part0031

DBT is most effective for people who experience emotions very intensely. They tend to be easily overwhelmed by life and relational stressors to the point that they feel that their emotional responses are out of control. Consequently, they often act in an impulsive manner in an attempt to temporarily relieve some of their distress. However, their reactions over the long term tend to create additional problems.

DBT was initially used to help individuals who were diagnosed with Borderline Personality Disorder (BPD). This was and continues to be a very effective form of therapy to use with these individuals. However, in more recent years, DBT has also been very successfully used with other individuals who demonstrate severe mood swings and are unable to apply coping strategies to successfully deal with these intense and sudden emotional urges. Many of these people struggle with severe depression, PTSD, eating disorders, severe compulsory disorders, Bipolar Disorder, ADHD, anger management, and/or substance abuse. Many people who seek out DBT also engage in self-harm, as this therapy has been shown to be very effective in helping individuals with this level of emotional trouble.

In order to really understand more about the person who generally does well in DBT, let’s take a look at the specific characteristics that many of these people share. People who do well with DBT usually have a high level of emotional vulnerability. What this means is that they are prone to experiencing emotions in a very reactive and intense way. Sometimes, they are just hardwired to feel emotions more intensely than the average person. In fact, DBT theory asserts that the automatic nervous system of an emotionally vulnerable person is predisposed to be reactive to relatively low levels of stress. Their nervous system also takes much longer to return to baseline levels when the stressor is removed. Additionally, some people have mood disorders such as major depression or generalized anxiety that is not being effectively controlled by medication, and that influence how intensely they experience their emotions. Consequently, emotionally vulnerable people tend to have quick, intense, emotional reactions that are difficult to control. This keeps them on a roller coaster ride throughout their lives.

However, clinicians have found that most emotionally vulnerable people who seek DBT treatment are not JUST hardwired to have more intense emotions or have mood disorders. Typically, they have also been exposed to invalidating environments for extensive periods of time. Such environments generally stem from early childhood, but could have occurred at any point. These environments did not provide them with the support, attention, respect, or understanding that they needed to properly work through their emotions. Invalidating environments can range from ones involving severe emotional or physical abuse to mismatched parent and child personalities. Consider the shy child who is born or adopted into a family full of extroverts, and who is constantly teased about his or her introverted personality. Or perhaps it’s the child with ADHD who has a mother and stepfather who are inflexible and constantly yelling at them. These are both examples of environments that are invalidating. When the person who already has a predisposition to experience more extreme emotions is placed in an environment that does not support or validate their feelings, they can become even more emotionally vulnerable. They may then begin to demonstrate even greater emotional reactivity because they inadvertently learned that the only time they were taken seriously was when they demonstrated extremely emotional behavior.

Let’s take the introverted child as an example, and let’s say it’s a boy. Say he was constantly told by his father that he had to “man up” and become more aggressive in his approach to life. He felt ridiculed and began to think that there was something wrong with him. So, one day when his father was addressing him, the boy began to cry uncontrollably. His father immediately lightened up, and his mother came rushing to his aid, showering him with tons of attention. Then it happened again. And then again. An interesting thing began to happen. The young boy’s unconscious mind began to see a pattern that looked like this: ‘My dad harasses me, I cry uncontrollably, the hassling stops, I get lots of attention.’ He began to do it more and more because it worked and each successful demonstration inadvertently reinforced the behavior. His emotional outbursts became validated, and then it ultimately becomes an ingrained coping skill.

The process described above unconsciously reinforced the child’s emotional vulnerability, and you guessed it – made it worse. This is typically the pattern you see with people with Borderline Personality Disorder, Bipolar Disorder, eating disorders, and other disorders that DBT treats. The next section will give an overview of several of the disorders that are successfully treated with DBT.

People with Borderline Personality Disorder (BPD) experience emotions more intensely and for longer periods of time than other people. They are prone to frequent and chronic outbursts to the point that many mental health professionals have described this population as one that is experiencing an unrelenting crisis. They are nearly always in crisis mode as they have generally not learned the coping skills they need to better regulate their intense emotions.

Individuals with BPD are emotionally vulnerable, and it takes them much longer to return to baseline following an event. In addition, one of the patterns that therapists have described regarding people with BPD is their tendency to take on the same belief system as the invalidating environment that they are subjected to. This results in their own “self-invalidation,” where they reject their own emotions and ability to solve problems. They also tend to develop unrealistic expectations for themselves and experience intense shame and anger when they fail to meet their goals or when difficulties arise.

Another defining characteristic of individuals with BPD is their tendency to make rigid and unrealistic demands of themselves and others. When things don’t go as they planned or desire, they often resort to “blaming.” Blaming is a thinking error that many people with BPD have. They blame everyone and everything for their problems and have trouble acknowledging the personal behavioral changes that need to be made in order to see different outcomes in their lifestyle.

Individuals with BPD have a poor sense of self and tend to struggle with interpersonal relationships. They tend to seek out individuals who will take control and solve their problems for them so that they can shrink back and not have to do so. However, they tend to wear the mask of competence so that others think that they are capable of solving their own problems and dealing with their intense emotions. Although they may have mastered certain areas of their life, they have not been successful at generalizing their competence in other areas.

Due to the lifestyle that most people with BDP have created, in combination with their difficulties in returning to baseline following an emotional event, they end up experiencing significant traumatic experiences on an ongoing basis. They also tend to avoid experiencing negative emotions altogether because they do not know how to regulate even healthy negative emotions. As a result, they do not know what to do when an emotional situation arises that they are unable to tolerate, which throws them into an intense and prolonged emotional state.

People with Borderline Personality Disorder sometimes engage in cutting or other self-harm and suicidal behavior to deal with the intense emotional pain. Emotional vulnerability is often seen in individuals who are suicidal or engage in chronic self-injury. The individual is highly emotionally reactive, and when exposed to very severe trauma such as physical or emotional abuse, they begin to think about suicide. Eventually, in an attempt to be relieved of the ongoing pain, they try to kill themselves and are taken to hospital. Here, they are given loads of attention, and for the first time, they begin to feel like they are being validated and taken seriously.

Consider the boy who engages in some type of self-injury, such as cutting or burning himself because he finds that it provides temporary relief. When someone else finds out that this is happening, people are suddenly taking him seriously. Similar to the experience of the first example, he is finally feeling validated.

An eating disorder is an illness whereby a person has eating habits that are considered irregular. However, the illness goes beyond simple disruption of food intake, as the person experiencing the eating disorder generally feels severe distress regarding their body weight and/or shape. In an attempt to regulate their appearance and feel better about themselves, people with eating disorders may begin to eat significantly less and become obsessed with exercise. This emotional and behavioral disturbance can occur in both sexes and generally has an extreme impact on the physical and emotional well-being of the person.

Although eating disorders can occur at any developmental stage, they typically emerge during adolescence or early adulthood and often coexist with other psychological and behavioral conditions such as substance abuse, mood disorders, and anxiety disorders. The three most common types of eating disorders are discussed below.

An individual who experiences anorexia nervosa usually demonstrates a strong obsession with their weight. Due to their poor and unrealistic perceptions of body image, they are fearful of gaining weight and often refuse to maintain a weight that is healthy. Many people who struggle with this disorder limit the amount of food they eat to the point that their caloric intake cannot sustain their health. Even when they are visibly underweight and their appearance begins to generate concern in others, they continue to view themselves as overweight. Anorexia can lead to major health issues such as infertility, heart problems, organ failure, brain damage, and bone loss. People with this disease have a high risk of death.

Individuals who struggle with bulimia generally fear being overweight and are very unhappy with the appearance of their body. This disorder is characterized by the cycle of binge eating followed by overcompensation for the binge eating. For example, a person may sit and eat excessive amounts of food in one sitting and then follow the eating with forced vomiting, excessive exercise, extreme use of laxatives and diuretics, or any combination of these compensatory behaviors. The cycle is done in secret as they generally harbor a lot of shame, guilt, and lack of self-control. Bulimia can also lead to health problems such as gastrointestinal problems, dehydration, and heart issues that result from an imbalance of electrolytes caused by the eating-purging cycle.

Individuals who struggle with binge eating often lose control of their eating but do not engage in the purging process as with bulimia. Consequently, many people who experience binge eating may also have the corresponding disorder of obesity, which increases health-related problems such as heart disease. As with individuals with other eating disorders, individuals who battle this disorder often have feelings of intense shame, guilt, embarrassment, and feelings of loss of control.

It is believed that the development of eating disorders is multifaceted, as the disorders are generally quite complex. Some of the things that contribute to the emergence of an eating disorder include biological, psychological, and of course, environmental factors. These factors include:

Nutritional deficiencies

Psychological factors such as a negative body image and poor self-esteem

Environmental factors such as a dysfunctional family unit

Professions and careers that promote excessive thinness – like modeling

Sports that promote thinness for performance such as gymnastics, wrestling, long-distance running, and others

Sexual abuse in childhood

Family, peer, and media pressure to be thin

Transitions and life changes

Here are some of the signs and symptoms that someone may exhibit when struggling with an eating disorder:

Chronic and excessive dieting even when underweight

Obsession with caloric intake and the fat content of food

Demonstrating eating patterns that are ritualistic. These rituals might include behaviors like eating alone, breaking food into small pieces, and hiding food for later consumption

A fixation on food. Some individuals with eating disorders may prepare delicious complex meals for other people but refuse to eat the meal.

People with eating disorders may also suffer from depression or lethargy

Although DBT has been shown to be very successful in treating individuals with eating disorders, they may need additional support in the early stages of treatment. Additional support may include being monitored by a physician to address any health issues that may have developed as well as working with a nutritionist until weight is stabilized. Often, the nutritionist will develop an individualized meal plan to help individuals return to a healthy weight.

This is also often referred to as Manic Depressive Disorder because of the individual’s tendency to vacillate between manic episodes and more depressive states. This disorder is characterized by unusual and extreme changes in activity levels, energy levels, mood, and the ability to perform daily tasks. The symptoms are not the same as normal mood fluctuations, as they are severe and generally quite extreme to the point that individuals may damage relationships, jeopardize performance at work and school, and even contemplate suicide.

Like most psychological disorders, there is generally no single cause for Bipolar Disorder. It is often an illness that develops from a combination of biological and environmental factors. Many factors act together to produce the illness or increase the risk of the illness manifesting.

Genetics seems to play a role in the emergence of Bipolar Disorder as research has identified some genes that are more likely to influence the development of the disorder. Other research has shown that children from particular families or those who have a sibling with the disorder are more likely to develop the disorder themselves.

However, research has also shown that environmental factors play a strong role in its emergence. In identical twin studies where siblings share the same exact genetic makeup, when one twin develops the disorder, the other twin does not always. This indicates that something other than genetics is at work, which points to environmental triggers.

Individuals with this condition experience strong emotional states known as “mood episodes.” Each episode can last for days or months. Each episode reflects an extreme change in presentation from the person’s normal behavior. An exceedingly joyful, ecstatic state that is full of increased activity is typically the “manic” episode. The sad, dysphoric, hopeless, and sometimes irritable and explosive state is the “depressive” episode. A “mixed state” is when behavior characteristics of both a manic and depressive episode are present at the same time.

Here are some symptoms that are characteristic of Bipolar Disorder:

The manic episode includes symptoms such as:

Feeling “high” for a long period, demonstrated by an excessively happy mood

Fast-talking and hopping from one idea to another. This is reflective of running thoughts.

Being easily distracted

Excessive activity level and taking on many new projects

Unrealistic thoughts about what one can do

Impulsiveness and preoccupation with pleasurable and risky activities

The characteristics of a depressive episode include:

Long periods of extreme irritability

Long periods of sadness or hopelessness

Losing interest in events that a person once loved

Tiredness and feeling sluggish

Difficulties remembering, concentrating, and decision making

Change in eating, sleeping, and other habits

Suicidal ideation, gestures, and/or suicidal attempts may also be present

Bipolar Disorder can occur even when a person’s mood swings are low. For example, hypomania, which is not severe, is experienced by some individuals with Bipolar Disorder. The individual may feel good during a hypomanic episode and is even highly productive. However, though they are functioning well, their friends and family note the significant difference in mood. The mood change is so remarkable that family and friends may wonder if symptoms of Bipolar Disorder are present. Hypomania may easily become full mania or symptoms of Bipolar Disorder may occur if a person does not get proper treatment.

As previously mentioned, Bipolar Disorder can be present in a mixed state. This is when a person experiences both depression and mania simultaneously. In a mixed state, one may feel very disturbed, experience sleep disruption, lose their appetite, and may even think of committing suicide. Individuals in this state may have a feeling of being hopeless or sad while still feeling extremely energized.

When experiencing a severe episode of depression or mania, an individual can experience psychotic symptoms such as delusions or hallucinations, as well. The psychotic signs tend to show and strengthen the extreme mood of an individual. For instance, if a person has psychotic signs in a manic episode, he may believe that he is the president of a country, has vast wealth, or has some kind of special power. Psychotic signs in a depressive episode might include believing that she is homeless, ruined, penniless, or a criminal on the run. Unfortunately, sometimes individuals with this condition are misdiagnosed with schizophrenia or another reality testing disorder because of their mood-induced hallucinations.

Individuals with Bipolar Disorder also often have the co-occurring disorder of polysubstance abuse or dependence. Anxiety disorders, such as Post-Traumatic Stress Disorder (PTSD) and phobias, also co-occur quite often. Bipolar Disorder also sometimes co-occurs with Attention Deficit Hyperactivity Disorder (ADHD). People with Bipolar Disorder also have a higher likelihood of diabetes, headaches, thyroid disease, heart disease, migraine obesity, and other physical sicknesses.

Bipolar Disorder usually begins to develop in the late teenage years or during early adulthood. However, some people have their first symptoms during childhood, while others may develop symptoms later on in life. At least half of all cases start before the age of 25.

Types of Bipolar Disorder are as follows:

If not diagnosed and treated, the bipolar condition can become worse. It becomes severe as episodes become frequent. This delay can result in the person demonstrating behavior that significantly impacts relationships, personal goals, finances, housing, work, school, and many other areas. DBT has been known to help individuals with this condition lead healthier and more productive lives. Many times, DBT has helped individuals decrease the episodes’ severity and frequency.

The body has a built-in and naturally occurring mechanism that makes individuals seek to escape danger. This mechanism is known as the fight-or-flight response. When your brain receives the signal that there is imminent danger, your body goes into an automatic response mode. You naturally begin to feel afraid and your body gears up to either flee the situation to get to safety or to fight to ensure your self-preservation and survival. Your fear of dangerous situations triggers many split-second and unconscious changes in the body that prepares you to either flee or fight in a particular situation. This is a natural process that is biologically incorporated to help people protect themselves from harm. However, in certain individuals, repeated exposure to trauma, or exposure to one extremely high-level traumatic experience causes this normal “fight-or-flight” response to go haywire. When this process is damaged, and individuals become stressed or frightened even when they are no longer in danger, this is called Post-Traumatic Stress Disorder (PTSD).

PTSD generally occurs after someone experiences a terrifying and/or life-threatening ordeal. The ordeal usually involves some type of actual physical harm or threat of physical harm. The harm or threat to harm may have involved the person themselves, a loved one, or the person may have witnessed a harmful event that happened to someone else or a group of other people. Some examples of situations that can cause PTSD are:

Rape or sexual abuse

Natural disasters such as floods, earthquakes, and tornadoes

Childhood physical abuse

Any other very traumatic event

PTSD is caused by a combination of genetic and environmental features. The way that a specific individual is biologically wired to deal with fear sensations and memories has a lot to do with the development of PTSD. People who are more emotionally vulnerable to fear due to their brain chemistry are more likely to develop PTSD.

Environmental factors also play a significant role in the emergence of PTSD. Environmental factors such as trauma that occurred in childhood, head injuries, or a personal history of mental illness may also increase a person's risk of developing the disorder. Also, personality and cognitive factors such as thinking errors, ability to tolerate distress, pessimism, and other cognitive-related factors increase risk. Similarly, social factors such as the availability of a support system help people adjust to trauma and may help them avoid the experience of PTSD.

PTSD symptoms are categorized into three groups:

Change in routine is also avoidant in nature. Sometimes, people with PTSD will purposefully change their routines so they don’t have to worry about dealing with a trigger. An example of this would be if a person avoids driving a car after a life-threatening car accident. This was very common after 9-11 when many people refused to get on airplanes after the terrorist attack.

In older children or adolescents, you may see symptoms that are more consistent with adult symptoms. However, you may also see an increase in disrespectful and explosive behavior. They can also become preoccupied with getting revenge or feel guilty for not doing more to prevent the event or the injuries that occurred in response to the event.

PTSD can happen at any age. Females have a higher risk of developing PTSD, and there seems to be a significant genetic link. Not all people who live through a risky event develop this condition.

There are several factors that determine if an individual will develop PTSD. Factors that increase the probability an individual getting PTSD are called risk factors. Factors that lower a person’s chances of getting PTSD are called resilience factors. Some of these risk and resilience factors are present before the trauma, while others develop during or after a traumatic event.

Resilience factors for PTSD include:

Access to an adequate support system following a trauma

Having an effective coping strategy

Feeling good about individual actions when there’s trouble

Therapy or counseling that addresses adjustment post-trauma

Risk factors for PTSD include:

Experiencing a trauma

Personal history of mental illness

Witnessing people getting killed or hurt

Inadequate or lack of social support after an incident

This is a psychological disorder that has the potential to be quite disabling if left untreated. It traps people into a relentless and never-ending series of behaviors and thoughts that are repetitive. They become overwhelmed with thoughts, fears, and images that they cannot control. So, they instead obsess about them continuously. These endless and negative thoughts produce anxiety that causes these individuals to feel an urgent and immediate need to engage in certain rituals, routines, or safety-seeking behavior. These compulsive behaviors are the person’s way of trying to eliminate the anxiety that comes with obsessive and ruminating thoughts.

Although the ritualistic behavior generally does temporarily alleviate the anxiety, it becomes a chronic problem because the person must carry out the ritual again when the obsessive thoughts come back. This OCD cycle can really begin to impact the person’s relationships and even personal health. It is not uncommon for a person with OCD to take up hours of their time that they would normally be using to engage in normal activities to complete the ritualistic tasks. People with OCD are often aware of their behavior, and they know that their rituals are unrealistic and problematic, but they cannot stop them.

Common obsessions include:

Fear of causing harm to others

Fear of making a mistake

Fear of being embarrassed

Fear of behaving in a socially unacceptable manner

Fear of thinking thoughts that are sinful or evil

Excessive doubt and the need for constant reassurance

Common compulsions include:

Repeating specific prayers, phrases, or words

Washing hands, showering or bathing repeatedly

Eating in a certain order

Having to do errands a certain number of times

Declining to touch doorknobs or shake hands

It is thought by researchers that OCD comes from problems in the pathways that link the parts of the brain that deal with planning and judgment with the part responsible for filtering body movement messages. Moreover, some evidence shows that OCD is passed to children from their parents.

Environmental stressors can cause OCD in some individuals. Other factors may make the symptoms worse. Some of these are:

Death of someone close

Relationship concerns

Almost everyone has experienced some level of sadness in their life. Sadness is a normal emotional response to bad situations. However, when sadness becomes so pronounced that it interferes with daily performance and activities, help may be needed.

Major depression or clinical depression is characterized by a depressed mood that is prevalent throughout the day and can be particularly prevalent in the morning. The disorder is characterized by a lack of interest in relationships and normal chores and symptoms are present every day for at least 2 weeks.

Here are the typical symptoms of major depression:

Reduced concentration

Insomnia or hypersomnia

Sluggishness or restlessness

Recurring thoughts of death or suicide

Major depression affects almost 10% of the US population over the age of 18. Some statistics indicate that between 20% and 25% of all US adults suffer an episode of major depression at some point during their lifetime. Major depression also affects elderly adults, teenagers, and children, but unfortunately, the disorder often goes undiagnosed and untreated in these populations.

Almost twice as many women as men have been diagnosed with major or clinical depression, which means that more women than men will likely be in treatment. Hormonal changes, pregnancy, miscarriage, and menopause may also increase the risk. Other factors that boost the risk of clinical depression in women who are biologically vulnerable include environmental stressors such as increased stress at home or work, balancing family life with career, and caring for an aging parent. Being a single parent has also been shown to increase the risk of depression.

It is believed that one of the reasons that women outnumber men diagnosed with major depression is because men are less likely to report symptoms. In fact, major depression in men is extremely underreported. Unfortunately, men who suffer from clinical depression are less likely to seek help or even talk about their experience.

Signs of depression in men may be a little different than in women. Here’s what you can expect to see:

Increased irritability and anger

Violent behavior directed both inwardly and outwardly (due to repressed feelings)

Deterioration of health

Increase risk of suicide and homicide

Here are triggers that are common:

Grief from losing a loved one through separation, divorce, or death

Being isolated socially

Relationship conflict with a partner or supervisor

Emotional, sexual, or physical abuse

Individuals who experience the various disorders described in this section experience extreme difficulty regulating their emotions. In addition, there is generally a social component that contributes to the manifestation of the disorder. DBT takes the psychosocial components that traditional CBT therapies take into consideration with the intention of helping individuals learn how to manage their out-of-control emotions and behaviors. As you will see in the following chapters, two of the models of DBT emphasize acceptance while two of them emphasize change so that the individual feels both validated and motivated to make the necessary behavioral changes.