DBT: Dialectical Behavioral Therapy

I previously posted a little about Dialectical Behavior Therapy or DBT in the post, Therapies for Depression. However, I would also like a chance to explain it more in depth as it is the foremost therapy that is being taught at my outpatient program.

DBT was developed by Marsha M. Lineham in response to research regarding the use of Cognitive Behavioral Therapy (CBT) towards people suffering from Borderline Personality Disorder, or traits of such. After realizing that CBT, a change based-strategy therapy, offered no validation, DBT was developed to bridge that gap. DBT still focuses on change, but that change was now based on the comfortability level of the client. In DBT, the therapist assures the patient that their behaviors and feelings are valid and understood but that negative or unhealthy behaviors needed to change for the benefit of the patient’s life.

This therapy is designed particularly for people vulnerable to emotions, which is why it is particularly effective for those people suffering from depression and anxiety. The term “dialectics” refers to resolving contradictions that exist between competing demands and wants. The assumption is that emotionally vulnerable people experience the major contradiction of needing acceptance or validation but also desiring change in their behaviors and lives.

There are four sets of behavioral skills taught in DBT; Mindfulness, Interpersonal Effectiveness, Emotion Regulation, and Distress Tolerance. Acceptance is emphasized through mindfulness and distress tolerance, while change is emphasized through interpersonal effectiveness and emotion regulation.

Because I don’t want these posts to get too long, I have split this post into two. This first, will be followed by DBT: The Skills.

DBT Selp Help -A website written by people who have been treated with DBT

National Alliance on Mental Health – Fact Sheet

The Linehan Institute: Behavioral Tech – DBT Overview

Dialectical Behavioral Therapy Skills Handbook

Therapies for Depression

Therapy is one of the best ways to face mental disorders head on. It gives you a chance to confront your issues and learn to cope with them, if not completely solve them. This post is going to focus on a variety of the therapies offered, however it will only touch upon some of the most popular forms of treatment.

Psychotherapy, known as ‘talk therapy’, is a form of treating depression by counseling patients and helping them understand their illness. It helps them develop strategies and tools for dealing with their symptoms, stress, and behaviors. There are many different kinds of psychotherapies as it is not a ‘one-size-fits-all” approach. The kind of psychotherapy a person receives depends on his or her needs.  While psychotherapy may be the best, and only option for those with mild or moderate mental illnesses, those with severe depression may need medication as well. Several, but not all, forms of psychotherapies will be discussed.

Cognitive Behavioral Therapy, or CBT is a blend of cognitive therapy and behavioral therapy. Cognitive therapy focuses on a person’s thoughts and beliefs while behavioral therapy focuses on a person’s learning, actions, and behaviors. Both of these can influence a person’s mood and actions. CBT attempts to change a person’s thinking to be more positive, healthy and adaptable. CBT helps restructure negative thought patterns so a person can interpret their environment and personal interactions in a positive and realistic way. It also helps a person recognize things that could be contributing to the depression and teaches realistic coping skills.

Interpersonal Therapy, or IPT focuses on the interactions and behaviors a person has with important people in their life on a day-to-day basis. IPT is used to treat depression and dysthymia and focuses on helping a person improve their communication skills and increase their self-esteem. This therapy focuses on emotions and depression that is usually situational, such as loss/grief, relationship conflicts and major life events. The therapist helps the patient identify their troubling emotions and triggers and teaches them how to express their emotions in a more appropriate and healthy manner. A variation of IPT, known as Interpersonal and Social Rhythm Therapy or IPSRT is used to treat bipolar disorder

Dialectic Behavioral Therapy, or DBT is a form of CBT developed to treat people with suicidal thoughts and actions. Dialectical refers to a discussion of two opposing views until a balance of the two extremes is found. The therapist assures the patient that their behaviors are valid and understood but also teaches that it is the patient’s responsibility to change disruptive or unhealthy behaviors. DBT involves both individual therapy, to learn new skills and group therapy, to practice them. DBT is also an effective treatment for patients with borderline personality disorder.

Family focused therapy, or FFT was designed specifically for treating bipolar disorder. FFT includes family members in therapy sessions to improve relationships and identify difficulties and conflicts which could be detrimental to a patient’s treatment. This therapy specifically focuses on educating the family about the disorder, teaching family members how to effectively communicate, and solving problems together as a family. FFT focuses on the stress families feel when they are caring for their relative, and aims to prevent ‘burning out’ but also holds the patient responsible for their own well being and actions. Several studies have found FFT to be effective in helping a patient become stabilized and preventing relapses.

There is also the therapies developed by Sigmund Freud, psychodynamic and psychoanalytic therapies. These therapies will discussed in a future post, as well as an explanation for why there therapies are no longer used by today’s therapists.

National Institute of Mental Health

The Mayo Clinic

Medication

In this post I’m going to discuss the various types of antidepressants that a doctor may prescribe. I am not a doctor and I will not claim anything other than a basic understanding of medicine. If you have questions about any of these medications please ask your doctor.

The initial group of antidepressants a doctor may prescribe are reuptake inhibitors. The first medication a doctor will generally choose will be a Selective Serotonin Reuptake Inhibitors, or SSRIs. This type of medication blocks the reuptake of serotonin to the nerve, which increases the level of serotonin in the brain. SSRIs are the most commonly prescribed, generally non-sedating and best tolerated by patients.

The second most popular medication is Serotonin and Norepinephrine Reuptake Inhibitors, or SNRIs. This medication blocks the reuptake of serotonin and norepinephrine to the nerve, which increases the level of these chemicals in the brain. SNRIs are often prescribed for severe depression and are safer if a person overdoses. SSRIs and SNRIs have fewer side effects than older antidepressants, although some people tend to experience sexual problems which may be fixed by switching medication or adjusting the dosage.

Norepinephrine and Dopamine Reuptake Inhibitors, or NDRIs, block the reuptake of dopamine and norepinephrine and increases these chemicals in the brain. This is one of the few antidepressants not associated with sexual side effects. There are various other types of reuptake inhibitors including but not limited to Serotonin Antagonist and Reuptake Inhibitors (SARIs) and Noradrenalin Reuptake Inhibitors (NARIs), which affect various brain chemicals.

Another group is cyclic antidepressants. These are generally known as the first generation of antidepressants. Tricyclics (TCAs) and Tetracyclics act in the same way as reuptake inhibitors by blocking serotonin and/or noradrenaline which increases these chemicals in the brain, elevating mood. Cyclic antidepressants are designated by tri or tetra dependant on the number of rings in their chemical structure. Cyclics are powerful but less used today because of the serious nature of their potential side effects.

The last type of antidepressant I’m going to discuss is Monoamine Oxidase Inhibitors, or MAOIs. MAOIs block the natural enzyme that breaks down serotonin, epinephrine and dopamine which increases the level of these chemicals in the brain. Using MAOIs requires a strict diet because of dangerous, even deadly, interactions with foods and other medications. MAOIs cannot be combined with SSRIs. They can also be especially effective in cases of ‘atypical’ depression.

Finding the right medication takes time and patience. You may need to try several medications before you find one that works. It can take several weeks for the medication to go into effect. Medication should only be stopped under a doctor’s supervision. Make sure to report side effects to a doctor immediately. Your doctor may recommend combining two antidepressants or adding mood stabilizers or anti-psychotics.

On some occasions, antidepressants can worsen depression or lead to unusual behavior. If you or someone you know has suicidal thoughts when taking an antidepressant immediately contact your doctor or get emergency help. Remember, that antidepressants improve mood and reduce suicide risk in the long run.

Occasionally, hospitalization is needed because depression is so severe. Inpatient hospitalization is necessary is you are in danger of harming yourself or others. Psychiatric treatment at a hospital can help keep you calm and safe until your mood improves. Many hospitals have partial hospitalization or day treatment programs to help people while they get their symptoms under control.

Please remember I am not a doctor and I will not claim anything other than a basic understanding of medicine. If you have questions about any of these medications please ask your doctor.

National Institute of Mental Health

Mayo Clinic

Beyond Blue, Depression & Anxiety

Disclaimer

When you are first diagnosed with depression, it can seem overwhelming. There are so many different types of medications and therapies that can treat depression.

In the next couple of posts, I will be describing the various types of medications, therapies, lifestyle changes and alternative medicines that can help treat depression. I am not a doctor and I will not claim anything other than a basic understanding of medicine. I am just trying to set down a basic understanding for everyone.

If you have questions about any of these medications or treatments, please talk your doctor.

Being Diagnosed

If you think you have depression, the first step you need to take is to make an appointment with your primary care physician.

Before your appointment, you should get an in-depth family history. You should also include any symptoms and behaviors, whether they seem related or not, as well as personal information including stress, life changes and lifestyle habits (exercise, diet, sleep, alcohol & drug use). The doctor will also ask for all medications, vitamins and supplements, both prescribed and over-the-counter, that you are taking. It is usually best to sit down and write out this information before your appointment, to insure that you remember everything.

During your appointment, your doctor will ask a lot of questions. Many of these questions may seem extremely personal, but you need to answer them as honestly as possible. The doctors won’t judge you, they want to make sure you get the help you need. The doctor may do a physical exam to rule out a physical health problem. They may also do lab test including a blood test to check your thyroid. An overactive or underactive thyroid will also present the same symptoms as depression. You might also have to have a psychological evaluation. Don’t hesitate to ask questions anytime you don’t understand anything.

To be diagnosed with depression, you must meet the symptom criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association. This manual is used by mental health providers to diagnose mental conditions and by insurance companies to reimburse for treatment. As previously discussed, major depression is characterized as having more than 5 of the symptoms discussed in a previous post, for over a 2 week period.

If you see your primary care physician, get referrals for a psychiatrist and/or a psychologist. I will go into more detail on the differences between the two in another post.

If you are diagnosed with depression, seek the help that you need. Be your own advocate & realize you are not alone.

Forms of Depression

There are many types of depression.

Major Depression interferes with everyday life. It is characterized as having more than 5 of the symptoms discussed in a previous post, for over a 2 week period. Major depression can occur only once, but there are often several episodes.

Seasonal Affective Disorder or SAD, is the onset of depression during winter months. It is generally attributed to the lessening of sunlight and it is usually effectively treated with light therapy.

Postpartum Depression occurs after the birth a newborn. It is attributed to hormonal and physical changes, as well as the new, overwhelming responsibility of a newborn. If not treated, it could lead to trouble caring and bonding with the baby.

Bipolar Disorder, also known as manic-depressive disorder is characterized by major mood swings. The moods swings from manic to depressive are often gradual, although they can occasionally occur abruptly. There are multiple types of bipolar disorder, depending on the severity of the mood swings.

Persistent Depression Disorder, or PDD, also formerly known as dysthymia is a form of depression where the symptoms last for at least 2 years. It is usually less severe, but more chronic. It is not disabling but persistent as described in the title. People with PDD usually look at life with a “glass half empty” mentality.

Psychotic Depression is major depression with psychosis. This is characterized by hallucinations, delusions and paranoia.

Premenstrual Dysphoric Disorder or PMDD, is depression that occurs with the hormonal changes a week before a woman’s period and improve with the onset her period.

Atypical depression, which is actually more common than the name suggests, is depression where mood is temporarily improved by a  positive event. This depression is characterized by a heaviness in the arms and legs.

Adjustment Disorder is a severe reaction to a difficult event. It is triggered by a stressful, life-changing event and is a type of stress-related mental illness that may affect feelings, thoughts and behavior.

 

  1. National Institute of Mental Health
  2. Anxiety and Depression Association of America
  3. Mayo Clinic 

The Causes of Depression

Depression is caused by a variety of genetic, biological, environmental and psychological factors. It can also go hand in hand with various other diseases or illnesses. Despite the recent increased research into mental illnesses and depression, it is still not known what exactly can trigger depression.

Genetic

It is theorized that depression can run in the family. Those who have family members diagnosed with depression are more prone to this condition. Scientists are now researching various genes that may factor into depression. “Some genetics research indicates that risk for depression results from the influence of several genes acting together with environmental or other factors”.₁ However, depression is not exclusive those families who are diagnosed with depression. It can occur in anyone, which is what makes it so hard to research.

Biological

One of the primary theories regarding depression is biological differences, brain chemistry and hormones. According to research, chemicals in the brain may be out of balance, causing depression. According to NIMH, “brain imaging technologies, such as magnetic resonance imaging (MRI), have shown that the brains of people who have depression look different than those of people without depression”.₁ These parts of the brain include those regulating mood, sleep, thinking, behavior and appetite. However, there are many biological issues that can cause depression from neurotransmitters to cell connections so it is hard to pinpoint the exact issue.

Environmental

Environmental issues are also considered to impact depression. These issues can range from traumatic events to the abuse of drugs or alcohol to certain medications or chronic illnesses. While some of these examples may lead to temporary depression, or a single episode, others can continue to impact a person for life. While a person’s environment is considered to impact depression, depressive episodes may occur without an obvious trigger.

Psychological

The final factor that affects depression can be psychological. This includes certain personality traits, such as low self-esteem, pessimism and dependence. Psychological factors are the thoughts going on in the brain, or the thinking pattern. It is not clear, however, if this represents an early form of depression or a psychological predisposition. People with a history of PTSD, anxiety, or other mental illnesses are also at a higher risk.

Despite these factors being recognized, researchers are still unsure of how depression works. Because these factors differentiate between people, it is harder to understand how depression occurs. With more research, hopefully the medical world will have a better understanding of this mental illness.

In the meantime, I find that a more personal view can give the public a better understanding of life as a depressive. It is not all good, but it is not all bad. What I’m trying to say, is though it may seem like it to outsiders, depression is NOT a simple disease.  There are so many factors, triggers and types that experts can’t just figure out a way to turn a depressed person into a happy person.  Research and experimentation have been unable to pinpoint a common factor of the human psyche that causes depression and thus haven’t been able to develop a surefire way of treating it.

  1. NIMH – National Institute of Mental Health

Depression: A Clinical Definition

To have a better understanding of depression, you need to understand the medical definition as well as how it relates to a depressed person.

Depression, as defined by Mayo Clinic, “is a mood disorder that causes a persistent feeling of sadness and loss of interest. Also called major depression, major depression disorder or clinical depression, it affects how you feel, think and believe and can lead to a variety of emotional and physical problems.”₁

While this is the definition Mayo Clinic, NAMI₂ and various other institutions use to describe depression; the easiest and most forthright definition is that depression is a disease.

Let me repeat that.

Depression is a disease.

And like many diseases, depression can be fatal. Of course, it doesn’t have to be. With proper treatment, depression can be managed. Many depressives may only experience one episode or can even go into remission.

The best way to recognize depression in a person, or in yourself, is to know the symptoms.

Depression signs and symptoms vary from person to person, but they can include:

  • Angry outbursts, irritability or frustration, even over small matters
  • Loss of interest or pleasure in normal activities, such as sex
  • Sleep disturbances, including insomnia or sleeping too much
  • Tiredness and lack of energy, so that even small tasks take extra effort
  • Changes in appetite — often reduced appetite and weight loss, but increased cravings for food and weight gain in some people
  • Anxiety, agitation or restlessness — for example, excessive worrying, pacing, hand-wringing or an inability to sit still
  • Slowed thinking, speaking or body movements
  • Feelings of worthlessness or guilt, fixating on past failures or blaming yourself for things that are not your responsibility
  • Trouble thinking, concentrating, making decisions and remembering things
  • Frequent thoughts of death, suicidal thoughts, suicide attempts or suicide
  • Unexplained physical problems, such as back pain or headaches
  • Feelings of sadness, emptiness or unhappiness
  • Abusing alcohol or drugs

The thing to remember, is that everyone is different and each person experiences depression in their own way. My next post, will be about my beginnings with depression. It is important to differentiate between the clinical definition of depressive and the life a depressive person, lives. Although the definition explains the symptoms, depression is a complicated disease that is caused by genetic, biological, environmental and psychological factors.

I’m hoping this clinical definition will give you a better understanding of depression as I take you through my life as a mentally ill, depressed person.

For more information view this video on The Science of Depression.

  1. Mayo Clinic
  2. NAMI – National Alliance on Mental Health