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Letters to the Editor

Drs Goodman and Hazlett Reply

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See letter by Kronemyer and article by Goodman et al

Drs Goodman and Hazlett Reply

To the Editor: Dr David Kronemyer’s letter to the editor expounds on the misapplication of dialectic principles in the dialectical behavior therapy (DBT) treatment approach and suggests that instead, clinicians should focus on "emotional regulation’ ¦DBT’s most important theoretical contribution." We agree with this point.

Our research group has spent the last 20 years examining the biological underpinnings of borderline personality disorder and more recently focused on the role of affective instability and emotion dysregulation in the etiology of the disorder. We are particularly interested in DBT, an evidence-based treatment, because it targets affective instability by teaching emotion-regulation skills. Exciting advances in neuroimaging have provided clinical investigators the ability to visualize brain activity and circuitry, which we leveraged to study the role of the amygdala and its changes with 1 year of DBT treatment in patients with borderline personality disorder.1

Our functional magnetic resonance imaging study indicated that unmedicated borderline personality disorder patients receiving standard 1-year DBT therapy1 showed a reduction in overall amygdala activation following 12 months of DBT treatment. In addition, among the borderline personality disorder group, improvement in emotion regulation and strategy as measured by the Difficulties in Emotion Regulation Scale2 was associated with decreased amygdala activity to repeated unpleasant pictures. These neurobiological findings highlight the importance of emotion regulation skill acquisition as a critical component to DBT’s treatment effect.

Our recent randomized controlled trial3 examining the effect of a 6-month DBT intervention on suicide-related clinical outcomes in a sample of veterans at high risk for suicide, irrespective of diagnosis, showed that both DBT and treatment as usual result in statistically significant improvements in suicidal ideation, depression, and anxiety that did not differ between treatment arms. Future research is needed to focus on the negative valence system and its underlying neural circuitry (eg, amygdala and related regions), as this circuitry is a promising treatment target for suicidal behavior.4 However, emotion dysregulation is not the only pathway for the expression of suicidal symptomatology. Other treatment approaches will be necessary to augment treatment response in these high-risk individuals.

References

1. Goodman M, Carpenter D, Tang CY, et al. Dialectical behavior therapy alters emotion regulation and amygdala activity in patients with borderline personality disorder. J Psychiatr Res. 2014;57:108-116. PubMed doi:10.1016/j.jpsychires.2014.06.020

2. Gratz KL, Roemer L. Multidimensional assessment of emotion regulation and dysregulation: development, factor structure, and initial validation of the Difficulties In Emotion Regulation Scale. J Psychopathol Behav Assess. 2004;26:41-54. doi:10.1023/B:JOBA.0000007455.08539.94

3. Goodman M, Banthin D, Blair NJ, et al. A randomized trial of dialectical behavior therapy in high-risk suicidal veterans. J Clin Psychiatry. 2016;77(12):e1591-e1600. PubMed doi:10.4088/JCP.15m10235

4. Hazlett EA, Blair NJ, Fernandez N, et al. Startle amplitude during unpleasant pictures is greater in veterans with a history of multiple-suicide attempts and predicts a future suicide attempt. Psychophysiology. 2016;53(10):1524-1534. PubMed doi:10.1111/psyp.12698

Marianne Goodman, MDa,b,c

marianne.goodman@va.gov

Erin A. Hazlett, PhDa,b

aDepartment of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York

bVISN 25 Mental Illness Research, Education, and Clinical Center (MIRECC), James J. Peters VA Medical Center, Bronx, New York

cOutpatient Psychiatry, James J. Peters VA Medical Center, Bronx, New York

Potential conflicts of interest: None.

Funding/support: The study discussed in this letter was supported by US Department of Defense Grant WX81XWH-09-1-0722 (to Dr Goodman, principal investigator).

J Clin Psychiatry 2017;78(3):e311

https://doi.org/10.4088/JCP.16lr11394a

© Copyright 2017 Physicians Postgraduate Press, Inc.

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