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

1. 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

2. 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

3. DSM-IV Substance Use Disorder “The individual continues use of the substance despite significant substance-related problems”

4. 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

5. Prevalence of substance use disorders among psychiatric inpatients with BPD (Zanarini et al. 2004)

6. 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)

7. 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)

8. 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.

9. Polarized Attributions of BPDGregory RJ (2007). Am J Psychotherapy 61:131-147 Motivation: dependency vs. autonomy Agency: self vs. other Value: self vs. other

10. 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)

11. Medial prefrontal cortex Anterior cingulate cortex (ACC) Amygdala

12. 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)

13. attributions of self and other Action label emotions & sequence experience interpersonal stimulus

14. diffuse distress label emotions & sequence experience interpersonal stimulus

15. compensatory behaviors • symbolic objects • idealized attachment diffuse distress label emotions & sequence experience interpersonal stimulus

16. A B C Lieberman et al., Psychological Science, 2007

17. Amygdala Activity in fMRI scan C B A

18. Daily Connections Sheet

19. 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

20. 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%)

21. Individual Mental Health Contacts/Month Baseline Active Treatment F/U

22. Proportion Receiving Group Therapy (combined paid and self-help) * * p = .015 Baseline Active Treatment F/U

23. 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

24. Beck Depression Inventory * * p = .012 Base Active Treatment F/U

25. Mean Number of Suicide Attempts * * p = .013 Baseline Active Treatment F/U

26. Inpatient Days Per Month (psychiatric and detox/rehab) Baseline Active Treatment F/U

27. % Heavy Drinking Days ** ** p = .043 * * p = .066 Baseline Active Treatment F/U

28. % Days Using Recreational Drugs * * p = .001 Baseline Active Treatment F/U

29. 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

30. 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

31. 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.

32. Psychological Aspects of Addiction • Shame • Denial • Avoidance • Blame/Control Struggles

33. 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

34. 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

35. www.upstate.edu/ddp