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Cognitive Behavior Therapy Of DSM-5 Personality...


Therapy-interfering behaviors can occur on the behalf of both therapist and patient. Patient interference includes anything that may interfere with receiving therapy or lead to therapist burnout (eg, nonadherence, inattentive behavior, breaking agreements with the therapist that are repeatedly addressed). By reducing therapy-interfering behaviors, drop-out rates can be significantly reduced.9




Cognitive Behavior Therapy of DSM-5 Personality...



Behavioral skills are considered those skills that will be used in the patient's daily life. These behaviors specifically address BPD traits defined in the DSM-5. Mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness skills are explained in further detail and applied to the patient's everyday life. In addition, new self-management skills (eg, learning/maintaining healthy behaviors, eliminating unhealthy behaviors) are taught and reinforced throughout individual therapy.9


Most patients, particularly those with BPD, enter therapy with a trauma history.9 Although trauma and posttraumatic symptoms may initially remain unaddressed because of the priority of suicidal behaviors, it is important that the therapist address trauma history when the patient appears ready. This focus includes remembering the abuse (eg, validation of memories, acknowledging emotions related to abuse), reducing self-blame and stigmatization, ending denial and intrusive thoughts regarding abuse (eg, exposure techniques), and reducing polarization or dialectical view of the self and the abuser.9


The strategies used for telephone consultation are designed to minimize reinforcement of parasuicidal behaviors. For that reason, patients are told at the beginning of therapy that they are expected to call their individual therapist before engaging in parasuicidal behavior. In addition, the patient is not allowed to call the therapist for 24 hours after engaging in parasuicidal behavior unless there are life-threatening injuries. The 24-hour rule is meant to encourage patients to seek help from the therapist at earlier stages of a crisis while the therapist can still offer assistance and not after the patient has already chosen maladaptive behaviors.1


In the scientific literature, there appears to be mixed evidence on the efficacy of medications for the management of BPD, and psychopharmacologic interventions usually have nonspecific results.14 A 2011 meta-analysis evaluated the effectiveness of medications in treating impulsivity, aggression, depression, anxiety, anger, and suicidal behavior in patients with BPD, and concluded the following: (1) selective serotonin reuptake inhibitors (SSRIs) can improve impulsivity and aggression but have little effect on other symptoms; (2) mood stabilizers and anticonvulsants have a moderate effect on depression and can improve aggression and impulsivity; (3) first-generation antipsychotics can reduce anger and suicidal behavior in patients with BPD but have little effect on psychosis and anxiety; and (4) second-generation antipsychotics can have an effect on aggression, but there are mixed results for other symptoms.12 Benzodiazepine use by patients with BPD has been greatly discouraged, as it may be abused (ie, used to self-medicate intrapersonal issues) and exacerbate BPD symptoms.12 Other research has supported this finding, as 87% of psychiatrists interviewed cited medication misuse, including overdose, as a common problem among their BPD patients.15 Despite continued use of pharmacotherapy, researchers have concluded that conservative use should be considered best practice, given potential lethality of most medications, with the exception of SSRIs.14


There is some evidence that DBT is effective in lowering psychotropic medication use in patients. One study noticed significant decrease in psychotropic medication use among college students with parasuicidal behaviors following DBT treatment.16 One particular study focusing on adolescent DBT during long-term inpatient therapy also found a reduction in psychotropic medications prescribed.17 However, there were no comparison group results with which to run a statistical analysis on the significance in the DBT group's reduction in medication. This is an area that deserves further consideration, given the mixed evidence for medication effectiveness, medication side effects, and potential for misuse of psychotropic medications.


In this 2-hour continuing education web conference, Dr. Jon Sperry will discuss cognitive behavioral therapy (CBT) assessment, conceptualization, and treatment of various Diagnostic and Statistical Manual of Mental Disorders (DSM-5) personality disorders, including borderline personality and narcissistic personality. Dr. Sperry will highlight a CBT functional assessment model and also empirically-validated CBT strategies to use with this population. He will introduce participants to each step of the CBT process, from assessment to case conceptualization to selection and implementation of various interventions.


CBT techniques emerge from a fundamental premise of cognitive-behavioral theory. Our thoughts (cognitions) lead to our emotions and subsequent behavior. Of particular importance for people with personality disorders is the way in which external events in the environment (such as interpersonal interactions with others) are uniquely interpreted and assigned a meaning based upon core beliefs. Childhood experiences, coupled with an innate, biologically-determined disposition, establish our initial beliefs about the world. These initial beliefs evolve into fairly stable, core beliefs that shape people's perceptions and interpretations of subsequent experiences. When these preconceived beliefs are faulty, distorted, or biased, we may end up drawing incorrect, irrational conclusions about the meaning of external events (particularly interpersonal interactions). We may subsequently behave in ways that cause us unnecessary distress and suffering. For more detailed information about these concepts please return to the section on cognitive-behavioral theory.


You may recall, people with personality disorders have characteristic patterns of thinking that get them into trouble. This is because their ways of thinking tend to be somewhat extreme, inflexible, and distorted. CBT is particularly helpful for people with personality disorders because of its emphasis on identifying and changing dysfunctional thinking patterns. In particular, core beliefs underlying those patterns are exposed and challenged. Thus, cognitive-behavioral therapy functions to identify and challenge automatic and faulty interpretations of the environment that are driven by core beliefs.


Cognitive behavioral therapy (CBT) is a psycho-social intervention[1][2] that aims to reduce symptoms of various mental health conditions, primarily depression and anxiety disorders.[3] CBT focuses on challenging and changing cognitive distortions (such as thoughts, beliefs, and attitudes) and their associated behaviors to improve emotional regulation[2][4] and develop personal coping strategies that target solving current problems. Though it was originally designed to treat depression, its uses have been expanded to include the treatment of many mental health conditions, including anxiety,[5][6] substance use disorders, marital problems, and eating disorders.[7][8][9] CBT includes a number of cognitive or behavioral psychotherapies that treat defined psychopathologies using evidence-based techniques and strategies.[10][11][12]


CBT is a common form of talk therapy based on the combination of the basic principles from behavioral and cognitive psychology.[2] It is different from historical approaches to psychotherapy, such as the psychoanalytic approach where the therapist looks for the unconscious meaning behind the behaviors, and then formulates a diagnosis. Instead, CBT is a "problem-focused" and "action-oriented" form of therapy, meaning it is used to treat specific problems related to a diagnosed mental disorder. The therapist's role is to assist the client in finding and practicing effective strategies to address the identified goals and to alleviate symptoms of the disorder.[13] CBT is based on the belief that thought distortions and maladaptive behaviors play a role in the development and maintenance of many psychological disorders[3] and that symptoms and associated distress can be reduced by teaching new information-processing skills and coping mechanisms.[1][13][14]


Precursors of certain fundamental aspects of CBT have been identified in various ancient philosophical traditions, particularly Stoicism.[22] Stoic philosophers, particularly Epictetus, believed logic could be used to identify and discard false beliefs that lead to destructive emotions, which has influenced the way modern cognitive-behavioral therapists identify cognitive distortions that contribute to depression and anxiety.[23] Aaron T. Beck's original treatment manual for depression states, "The philosophical origins of cognitive therapy can be traced back to the Stoic philosophers".[24] Another example of Stoic influence on cognitive theorists is Epictetus on Albert Ellis.[25] A key philosophical figure who influenced the development of CBT was John Stuart Mill.[26][how?]


Groundbreaking work of behaviorism began with John B. Watson and Rosalie Rayner's studies of conditioning in 1920.[27] Behaviorally-centered therapeutic approaches appeared as early as 1924[28] with Mary Cover Jones' work dedicated to the unlearning of fears in children.[29] These were the antecedents of the development of Joseph Wolpe's behavioral therapy in the 1950s.[27] It was the work of Wolpe and Watson, which was based on Ivan Pavlov's work on learning and conditioning, that influenced Hans Eysenck and Arnold Lazarus to develop new behavioral therapy techniques based on classical conditioning.[27][30]


During the 1950s and 1960s, behavioral therapy became widely used by researchers in the United States, the United Kingdom, and South Africa. Their inspiration was by the behaviorist learning theory of Ivan Pavlov, John B. Watson, and Clark L. Hull.[28] 041b061a72


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