NADA: A Simple Tool to Aid in the Recovery from Borderline Personality Disorder Libby Stuyt, MD Department of Psychiatry University of Colorado Health Sciences Center Colorado Mental Health Institute at Pueblo May 2014
Borderline Personality Disorder
Borderline Personality Disorder
Etiology Multifactorial but extensive research supports the notion that early abuse and neglect is a significant factor Early childhood separations, chaotic home environments, insensitivity to the child s feelings and needs, emotional discord in the family and trauma of varying degrees have all been implicated in the etiology
Consequences of Early Childhood Trauma Hippocampus vulnerable to the effects of stress Reduced hippocampal volume found in adult patients with borderline personality disorder Early trauma may promote hemispheric lateralization and adversely affect integration of the right and left hemispheres Abused children used their left hemisphere when thinking about neutral memories and their right hemisphere for frightening memories, control group used both left and right equally regardless of memory content
Failure of Hemispheric Integration Reflected in splitting major defense mechanism Tend to compartmentalize self and object representations into all good and all bad
Absence of Secure Attachment Difficulty discerning their own mental states or those of others diminished capacity for mentalization recognizing that someone else has a different mind from their own Almost delusional conviction that their perception is a direct reflection of reality rather than a representation of reality based on their internal belief, feelings and past experiences
Symptoms Include Frantic attempts to avoid real or imagined abandonment (reject first before being rejected) Highly unstable relationships over idealizing one minute, devaluing the next Rapid mood swings (minute to minute), feelings of emptiness, anger Impulsive, self-destructive behavior (risky sex, excessive spending, reckless driving, binge eating, substance abuse)
Neuropeptide Model of BPD Stanley B and Siever LJ Am J Psychiatry 2010;167:24-39 Low basal opioid levels (leading to chronic dysphoria and lack of sense of well-being) with compensatory super sensitivity of µ-opioid receptors (SIB results in heightened relief of pain and restoration of sense of well-being) Dysregulation of oxytocin may distort the reading of social cues, establishment of trust and capacity for attachment Vasopressin associated with aggression
Oxytocin attenuates amygdala responses to emotional faces regardless of valence Domes G et al.biol Psychiatry 2007;62:1187-1190 13 healthy, non-smoking males, oxytocin and placebo intranasally 45 minutes before fmri sessions, observed pictures of facial affect with different intensity levels Higher activation in right amygdala in response to emotional faces compared with neutral faces in placebo condition A single dose of oxytocin attenuates right-sided amygdala responses to emotional faces
Substance Abuse Treatment The most stable predictor of positive treatment outcomes is retention in treatment Prevalence rates of Axis II disorders 70-80% among drug dependent persons treated inpatient or in residential programs Personality disorders (especially ASPD, BPD) are consistently associated with risk for early drop out from all types of substance abuse treatment
Impact of borderline personality disorder on residential substance abuse treatment dropout among men (Tull MT & Gratz KL, Drug and Alcohol Dependence 2012;121:97-102) Patients with borderline personality disorder (BPD) are significantly more likely to prematurely drop out of substance abuse treatment This study focused on males 159; 34 with BPD Found that BPD significantly predicted treatment dropout (38.2% versus 16% of those without BPD) Particularly true in center initiated treatment dropouts (26.5% versus 6.4%, p<0.01)
NADA and Self-Injurious Behavior Nixon MK, Cheng M, Cloutier P. An open trial of auricular acupuncture for the treatment of repetitive self-injury in depressed adolescents. Canadian Child and Adolescent Psychiatry Review. 2003;12:10-12. 9 adolescents, NADA treatments once a week for three weeks with metallic balls on tape on all five points after needles Comparison of baseline frequency of SIB and urges to one week and four weeks post treatment, also BDI, HDRS, STAXI Significant reduction in SIB at 1 week (p=.004), and at 4 weeks (p=.03) No change on depression rating scales but significant reduction in internalizing anger scores I felt as if the stress was relieved. I was calmer and didn t have any urges (to self injure). treatments three times per week would be better.
Circle Program 90-day inpatient dual diagnosis program We have had a different experience We are mandated to treat those who have failed everything else We have really good success with people with borderline pd Used outcome study to explain this
Optimum Treatment Components Because they come from a back ground of chaos they think this is their normal and will seek to create chaos when it doesn t exist, to feel normal They benefit from grounding techniques to experience a new normal anything to increase the parasympathetic tone is helpful First step = NADA 5-point ear acupuncture protocol Then - Dialectical Behavioral Therapy (DBT) mindful meditation Heartmath TFT, EFT, BST, Yoga, Tai Chi
Medications Should be seen as an aid only Pills often used as transferential objects (avoid benzos and opiates iatrogenic addiction ) Naltrexone self injurious behavior - +/- benefit Mood stabilizers Antidepressants Antipsychotics My goal is to reduce medication and discontinue if at all possible (remove external locus of control encourage internal locus of control)
Circle Program Outcome Study 231 patients, 78 with borderline personality disorder, 37 patients with antisocial personality disorder and 49 with no personality disorder or marked personality traits 98% of those with no Axis II diagnosis successfully completed program 87 % of those with BPD completed (13% dropout) 59% of those with ASPD completed (41% dropout)
Borderline PD patients and Acudetox sessions 49 females 83% completed program 44 (90%) of those completing used acudetox Average number of sessions = 12 ± 8 7 (70%) of those not completing used acudetox Average number of sessions = 6 ± 6 19 males 100% completed program 18 (95%) used acudetox Average number of sessions = 14 ± 9
NADA helps with Distress tolerance Anger/acting out Developing therapeutic alliance Improved motivation to engage in treatment Acupunct Med doi:10.1136/acupmed-2014-010540 Ear acupuncture for co-occurring substance abuse and borderline personality disorder: an aid to encourage treatment retention and tobacco cessation
Length of stay (LOS) in days in the program by number of acudetox sessions compared with attitude about tobacco use after discharge Cell: Plans to use tobacco as soon as possible N=67 Cell: Wants to stay quit from tobacco N=126 120 Regression Plot Split By: tobacco p tx Cell: plans to smoke 160 Regression Plot Split By: tobacco p tx Cell: wants to quit 100 80 140 120 100 LOS 60 LOS 80 40 20 60 40 20 0-5 0 5 10 15 20 25 30 35 acudetox sessions Y = 48.441 + 1.592 * X; R^2 =.155 0-5 0 5 10 15 20 25 30 35 acudetox sessions Y = 84.307 +.137 * X; R^2 =.01 p=.001 p=.2714
Program completion by acudetox sessions average number of acudetox sessions 14 12 10 8 6 4 2 0 6 Antisocial PD N=37 7 7 Borderline PD N=78 13 11 no Axis II N=49 12 did not complete completed program
Status at end of year follow-up 60% 54% 55% 50% 40% 30% 24% 18% 19% 25% Total Group N=140 Borderline PD N=51 20% 10% 3% 2% 0% Sober and doing well Deceased Incarcerated Relapsing
Quitting tobacco in treatment improves the ability to maintain sobriety one year after tobacco-free substance abuse treatment 80% 12 Percent 70% 60% 50% 40% 30% 20% 10% 60% 8 69% 6 9 28% 10 8 6 4 2 m o n t h s Relapsed to drugs/alcohol p=.0115 Average time to first relapse in months p=.008 0% Not using tobacco on admission N=20 Resumed tobacco use after treatment N=102 Tobacco Use Quit tobacco use in treatment N=18 0
Those with BPD more likely to quit tobacco use BPD 12% not using tobacco on admission, 33% not using tobacco at the end of year ASPD 6% not using tobacco on admission, 12% not using tobacco at end of year No Axis II 23% not using tobacco on admission, 29% not using tobacco at end or year Those not using tobacco at end of year had more acudetox sessions in treatment 15 ± 9 vs 12 ± 8 sessions in those still using tobacco (p=.04)
Management Tips Because their boundaries were always blurred growing up they are constantly seeking what the boundaries are Establish boundaries immediately but remember that the boundaries need to be consistent and flexible Provide a secure base and give support and encouragement, establish realistic expectations and give feedback (positive and negative)