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Borderline PD Co-Occurring With Substance Dependence: Understanding Mechanisms and Developing Treatments. Robert J. Gregory, M.D. Professor, SUNY Upstate Medical University Dir., Psychotherapy Division Dir., Borderline P.D. Program Dir., Center for Emotion and Behavior Integration.

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Borderline PD Co-Occurring With Substance Dependence: Understanding Mechanisms and Developing Treatments

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Borderline pd co occurring with substance dependence understanding mechanisms and developing treatments

Borderline PD Co-Occurring With Substance Dependence: Understanding Mechanisms and Developing Treatments

Robert J. Gregory, M.D.

Professor, SUNY Upstate Medical University

Dir., Psychotherapy Division

Dir., Borderline P.D. Program

Dir., Center for Emotion and Behavior Integration


Borderline pd co occurring with substance dependence understanding mechanisms and developing treatments

BPD DSM-IV CRITERIA

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood. > 5/9

1. Frantic efforts to avoid real or imagined abandonment

2. Unstable and intense interpersonal relationships, alternating idealization and devaluation

3. Persistently unstable self-image or sense of self

4. Impulsivity that is potentially self-damaging

5. Recurrent suicidal behavior or threats, or self-mutilation

6. Mood lability and reactivity

7. Chronic feelings of emptiness

8. Frequent or intense anger outbursts

9. Transient paranoid ideation or severe dissociative symptoms


Borderline pd co occurring with substance dependence understanding mechanisms and developing treatments

DSM-IV Substance Use Disorder

“The individual continues use of the substance despite significant substance-related problems”


Borderline pd co occurring with substance dependence understanding mechanisms and developing treatments

Prevalence of BPD

  • 1-2 % point prevalence and 6% lifetime prevalence

  • 10% of psychiatric outpatients and 20% of psychiatric inpatients

  • 10% of drug & alcohol rehabilitation outpatients and 20% of drug & alcohol rehabilitation inpatients


Borderline pd co occurring with substance dependence understanding mechanisms and developing treatments

Prevalence of substance use disorders among psychiatric inpatients with BPD

(Zanarini et al. 2004)


Challenges with co occurring bpd and substance use disorders sud

Challenges with co-occurring BPD and Substance Use Disorders (SUD)

  • Worse anxiety, impulsivity, mood lability, antisocial traits, suicidality, and work functioning than BPD alone (Miller 1993; Trull 2000; Van den Bosch 2001)

  • More likely to drop out of psychotherapy and worse outcomes than BPD alone (Karterud 2009; Linehan 1999, 2002; Zanarini 2004)

  • More likely to drop out of rehab, more distress, more suicide attempts and lower abstinence than SUD alone (Darke 2004; Marlowe 1997)


Borderline pd co occurring with substance dependence understanding mechanisms and developing treatments

BPD MechanismsAltered Neurocognitive Processing of Emotional Experiences

  • Difficulty labeling emotions(Ebner-Premier 2007; Leible & Snell 2004; Levine 1997),linked to distress (Ebner-Premier 2008) and activation of the amygdala (Gur 2007, Lieberman 2007)

  • Deficit in episodic memory(Levy 2006, Westen 2006) and production of over-general memories (Startup 2001)

  • Polarized attributionsof self and others(Arntz & Veen 2001, Conklin & Westen 2005, King-Casas 2008)


Borderline pd co occurring with substance dependence understanding mechanisms and developing treatments

  • Difficulty labeling emotions

  • Deficit in episodic memory

  • Polarized attributions

Pseudonarrative

I know this sounds incredibly mean, but I get so sick of people coming to me for advice. When my friends are talking about what jerks their boyfriends are and how annoying their parents are, I keep thinking about drinking because no one around me thinks I’m going through anything at all.


Borderline pd co occurring with substance dependence understanding mechanisms and developing treatments

Polarized Attributions of BPDGregory RJ (2007). Am J Psychotherapy 61:131-147

Motivation: dependency vs. autonomy

Agency: self vs. other

Value: self vs. other


Borderline pd co occurring with substance dependence understanding mechanisms and developing treatments

Functional Imaging Studies in BPD

Responses to emotional stimuli:

  • Amygdala – increased activation in response to emotionally aversive pictures (Donegan 2003, Herpetz 2001)

  • Medial prefrontal cortex – deactivation in response to trauma scripts (Schmahl 2003), negative word cues (Silbersweig 2007)

  • Anterior cingulate – deactivation in response to fearful faces (Donegan 2003), trauma scripts (Schmahl 2004), and negative word cues (Silbersweig 2007)


Borderline pd co occurring with substance dependence understanding mechanisms and developing treatments

Medial prefrontal cortex

Anterior cingulate cortex (ACC)

Amygdala


Function of addiction as it relates to bpd

Function of Addiction (as it relates to BPD)

  • Soothes anxiety or arousal (Tragesser 2007)

  • Enhances euphoria and short-term self-esteem (Tragesser 2008)

  • Shuts down the prefrontal cortex, thereby fostering avoidance of emotions (Goldstein 2004)

  • Satisfies attachment needs, thereby allowing patients to remain autonomous and detached (Barr 2004)


Borderline pd co occurring with substance dependence understanding mechanisms and developing treatments

attributions of

self and other

Action

label emotions &

sequence experience

interpersonal

stimulus


Borderline pd co occurring with substance dependence understanding mechanisms and developing treatments

diffuse distress

label emotions &

sequence experience

interpersonal

stimulus


Borderline pd co occurring with substance dependence understanding mechanisms and developing treatments

  • compensatory behaviors

  • symbolic objects

  • idealized attachment

diffuse distress

label emotions &

sequence experience

interpersonal

stimulus


Borderline pd co occurring with substance dependence understanding mechanisms and developing treatments

A

B

C

Lieberman et al., Psychological Science, 2007


Borderline pd co occurring with substance dependence understanding mechanisms and developing treatments

Amygdala Activity in fMRI scan

C

B

A


Borderline pd co occurring with substance dependence understanding mechanisms and developing treatments

Daily Connections Sheet


Borderline pd co occurring with substance dependence understanding mechanisms and developing treatments

Dynamic Deconstructive PsychotherapyGregory & Remen (2008). Psychotherapy: Theory, Research, Practice, Training, 45, pp. 15-27

  • Manual-based, weekly individual psychotherapy

  • Preset duration (12 months)

  • Targets BPD/SUD

  • Remediation of emotion processing through repeated activation of the 3 neurocognitive functions of: labeling emotions, episodic memory, and attributions


Borderline pd co occurring with substance dependence understanding mechanisms and developing treatments

DDP ResearchGregory et al. (2008)Psychotherapy: Theory, Research, Practice, Training,45, pp. 28-41Gregory et al. Journal of Nervous and Mental Disease (in press)

  • N=30, BPD and active alcohol abuse or dependence

  • RCT of 12 months DDP vs. optimized community care + 18 months naturalistic f/u

  • Multiple comorbidities (antisocial PD – 43%, illicit drug use – 83%)


Borderline pd co occurring with substance dependence understanding mechanisms and developing treatments

Individual Mental Health Contacts/Month

Baseline

Active Treatment

F/U


Borderline pd co occurring with substance dependence understanding mechanisms and developing treatments

Proportion Receiving Group Therapy (combined paid and self-help)

*

* p = .015

Baseline

Active Treatment

F/U


Borderline pd co occurring with substance dependence understanding mechanisms and developing treatments

Proportion Achieving Clinically Meaningful Change in BPD Symptoms (25% Δ in BEST, Blum et al. 2002)

*

*

* p = .005

odds ratio = 16

Base

Active Treatment

F/U


Borderline pd co occurring with substance dependence understanding mechanisms and developing treatments

Beck Depression Inventory

*

* p = .012

Base

Active Treatment

F/U


Borderline pd co occurring with substance dependence understanding mechanisms and developing treatments

Mean Number of Suicide Attempts

*

* p = .013

Baseline

Active Treatment

F/U


Borderline pd co occurring with substance dependence understanding mechanisms and developing treatments

Inpatient Days Per Month

(psychiatric and detox/rehab)

Baseline

Active Treatment

F/U


Borderline pd co occurring with substance dependence understanding mechanisms and developing treatments

% Heavy Drinking Days

**

** p = .043

*

* p = .066

Baseline

Active Treatment

F/U


Borderline pd co occurring with substance dependence understanding mechanisms and developing treatments

% Days Using Recreational Drugs

*

* p = .001

Baseline

Active Treatment

F/U


Borderline pd co occurring with substance dependence understanding mechanisms and developing treatments

Conclusions From the Study

  • Broad effectiveness that continues after treatment ends

  • May be effectively applied by inexperienced therapists

  • Very cost effective, i.e. better outcomes obtained with less treatment

  • Limitations: single study, small N, interview-based drug use estimates


Practicing ddp remediating interventions

Practicing DDP: Remediating Interventions

  • Verbalize recent interpersonal episodes and label emotions

    2.Explore alternative or opposing attributions towards self and other, while remaining generally non-directive and non-judgmental

    3.Provide unanticipated, positive experiences in the patient-therapist relationship


Borderline pd co occurring with substance dependence understanding mechanisms and developing treatments

Interventions

  • Verbalize episodes

  • Integrate attributions

  • Patient-therapist relationship

Pseudonarrative

I know this sounds incredibly mean, but I get so sick of people coming to me for advice. When my friends are talking about what jerks their boyfriends are and how annoying their parents are, I keep thinking about drinking because no one around me thinks I’m going through anything at all.


Psychological aspects of addiction

Psychological Aspects of Addiction

  • Shame

  • Denial

  • Avoidance

  • Blame/Control Struggles


Special considerations for treatment of substance misuse in patients with bpd

Special Considerations for Treatment of Substance Misuse in Patients with BPD

  • Convey respect and support self-esteem

  • Educate about: 1. Harmful aspects of substance use and 2. Addiction is an illness, not a moral issue

  • Avoid benzodiazepines, such as Xanax or Klonopin, and change focus from medication to therapy

  • Check-in with patient about recent substance use

  • Avoid control struggles: Help patient to develop an internal conflict


Video of 19 year old woman with bpd and alcohol dependence sm3 video attributions

Video of 19-year-old woman with BPD and alcohol dependence(SM3 video)Attributions:

Agency in the other

Intervention:

Avoid control struggles: Help patient to develop an internal conflict


Borderline pd co occurring with substance dependence understanding mechanisms and developing treatments

www.upstate.edu/ddp


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