Introduction to DBT: Treatment of Comorbid Depression and Anxiety
Course Description
Dialectical Behavior Therapy (DBT) is a newer treatment methodology (Linehan, 1993a, 1993b) originally developed to treat chronically suicidal (Linehan, Armstrong, Suarez, Allmon, & Heard, 1991) and borderline personality disordered patients (Linehan, 1993). However, DBT is a robust treatment methodology that more recently has been applied to a variety of psychological disorders, including eating disorders (Fresco, Wolfson, Crowther, & Docherty, 2002; Palmer et al., 2003; Safer, Telch, & Agras, 2001; Wilson & Roberts, 2002), treatment of adolescents (Miller, 1999; Miller, Glinski, Woodberry, Mitchell, & Indik, 2002), substance abuse (Dimeff, Rizvi, Brown, & Linehan, 2000; Linehan et al., 2002; Marlatt, 2002; van den Bosch, Verheul, Schippers, & van den Brink, 2002), and now by this author to the treatment of comorbid depression and anxiety (Marra, 2004). If you are familiar with DBT for the treatment of Borderline Personality Disorder, you will find this workshop different. DBT has been expanded for the treatment of other disorders by placing greater emphasis upon dialectics in the treatment process, and adding new treatment strategies including Meaning Making Skills and Strategic Behavior. If you have previous familiarity with DBT, you will thus see revisions to make the treatment process applicable to a wide variety of disorders.
While comorbidity of disorders is widely recognized in the literature (Abramowitz & Foa, 2000; Beidel & Turner, 1997; Boyd, Burke, Gruneberg, & al., 1984; Brown & Harris, 1993; Fresco et al., 2002; Garvey, Noyes, Anderson, & Cook, 1991; Grilo, McGlashan, & Skodol, 2000; Kendler, Neale, Kessler, Heath, & Eaves, 1992a; Kendler et al., 1995; Kessler, Davis, & Kendler, 1997; Kessler, McGonagle, Zhao, & al., 1994; Mineka, Watson, & Clark, 1998; Skodol et al., 1999; Thapar & McGuffin, 1997; Westen & Morrison, 2001), it is only more recently that the severity of comorbidity has been examined. For example, Meichenbaum, one of the leaders of the cognitive-behavioral therapy revolution, estimates that fewer than 20% of patients who present for treatment have only one clearly defined Axis I disorder (Meichenbaum, 2003), while the rest have comorbid diagnoses. It also has been estimated that 85% of private practice patients would be excluded from pharmaceutical drug trials due to comorbidity (Zimmerman, Posternack, & Chelminski, 2002). Thus, most of both the treatment strategies and pharmaceuticals designed for treatment of major mental disorders address the rarer individual who has only one major mental disorder.
We know that the longer an individual has a major mental disorder of any kind, the higher the probability that either mood or anxiety disorder symptoms will also be present (Westen & Morrison, 2001). This makes sense, since it is depressing and anxiety-engendering to have emotional issues that impair functioning in major ways. In fact, Westen and Morrison estimate that 75% of all patients would be excluded from typical studies due to comorbidity.
This workshop thus provides both a theoretical and strategic foundation for the treatment of comorbid mood and anxiety disorders. DBT is appropriate treatment for individuals who present with high emotional arousal, slow return to emotional baseline following stressors, and hypersensitivity to threat cues. The DBT theoretical model of psychopathology is thus ideal for the treatment of most complex emotional disorders. Therapists who are familiar with DBT are oriented to its application only to borderline personality disorder, so this workshop will demonstrate its applicability to comorbid mood and anxiety disorders. DBT has been modified from its original application only to parasuicidal and borderline personality disorder in order to treat the kinds of patients typically found in a therapist's private practice (Marra, 2004).
This course will review the major theoretical assumptions of DBT, teach therapists how to identify dialectic conflict in patients, review the psychopathological elements of emotional escape and avoidance with comorbid mood and anxiety disorders, and teach psychosocial coping skills designed to replace avoidance and escape strategies that power such comorbid conditions. Therapists will be provided with both in-session therapeutic strategies as well as between-session homework assignments to use with patients based upon bibliotherapy (Marra, 2004). The workshop thus provides an entire treatment orientation and sets of strategies that formulate a global treatment plan for patients with comorbid mood and anxiety disorders.
While this workshop will begin with the theoretical underpinnings of the DBT approach to treatment, the vast majority of the workshop is "how to" implement theory, and thus is highly practical and specific in review of treatment procedures.
Cost
$185 pre-registration ; $200 13 - 2 days prior to workshop date; $250 on-site registration. Refunds: 100% 45 days prior to workshop date; 80% 44 - 30 days prior to workshop date; 50% 29 - 5 days prior to workshop date; 0% 4 - workshop date or thereafter
Therapist Course Objectives
- Essential components of DBT for comorbid depression and anxiety
- Alternative assumptions from traditional Cognitive-Behavioral Therapy about the cause and cure of acute emotional disorders
- How to think dialectically both about patient case formulation and treatment planning
- Mindfulness Skills Training teaching strategies with comorbid anxiety and depression
- Dialectics of comorbid anxiety and depression
- How to normalize dialectic conflict
- Strategies to help patients shift from emotion-focused coping to solution-focused coping
- How to prompt and promote Meaning Making Skills, Emotion Regulation Skills, Distress Tolerance Skills, and Strategic Behavior Skills
- New DBT mnemonics designed to decrease mood-dependent behavior
Treatment Strategy Objectives
As a result of the above information and strategies, patients will be provided with treatment that will assist them to:
- increase meaning in patientÂ’s lives
- increase mindfulness
- decrease self-absorption
- improve problem-solving
- shift attentional strategies
- increase acceptance of that which can't be changed
- regulate emotions more easily
- be strategic in their behavior
- decrease emotional avoidance
- modify self-image and identity issues
- increase self-soothing behavior
- deal strategically with emotional sensitivity
- move from guilt and blame to problem solving
- decrease dichotomous thinking
- decrease urgency
- decrease fear of engulfment or abandonment
- increase self-validation of affect
- normalize dialectic conflict
Course Syllabus
Hours 1-3: Dialectical Behavior Therapy Theory Overview- DBT as a New Theoretical Orientation or School of Psychology
- DBT Defined
- Emotional Arousal Patterns
- Causes of Emotional Disorder According to DBT Theory
- Attachment, Loss, Trauma, Invalidating Environments, Neurobiological Kindling Effects
- Behavioral Treatment Targets for Comorbid Anxiety & Depression
- Dialectics
- Comparison of DBT to Cognitive Behavior Therapy (Different!)
- Primary Treatment Procedures with DBT
- Integrating Bibliotherapy/Homework Into the Psychotherapy Process
- Using Depressed & Anxious as between-session homework
- Providing structure, focus, and strategic treatment to comorbidity
- Mindfulness Decreases Avoidance and Escape
- Mindfulness Increases Powers of Observation
- Mindfulness Increases Acceptance/Decreases Agony
- Mnemonic: ONE MIND
- Practice Mindfulness
- The 3 Stages of Mindfulness for Comorbid Anxiety & Depression
- Meaning Making Skills
- Emotion Regulation Skills
- Distress Tolerance Skills
- Strategic Behavior Skills
References
Abramowitz, J. S., & Foa, E. B. (2000). Does major depressive disorder influence outcome of exposure and response prevention for OCD? Behavior Therapy, 31(4), 795 - 800. Beidel, D. C., & Turner, S. M. (1997). At risk for anxiety: 1. Psychopathology in the offspring of anxious parents. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 918-924.
Boyd, J. H., Burke, J. D., Gruneberg, E., & al., e. (1984). Exclusion criteria of DSM-III: A study of co-occurrence of hierarchy-free syndromes. Archives of General Psychiatry, 41, 983-959.
Brown, G. W., & Harris, T. O. (1993). Aetiology of anxiety and depressive disorders in an iner-city population: 1. Early adversity. Psychological Medicine, 23, 143-154.
Dimeff, L., Rizvi, S. L., Brown, M., & Linehan, M. M. (2000). - Dialectical behavior therapy for substance abuse: A pilot application to methamphetamine-dependent women with borderline personality disorder. - 7(- 4), - 468.
Fresco, D. M., Wolfson, S. L., Crowther, J. H., & Docherty, N. M. (2002). Distinct and overlapping patterns of emotion regulation in the comorbidity of generalized anxiety disorder and the eating disorders. Paper presented at the Annual Meeting of the Society for Research in Psychopathology, San Francisco, CA.
Garvey, M., Noyes, R., Jr., Anderson, D., & Cook, B. (1991). Examination of comorbid anxiety in psychiatric inpatients. Comprehensive Psychiatry, 32, 277-282.
Grilo, C. M., McGlashan, T. H., & Skodol, A. E. (2000). Stability and course of personality disorders: The need to consider comorbidities and continuities between axis I psychiatric disorders and axis II personality disorders. Psychiatric Quarterly, 71(4), 291 - 307.
Kendler, K. S., Neale, M. C., Kessler, R. C., Heath, A. C., & Eaves, L. J. (1992a). Major depression and generalized anxiety disorder: Same genes, partly different environments? Archives of General Psychiatry, 49, 716-722.
Kendler, K. S., Walters, E. E., Nealse, M. C., Kessler, R. C., Heath, A. C., & Eaves, L. J. (1995). The structure of the genetic and environmental risk factors for six major psychiatric disorders in women: Phobia, generalized anxiety disorder, panic disorder, bulimia, major depression, and alcoholism. Archives of General Psychiatry, 52, 374-383.
Kessler, R. C., Davis, C. G., & Kendler, K. S. (1997). Childhood adversity and adult psychiatric disorder in the U.S. National Comorbidity Survey. Psychological Medicine, 27, 1101-1119.
Kessler, R. C., McGonagle, K., Zhao, S., & al., e. (1994). Lifetime and twelve-month prevalence of DSM-III-R psychiatric disorders in the United States: Results fro the National Comorbidity Study. Archives of General Psychiatry, 51, 8-19.
Linehan, M. M. (1993). Dialectical behavior therapy for treatment of borderline personality disorder: implications for the treatment of substance abuse. NIDA Res Monogr, 137, 201-216.
Linehan, M. M. (1993a). Cognitive-Behavioral Therapy for Borderline Personality Disorder. New York: Guilford Press.
Linehan, M. M. (1993b). Skills Training Manual for Treating Borderline Personality Disorder. New York: Guilford Press.
Linehan, M. M., Armstrong, H. E., Suarez, A., Allmon, D., & Heard, H. L. (1991). Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Arch Gen Psychiatry, 48(12), 1060 - 1064.
Linehan, M. M., Dimeff, L. A., Reynolds, S. K., Comtois, K. A., Welch, S. S., Heagerty, P., et al. (2002). Dialectical behavior therapy versus comprehensive validation therapy plus 12-step for the treatment of opioid dependent women meeting criteria for borderline personality disorder. Drug & Alcohol Dependence, 67(1), 13-26.
Marlatt, G. A. (2002). Buddhist philosophy and the treatment of addictive behavior. Cognitive & Behavioral Practice, 9(1), 44 - 49.
Marra, T. (2004). Depressed and anxious: A dialectical behavior therapy workbook for overcoming depression and anxiety. Oakland: New Harbinger Press.
Meichenbaum, D. (2003). Treating individuals with angry and aggressive behaviors: A life-span cultural perspective. Atlanta, GA: Annual Meeting of the Georgia Psychological Association.
Miller, A. L. (1999). Dialectical behavior therapy: a new treatment approach for suicidal adolescents. Am J Psychother, 53(3), 413-417.
Miller, A. L., Glinski, J., Woodberry, K. A., Mitchell, A. G., & Indik, J. (2002). Family therapy and dialectical behavior therapy with adolescents: Part I: Proposing a clinical synthesis. Am J Psychother, 56(4), 568-584.
Mineka, S., Watson, D., & Clark, L. A. (1998). Comorbidity of anxiety and unipolar mood disorders. Annual Review of Psychology, 49, 377- 412.
Palmer, R. L., Birchall, H., Damani, S., Gatward, N., McGrain, L., & Parker, L. (2003). A dialectical behavior therapy program for people with an eating disorder and borderline personality disorder--description and outcome. Int J Eat Disord, 33(3), 281-286.
Safer, D. L., Telch, C. F., & Agras, W. S. (2001). Dialectical behavior therapy adapted for bulimia: a case report. Int J Eat Disord, 30(1), 101-106.
Skodol, A. E., Stout, R. L., McGlashan, T. H., Grilo, C. M., Gunderson, J. G., Shea, M. T., et al. (1999). Co-occurrence of mood and personality disorders: A report from the Collaborative Longitudinal Personality Disorders Study (CLPS). Depression and Anxiety, 10(4), 175 - 182.
Thapar, A., & McGuffin, P. (1997). Anxiety and depressive symptoms in childhood: A genetic study of comorbidity. Journal of Child Psychology and Psychiatry, 38, 651-656.
van den Bosch, L. M., Verheul, R., Schippers, G. M., & van den Brink, W. (2002). Dialectical Behavior Therapy of borderline patients with and without substance use problems. Implementation and long-term effects. Addict Behav, 27(6), 911-923.
Westen, D., & Morrison, K. (2001). A multidimensional meta-analysis of treatments for depression, panic, and generalized anxiety disorder: An empirical examination of the status of empirically supported therapies. Journal of Consulting and Clinical Psychology, 60, 875 - 899.
Wilson, K. G., & Roberts, M. (2002). Core principles in acceptance and commitment therapy: An application to anorexia. Cognitive & Behavioral Practice, 9(3), 237 - 243.
Zimmerman, M., Posternack, M. A., & Chelminski, I. (2002). Symptom severity and exclusion from antidepressant efficacy trials. Journal of Clinical Psychopharmacology, 22(6), 610 - 614.
Course Focus
This is an introductory course to DBT. It is appropriate for those who have little familiary with DBT and the theoretical assumptions underlying this approach. It is also for those who have experience in DBT, but only with borderline personality disorder. Professionals who have attended Dr. Linehan's "intensive" 2-week course should purchase the workbook, "Depressed & Anxious: The Dialectical Therapy Workbook" to transfer those skills to comorbid depression and anxiety. This course will not review the empirical basis of DBT. Those who are interested in the research data should go back to the main website window and review "Mindfulness Research" and "DBT Research." Brief literature reviews showing the empirical basis of this treatment approach will be found. These data will not be reviewed during the workshop.
