Psychiatry · Year 3 · from Psychiatry
Case 2: Dialectical Behavior Therapy for Borderline Personality Disorder
Patient Demographics
- Age: 26 years old
- Sex: Female
- Occupation: Barista (part-time)
Chief Complaint
"I can't control my emotions. I keep ruining every relationship I have."
History of Present Illness
The patient is a 26-year-old woman with a history of borderline personality disorder, presenting for treatment after her fourth psychiatric hospitalization this year for suicidal ideation following a breakup. She has a pattern of intense, unstable relationships, marked emotional reactivity, chronic feelings of emptiness, impulsive behaviors (binge eating, spending), and non-suicidal self-injury (cutting forearms) used to regulate emotions.
She describes her emotions as "going from 0 to 100 in seconds" and struggles to bring herself back down. She frequently splits people into "all good" or "all bad" and has difficulty tolerating being alone. She experiences identity disturbance ("I don't know who I am") and dissociative episodes when stressed.
She has tried multiple medications with limited benefit and several brief courses of therapy that ended when she felt the therapist didn't understand her.
Mental Status Examination
Appearance: Multiple visible scars on forearms, dressed in black
Behavior: Initially guarded, becomes tearful then irritable within session
Mood: "Empty... terrible... I don't know"
Affect: Labile, rapidly shifting, intense
Thought Process: Linear but dramatic
Thought Content: Chronic suicidal ideation without current intent; no homicidal ideation
Insight: Partial - recognizes patterns but feels unable to change
Judgment: Impaired during emotional crises
Diagnosis
- Borderline Personality Disorder
- Major Depressive Disorder, Recurrent
DBT Formulation
Biosocial Theory:
- Biological vulnerability: Emotional sensitivity from early age
- Invalidating environment: Childhood emotional neglect, told her feelings were "too much"
- Result: Never learned emotion regulation skills, learned that extreme behavior gets emotional needs met
Target Hierarchy:
- Life-threatening behaviors (self-harm, suicidal behaviors)
- Therapy-interfering behaviors (missing sessions, not completing homework)
- Quality of life interfering behaviors (relationship chaos, impulsivity)
- Skills acquisition
DBT Treatment Plan
Standard DBT Components (12-month commitment):
1. Individual Therapy (weekly):
- Behavioral chain analysis of target behaviors
- Solution analysis and skills application
- Exposure-based treatment for emotional cues
- Dialectical strategies (acceptance + change)
2. Skills Training Group (weekly, 2.5 hours):
Module 1: Core Mindfulness (2 weeks)
- "What" skills: Observe, Describe, Participate
- "How" skills: Non-judgmentally, One-mindfully, Effectively
- Wise Mind concept (emotion mind + reasonable mind)
Module 2: Distress Tolerance (6 weeks)
- Crisis survival skills (TIPP, ACCEPTS, IMPROVE)
- TIPP: Temperature, Intense exercise, Paced breathing, Progressive relaxation
- ACCEPTS: Activities, Contributing, Comparisons, Emotions, Push away, Thoughts, Sensations
- Radical acceptance
- Willingness vs. willfulness
Module 3: Emotion Regulation (6 weeks)
- Identifying and labeling emotions
- Reducing vulnerability (PLEASE: treat PhysicaL illness, balance Eating, avoid mood-Altering substances, balance Sleep, get Exercise)
- Opposite action
- Building positive experiences
Module 4: Interpersonal Effectiveness (6 weeks)
- DEAR MAN (asking for what you need)
- GIVE (maintaining relationships)
- FAST (maintaining self-respect)
- Balancing priorities vs. demands
3. Phone Coaching (as needed):
- Brief calls between sessions for skills application
- Not for processing therapy content
- Available for crisis skills coaching
4. Consultation Team (for therapists):
- Weekly team meeting
- Prevents therapist burnout
- Ensures adherence to DBT model
Session Example: Behavioral Chain Analysis
Target Behavior: Cut forearms after argument with boyfriend
Chain Analysis:
Vulnerability Factors:
- Hadn't slept well
- Skipped lunch
- Already anxious about work review
Prompting Event:
- Boyfriend said he needed space for the evening
Links (Thoughts, Feelings, Behaviors):
- Thought: "He doesn't love me anymore"
- Feeling: Panic (9/10)
- Behavior: Called him 6 times
- His response: Didn't answer
- Thought: "He's going to leave me"
- Feeling: Rage (10/10), then emptiness
- Behavior: Threw phone
- Feeling: Shame (9/10)
- Thought: "I'm too much, I deserve to hurt"
- Behavior: Cut forearms
- Feeling: Relief (temporary), then shame
Consequences:
- Short-term: Emotional relief, decreased intensity
- Long-term: Boyfriend more distant, scars, shame
Solution Analysis:
- Could have used TIPP skills at panic stage (cold water on face)
- Could have called different friend instead of repeated calls
- Could have used opposite action at "I deserve to hurt"
- Skills to practice: Distress tolerance before emotion becomes overwhelming
Dialectical Dilemmas in Session
Therapist balances:
- Validating her emotional pain (acceptance) WHILE
- Teaching that self-harm is not effective (change)
Example: "It makes complete sense that you felt abandoned when he didn't answer. Those feelings are painful and real. AND cutting isn't working as a long-term solution - you felt better for 10 minutes, then felt shame for days. What could we try differently next time?"