health Media. Retrieved from https://www.psycom.net/what-is-dialectical-behavior-therapy/

Mayo Clinic. Borderline Personality Disorder. Retrieved from https://www.mayoclinic.org/diseases-conditions/borderline-personality-disorder/symptoms-causes/syc-20370237

McCain, S., Chapman, A., Kuo, J., Guimond., Streiner, D., mDixon-Gordon, K., Isaranuwatchai, W., & Hoch, J. (2018). The effectiveness of 6 versus 12-months of dialectical behavior therapy for borderline personality disorder: the feasibility of a shorter treatment and evaluating responses (FASTER) trial protocol. BMC Psychiatry. 18: 230. doi: 10.1186/s12888-018-1802-z

Nauert, R. (2019). Brain scans clarify borderline personality disorder. Retrieved from http://Pschcentral.org

Olabi, B., & Hall, J. (2010, March). Borderline personality disorder: current drug treatments and future prospects. Search Results Web Result with Site Links National Center for     Biotechnology Information, 1(2), 59-66. doi:10.1177/ 2040622310368455

Pier, K. S. (2016). The neurobiology of borderline personality disorder. Retrieved from http://Psychiatrictimes.com

Psychology Today. Dialectical behavior therapy. Retrieved from https://www.psychologytoday.com/

us/therapy-types/dialectical-behavior-therapy

Reddy, M.S., & Vijay, M.S. (2017, March). Empirical reality of dialectical behavioral therapy in borderline personality. Indian Journal of Psychological Medicine, 39(2), 105-108. doi: 10.4103/IJPSYM.IJPSYM_132_17

Riopel, L. (2019). Positive Psychology. Retrieved from https://positivepsychology.com/what-is-dialectial-behavior-therapy-dbt/

Ripoll, L. H. (2013, June). Psychopharmacologic treatment of borderline personality dis

Search Results Web Result with Site Links National Center for Biotechnol

Information, 15(2), 212-224. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3811092/

Salmon, L. (2020).  Florida Borderline Disorder Association.  Florida Borderline Disorder Association. Retrieved from https://fbpda.org/2016/10/11/the-battle-between-dbt-treatment-and-insurance-companies/

Schimelpfening, N. (2020). Verywell Mind. Retrieved from https://www.verywellmind.com/dialectical-behavior-therapy-10674024

Zak, P. J. (2008). The oxytocin cure. Retrieved from http://psychologytoday.com

https://www.mayoclinic.org/diseases-conditions/borderline-personality-disorder/symptoms-causes/syc-20370237

ASSIGNMENT QUESTIONS

Explain the diagnostic criteria for your assigned personality disorder.

Explain the evidenced-based psychotherapy and psychopharmacologic treatment for your assigned personality disorder.

Describe clinical features from a client that led you to believe this client had this disorder. Align the clinical features with the DSM-5 criteria.

References

American Nurses Association. (2014). Psychiatric-mental health nursing: Scope and standards of practice (2nd ed.). Washington, DC: Author.

· Standard 12 “Leadership” (pages 76-77)

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.

· Chapter 4, “Theories of Personality and Psychopathology” (pp. 151–191)

· Chapter 22, “Personality Disorders” (pp. 742–762)

· Chapter 13, “Psychosomatic Medicine” (pp. 451–464)

Gabbard, G. O. (2014). Gabbard’s treatment of psychiatric disorders (5th ed.). Washington, DC: American Psychiatric Publications.

· Chapter 68, “Paranoid, Schizotypal, and Schizoid Personality Disorders”

· Chapter 69, “Antisocial Personality Disorder”

· Chapter 70, “Borderline Personality Disorder”

· Chapter 71, “Histrionic Personality Disorder”

· Chapter 72, “Narcissistic Personality Disorder”

· Chapter 73, “Cluster C Personality Disorders

Note: You will access this book from Walden Library databases.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

· “Personality Disorders”

Note: You will access this book from Walden Library databases.

Perry, J. C., Presniak, M. D., & Olson, T. R. (2013). Defense mechanisms in schizotypal, borderline, antisocial, and narcissistic personality disorders. Psychiatry: Interpersonal & Biological Processes, 76(1), 32–52. doi:10.1521/psyc.2013.76.1.32

Note: You will access this article from Walden Library databases.

Rees, C. S., & Pritchard, R. (2015). Brief cognitive therapy for avoidant personality disorder. Psychotherapy, 52(1), 45–55. doi:10.1037/a0035158

Note: You will access this article from Walden Library databases.

Laureate Education. (2017a). A woman with personality disorder [Interactive media file]. Baltimore, MD: Author.

Kernberg, O. (n.d.). Psychoanalytic psychotherapy for personality disorders: An Interview with Otto Kernberg, MD. [Video file]. Mill Valley, CA: Psychotherapy.net

Note: This video is approximately 94 minutes of length. You will access this article from Walden Library databases