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DISORDERS OF PERSONALITY 2011. Definitions: PERSONALITY Persona – “mask” in Greek "...the dynamic organization within the individual of those psychophysical.

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Presentation on theme: "DISORDERS OF PERSONALITY 2011. Definitions: PERSONALITY Persona – “mask” in Greek "...the dynamic organization within the individual of those psychophysical."— Presentation transcript:

1 DISORDERS OF PERSONALITY 2011

2 Definitions: PERSONALITY Persona – “mask” in Greek "...the dynamic organization within the individual of those psychophysical systems that determine his unique adjustments to his environment" (G. Allport, 1937). “...a dynamic organization, inside the person, of psychophysical systems that create the person's characteristic patterns of behavior, thoughts and feelings" (G. Allport, 1961). Personality is a dynamic organisation, inside the person, of psychophysical systems that create a person’s characteristic patterns of behaviour, thoughts, and feelings. (Carver & Scheier 2000) Personality refers to enduring patterns of cognition, emotion, motivation and behavior that are activated in particular circumstances (D. Westen 2005) Personality – a term employed to represent the more or less distinctive style of adaptive functioning that particular organism of a species exhibits as it relates to its typical range of environments. “Normal personalities” imply effective mode of adaptation in “average or expectable” environments. “Personality Disorders” imply maladaptive / ineffective functioning. (Millon 2005]

3 Definitions: PERSONALITY Personality is a neurocognitive system regulating the enduring patterns of one's internal experience and behavior. (Twardon 2008) Neurocognitive system = a functional unit of neuronal and cognitive architecture and activity within the Central and Peripheral Nervous Systems [CNS + PNS]* Related terms: ENDOPHENOTYPE = an intermediate neurocognitive characteristic that lies somewhere on the developmental pathway from genes to phenotype. Genotype = genetic constitution of an individual Phenotype = any observable characteristic of an organism and / or behavior The architecture of personality is usually described as a hierarchy of TRAITS. Trait = a neurocognitive circuit regulating propensity for a specific internal experience and behavior. Personality disorders are " pathologically amplified traits" (J.Paris 2005) * CNS = Brain + spinal cord PNS = Somatic + Autonomic [Sympathetic + Parasympathetic]

4 Definitions: IDENTITY, SELF, SUBJECTIVITY, CONSCIOUSNESS IDENTITY A large number of overlapping internal representations of who one is or takes oneself to be An aspect of person's uniqueness / singularity determined and defined by the external context and referents Innate identity - absolute uniqueness, singularity, can be concealed but cannot be erased DNA (genotype), time / place of birth, names, ID #, temperament, Acquired identity - unique personal episodic memory / narrative about oneself gender identity, character, personality, Self, endophenotype Chosen identity - declared identification with others, political, subcultural, personal, etc. I am a “Conservative”, “vegetarian”, “Buddhist”, “patriot”, etc. SELF, SUBJECTIVITY, CONSCIOUSNESS Self is the experiencing subject / the subject of experience. The self is an internal experience of one's inherent subjectivity. The self is mind experiencing itself. Consciousness and the self are user-defined, subject to an ongoing analysis and transformation, by the therapist and the patient.

5 Definitions: TEMPERAMENT, CHARACTER TEMPERAMENT: Constitutional, genetic-biological foundations of personality regulating: Activity-level, rhytmicity, approach-withdrawal, adaptability, responsiveness, intensity, mood, persistence, distractibility, attention (Thomas, Chess 1996) Emotionality, activity, sociability, impulsivity (Buss, Plomin 1975) Reactivity, self-regulation, positive emotionality / extraversion [pleasure, activity], Negative emotionality [fear, anger, sadness] Effortful control [inhibition, attention] (Rothard, Derryberry 1997) Probability of expereincing primary emotions (Goldmith, Campos 1982) Emotionality, Extraversion, Activity, Persistence (Mervielde, Asendorpf 2000) CHARACTER: A dynamic organization of enduring behavior patterns, including ways of perceiving and relating to the world, that are characteristic of the individual. Degree of flexibility vs rigidity. Character is a behavioral manifestation of identity. Procedurally learned habits in which people engage constantly, repeatedly, automatically and non-consciously which give them their own unique style of being in the world

6 Definition: PERSONALITY DISORDERS Chronic interpersonal dysfunction and problems with self and identity [Livesley 2001] Personality disorder – a failure solve life tasks related to the establishment of stable and integrated representations of self and others, the capacity for intimacy attachment and affiliation, and the capacity for prosocial behavior and cooperative relationships. [Livesley 1998] Neurodevelopmental dysregulation of phylogenetic / evolutionary polarities of adaptation [Millon 2005] PAIN-PLEASURE – survival & life preservation ACTIVITY-PASSIVITY – mode of adaptation SELF-OTHER – reproduction & affiliation THINKING-FEELING – mode of representation & experience Maladaptive exaggeration of nonpathological personality styles and traits (Oldham 2005) Personality disorders are " pathologically amplified traits" (J.Paris 2005) Problems with self and / or others resulting in persistent interpersonal dysfunction(s), not accounted for by other DSM disorder(s).

7 Definition: DISORDERS OF PERSONALITY A disorder of personality is an enduring disturbance of the neurocognitive system regulating patterns of internal experience, behavior and interpersonal adaptation.(Twardon 2008) “Disorders of personality” vs “personality disorders” Disorders of personality - maladaptive exaggeration of nonpathological personality style and trait(s) (Oldham 2005) - pathologically amplified trait(s) (J.Paris 2005) - ICD-10 Disorders of adult personality and behaviour Personality Disorders DSM-IV-R – 10 disorders grouped into 3 clusters

8 ICD-10 Classification of Mental and Behavioural Disorders F60-F69 Disorders of adult personality and behaviour (1) F60 Specific personality disorders F60.0 Paranoid personality disorder F60.1 Schizoid personality disorder F60.2 Dissocial personality disorder F60.3 Emotionally unstable personality disorder.30 Impulsive type.31 Borderline type F60.4 Histrionic personality disorder F60.5 Anankastic personality disorder F60.6 Anxious [avoidant] personality disorder F60.7 Dependent personality disorder F60.8 Other specific personality disorders F60.9 Personality disorder, unspecified F61 Mixed and other personality disorders F61.0 Mixed personality disorder F61.1 Troublesome personality changes F62 Enduring personality changes, not attributable to brain damage and disease F62.0 Enduring personality change after catastrophic experience F62.1 Enduring personality change after psychiatric illness F62.8 Other enduring personality changes F62.9 Enduring personality change, unspecified

9 ICD-10 Classification of Mental and Behavioural Disorders F60-F69 Disorders of adult personality and behaviour (2) F63.0 Pathological gambling F63.1 Pathological fire-setting [pyromania] F63.2 Pathological stealing [kleptomania] F63.3 Trichotillomania F63.8 Other habit and impulse disorders F63.9 Habit and impulse disorder, unspecified F63 Habit and impulse disorders F64 Gender identity disorders F64.0 Transsexualism F64.1 Dual-role transvestism F64.2 Gender identity disorder of childhood F64.8 Other gender identity disorders F64.9 Gender identity disorder, unspecified

10 ICD-10 Classification of Mental and Behavioural Disorders F60-F69 Disorders of adult personality and behaviour (3) F65 Disorders of sexual preference F65.0 Fetishism F65.1 Fetishistic transvestism F65.2 Exhibitionism F65.3 Voyeurism F65.4 Paedophilia F65.5 Sadomasochism F65.6 Multiple disorders of sexual preference F65.8 Other disorders of sexual preference F65.9 Disorder of sexual preference, unspecified F66 Psychological and behavioural disorders associated with sexual development and orientation F66.0 Sexual maturation disorder F66.1 Egodystonic sexual orientation F66.2 Sexual relationship disorder F66.8 Other psychosexual development disorders F66.9 Psychosexual development disorder, unspecified

11 ICD-10 Classification of Mental and Behavioural Disorders F60-F69 Disorders of adult personality and behaviour (4) F68 Other disorders of adult personality and behaviour F68.0 Elaboration of physical symptoms for psychological reasons F68.1 Intentional production or feigning of symptoms or disabilities, either physical or psychological [factitious disorder] F68.8 Other specified disorders of adult personality and behaviour F69 Unspecified disorder of adult personality and behaviour

12 ICD-10 Classification of Mental and Behavioural Disorders F21 SCHIZOTYPAL DISORDER A. The subject must have manifested, over a period of at least two years, at least four of the following, either continuously or repeatedly: (1) Inappropriate or constricted affect, subject appears cold and aloof; (2) Behaviour or appearance which is odd, eccentric or peculiar; (3) Poor rapport with others and a tendency to social withdrawal; (4) Odd beliefs or magical thinking influencing behaviour and inconsistent with subcultural norms; (5) Suspiciousness or paranoid ideas; (6) Ruminations without inner resistance, often with dysmorphophobic, sexual or aggressive contents; (7) Unusual perceptual experiences including somatosensory (bodily) or other illusions, depersonalization or derealization; (8) Vague, circumstantial, metaphorical, over-elaborate or often stereotyped thinking, manifested by odd speech or in other ways, without gross incoherence; (9) Occasional transient quasi-psychotic episodes with intense illusions, auditory or other hallucinations and delusion-like ideas, usually occurring without external provocation. B. The subject must never have met the criteria for any disorder in F20 (Schizophrenia).

13 Definition: PERSONALITY DISORDERS DSM-IV-TR A. An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture. This pattern is manifested in two (or more) of the following areas: (1) Cognition (perception and interpretation of self, others and events) (2) affectivity (the range, intensity, lability, and appropriateness of emotional response) (3) interpersonal functioning (4) impulse control B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations. C. The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The pattern is stable and of long duration and its onset can be traced back at least to adolescence or early adulthood. E. The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder. F. The enduring pattern is not due to the direct physiological effects of a substance or a general medical condition such as head trauma.

14 Definition: DISORDERS OF PERSONALITY: ICD-10 G1. Evidence that the individual's characteristic and enduring patterns of inner experience and behaviour deviate markedly as a whole from the culturally expected and accepted range (or 'norm'). Such deviation must be manifest in more than one of the following areas: (1) cognition (i.e. ways of perceiving and interpreting things, people and events; forming attitudes and images of self and others); (2) affectivity (range, intensity and appropriateness of emotional arousal and response); (3) control over impulses and need gratification; (4) relating to others and manner of handling interpersonal situations. G2. The deviation must manifest itself pervasively as behaviour that is inflexible, maladaptive, or otherwise dysfunctional across a broad range of personal and social situations (i.e. not being limited to one specific 'triggering' stimulus or situation). G3. There is personal distress, or adverse impact on the social environment, or both, clearly attributable to the behaviour referred to under G2. G4. There must be evidence that the deviation is stable and of long duration, having its onset in late childhood or adolescence. G5. The deviation cannot be explained as a manifestation or consequence of other adult mental disorders, although episodic or chronic conditions from sections F0 to F7 of this classification may co-exist, or be superimposed on it. G6. Organic brain disease, injury, or dysfunction must be excluded as possible cause of the deviation (if such organic causation is demonstrable, use category F07).

15 PERSONALITY DISORDERS CATEGORIES vs DIMENSIONS Categorical models [Fuzzy concepts] Monothetic [necessary and sufficient attributes] [Yes / No] Polythetic [none sufficient nor necessary] [List] e.g. DSM – arbitrary categories, arbitrary clusters, hierarchical Ideal types [configuration of interrelated attributes that appear interrelated based on theory and observation] Prototypes [categories organized around prototypical cases (BEST EXAMPLE) – handle well fuzzy categories [Rosch], different that ideal types because they are mainly lists of attributes, not integrated. Most clinicians make diagnostic impressions based on the degree to which patient resembles clinician’s conception of the disorder.

16 DSM-IV-TR Categorical [Prototypal / Polythetic] model CLUSTER A Paranoid, Schizotypal, Schizoid CLUSTER B Narcissistic, Borderline, Histrionic, Antisocial CLUSTER C Obsessive-Compulsive, Dependent, Avoidant

17 PERSONALITY DISORDERS CATEGORIES vs DIMENSIONS: PROBLEMS & ALTERNATIVES Problems with Categorical models: Fuzzy boundaries / excessive diagnostic co-occurrence Heterogeneity within the same diagnosis Poor and arbitrary norm vs disorder criteria Inadequate coverage Criteria / symptoms from different theoretical / clinical traditions Alternatives: Develop alternative categorical diagnostic system Use multidimensional personality profile (e.g. MCMI-III) Identify dimensions underlying personality disorders

18 DIMENSIONAL MODELS OF PERSONALITY DISORDERS Factor analytic models FFM - the Five Factors Model (McCrae & Costa 1999) DAPP-BQ - Dimensional Assessment of Personality Pathology - Basic Questionnaire (Livesley 2003) SNAP - Schedule for Nonadaptive and Adaptive Personality (Clark 1993) Neurobehavioral models Siever & Davis general model for DSM categories (1991) Three-Factor Eysenck’s model Seven-Factor Cloninger’s model (2005) Neurobehavioral Dimensional Model Depue & Lenzenweger (2001)

19 The “Big Five” Personality Factors [OCEAN] PERSONALITY RESEARCH BASED, DIMENSIONAL MODEL A remarkably strong consensus of what traits are basic has emerged over the last 20 years. Five superordinate factors have emerged and are referred to as the Big Five or the 5-factor model. These five factors are well supported by a wide variety of research. Neuroticism (vs. Emotional Stability) Anxiety, Angry hostility, Depression, Self-consciousness, Impulsiveness, Vulnerability Extraversion (vs. Introversion) Warmth, Gregariousness, Assertiveness, Activity, Excitement-seeking, Positive emotion Openness to experience (vs. Closedness to experiences) Fantasy, Aesthetics, Feelings, Actions, Ideas, Values Agreeableness ( vs. Antagonism) Trust, Straightforwardness, Altruism, Compliance, Modesty, Tender-mindedness Conscientiousness (vs. Lack of conscientiousness) Competence, Order, Dutifulness, Achievement striving, Self-discipline, Deliberation

20 Dimensional Assessment of Personality Pathology - Basic Questionnaire DAPP-BQ Emotional Dysregulation [Neuroticsm] affective instability, submissiveness, cognitive distortions, anxiousness, diffidence, self-harm, identity problems, suspiciousness, insecure attachment, avoidance, narcissism Dissocial Behavior [Disagreeableness] conduct problems, stimulus seeking, callousness, rejection, suspiciousness, passive oppositionality, Inhibition [Constraint] restricted expression, intimacy problems Compulsivity compulsivity

21 SNAP - Schedule for Nonadaptive and Adaptive Personality Positive Affectivity / Temperament Exhibitionism, Entitlement, Detachment Negative Affectivity / Temperament Distrust, Manipulativeness, Aggression, Self-harm, Eccentric Perceptions, ependency Disinhibition vs Constraint Impulsivity, Propriety, Workoholism

22 SIEVERS & DAVIS - GENERAL MODEL DIMENSIONS FOR THE DSM-IV AXIS I AND AXIS II DISORDERS Cognitive / Perceptual Organization – Dopaminergic Impulsivity / Aggression Regulation – Serotonergic Affective Instability – Noradrenergic-cholinergic Anxiety/ Inhibition – Dopamine + Serotonin

23 EYSENCK’S MODEL [E] - Extraversion – sociable, lively, active, assertive, sensation-seeking, carefree, dominant, surgent, venturesome [N] – Neuroticism – anxious, depressed, guilt feelings, low self-esteem, tense, shy, irrational, moody, emotional [P] – Psychoticism – aggressive, cold, egocentric, impersonal, impulsive, antisocial, unempathic, creative, tough-minded

24 EYSENCK’S MODEL (2) Biological basis for each of the three dimensions Eysenck (1967; 1990) proposes that there is a biological basis for introversion- extraversion: introverts have higher levels of activity in the cortico-reticular loop, and thus are chronically more cortically aroused, than extraverts. Neuroticism is based on a separate biological system related to the “visceral” brain (the hippocampus-amygdala, singulum, septum, and hypothalamus) that produces autonomic arousal. Eysenck distinguishes arousal produced by reticular activity, the basis for extraversion, which he calls "arousal," from autonomic arousal, the basis for neuroticism, which he calls "activation.“ Recent work shows that Eysenck's arousal systems are probably only two of a variety of arousal systems (Zuckerman & Como, 1983). Other work shows that psychoticism (i.e., tough mindedness) is not a dimension of temperament at all, but rather of character (Strelau & Zawadzki, 1997

25 CLONINGER'S MODEL TEMPERAMENT DIMENSIONS Novelty Seeking [Behavior Activation, Dopamine] Hypothesized to be a heritable tendency toward intense exhilaration or excitement in response to novel stimuli or cues for potential rewards or relief of punishment, which leads to frequent exploratory activity in pursuit of potential rewards as well as active avoidance of monotony and potential punishment. [Low basal activity in dopaminergic DA system] Harm Avoidance [Behavior Inhibition, Serotonin] Hypothesized to be a heritable tendency to respond intensely to signals of aversive stimuli, thereby learning to inhibit behavior in order to avoid punishment, novelty and frustrative non-reward. [High activity in serotonergic 5-HT system] Reward Dependence [Behavior Maintenance, Norepinephrine] Hypothesized to be a heritable tendency to signals of reward (particularly verbal signals of social approval, sentiment and succor) and to maintain or resist extinction of behavior that has been associated with rewards or relief from punishment. [Low basal noradrenergic activity in NE system] CHARACTER DIMENSIONS Persistence Self-Direction Cooperation Self-Transcendence

26 DEPUE - LEZENWEGER’S MODEL MULTIDIMENSIONAL, MULTIPLE NEUROTRANSMITTER-NEUROPEPTIDE MODEL Basic dimensions: AGENTIC EXTRAVERSION : NEUROTICISM [Positive Emotionality PEM : NEM Negative Emotionality] CONSTRAINT AFFILIATION FEAR

27 AGENTIC EXTRAVERSION Extraversion = Affiliation + Agency Social dominance, positive emotional feelings, sociability, achievement, motor activity Positive Affect vs Negative Affect modulation Gray: interaction of relative strength of sensitivity signals of rewards [extraverts] and punishment [introverts]. Affiliation - Warmth, sociability, agreeableness Agency - Social dominance, assertiveness, exhibitionism, sense of potency, efficacy, endurance, persistence, energy, assuredness, dominance Affiliation and Agentic Extraversion are two different neurobiological systems / circuits. Agentic Extraversion:Positive incentive motivation - attributes incentive motivation (intensity, salience) to stimuli. Positive affect (desire, wanting, excitement, enthusiasm, efficacy). Brings organism in contact with unconditional / conditioned positive incentive stimuli Agentic Extraversion is regulated by individual differences levels in State / Trait DA Receptor Activation and is modulated by Serotonin

28 AGENTIC EXTRAVERSION (2) NEUROBEHAVIORAL AREAS / CIRCUITS Ventral Tegmental Area (VTA) dopamine (DA) projections to the caudiomedial shell region of the NAS [individual differences in VTA-NAS DA pathway] Incentive Stimulation Magnitude + State / Trait DA Receptor Activation Main structures: Basolateral and extended amygdala + hippocampus + posterior medial orbital prefrontal cortical area 13 Glutamatergic excitatory afferents to VTA-NAS systems Dopamine and Glutamate in the Context of Reward: Dysfunction in the balance of dopamine (DA) and glutamate (Glu) in the brain pathway from the ventral tegmental area (VTA) to the nucleus accumbens (NAS) may play a role in human disorders of motivation, such as schizophrenia and drug abuse

29 NEUROTICISM Anxiety + Fear Correlation between fear and anxiety = 0 Gray: neuroticism= general amplifier of reactivity to both reward and punishment signals Different neuroanatomy of fear and anxiety NE involved in two nonspecific systems: peripheral [cortex to spine-muscle] and central [EEG activation]. Both interrupt ongoing behavior, reset cognition, increase sensory input, initiate selective attention,

30 NEUROTICISM (2) FEAR [harm avoidance] Escaping discrete, explicit unconditional aversive stimuli signaling danger. Behavioral inhibition Short-latency, strong phasic response of autonomic arousal + behavioral escape Amygdala is central. Norepinephrine NE in the locus coreuleus LC is the only source of NE in the cortex, hippocampus, limbic areas. Danger elicits fear and defensive motor escape, freezing, autonomic activation, midbrain, periaquiductal gray [PAG] which extend to medulla, spinal cord and also in the cortex to thalamus and amygdala, ANXIETY [neuroticism] Non-discrete, contextual stimuli denoting potential danger, uncertainty. No behavioral inhibition. Orthogonal to behavioral constraint Amygdala, sublenticular area and lateral BNST [bed nucleus of the stria terminalis] Norepinephrine NE in the locus coreuleus creates EEG arousal Prolonged contextual unfamiliar stimuli that connote uncertainty about outcome. NE increase sensory selection and attentional and cognitive processes. Autonomic arousal reverberates until uncertainty is resolved causing attentional scanning and cognitive worrying and rumination

31 NONAFFECTIVE CONSTRAINT LOW IMPULSIVITY / HIGH CONSCIENTIOUSNESS NONAFFECTIVE CONSTRAINT = CNS variable that modulates the threshold of stimulus elicitation of motor behavior, opposite to affective impulsivity [neuroticism / anxiety] Related to but independent from extraversion but relationship is controversial at this time Control of emotion, sensation-seeking, risk-taking, novelty-seeking, boldness, adventuresomeness, boredom susceptibility, unreliability, unorderliness. Serotonin [5-HT] modulation of a Response Threshold Gray: Impulsivity = interaction of Extraversion, Neuroticism and Psychoticism Cloninger: Impulsivity is related to ‘Novelty Seeking’ Depue-Lenzenweger: Impulsivity / sensation seeking lies between orthogonal High Extraversion and Low Constraint

32 AFFILIATION Warmth, sociability, agreeableness Sexual / social contact, cohesion. Approach / interaction of sociosexual behaviors. Facilitation of: positive reinforcement, sensory processing, social memories, feelings of warmth, affection, caring, nurturance, mating Gonadal Steroids [ estrogen, progesterone, testosterone] Neuropetides [ oxytocin OT; vasopressin VP] involve the limbic system and have a facilitative role in behavior and memory formation Opiates and opiate receptors [ mu, delta, kappa], in the cortico-limbic structures; B- endorphines – interpersonal warmth, euphoria, peaceful calmness [ naltrexone blocks those effects], co-localization with DA receptors

33

34 Depue - Lezenweger’s Model Hypothetical ranges for PDs on four dimensions 0-1000-100-10045-55SCHIZOID 0-10020-10030-850-15AVOIDANT 85-1000-10030-850-70DEPENDENT 0-10015-10085-10010-40COMPULSIVE 70-10030-1000-30 BORDERLINE 0-10015-4525-4560-80NARCISSISTIC 0-200-250-2060-100ANTISOCIAL 20-10025-1000-2085-100HISTRIONIC FEARAFFILIATIONCONSTRAINTPEM : NEMP. D.

35 -------------- EMOTIONAL DYSREGULATION IMPULSIVITYDISSOCIAL(-) INHIBITIONDABB-BQ NEUROTICISM / FEAR CONSTRAINT(-) AFFILIATIONAGENTIC EXTRAVERSION DEPUE- LEZENWEGER REWARD DEPENDANCE SELF-DIRECTIVENESS? TRANSCENDENCEHARM AVOIDANCE PERSISTENCE(-) COOPERATIVENE SS NOVELTY SEEKING TCI CLONIGER COGNITIVE / PERCEPTUAL DISTORTION AFFECTIVE INSTABILITY AGGRESSIVITY / IMPULSIVITY(-) INHIBITIONSIEVER / DAVIS ---------------NEUROTICISMPSYCHOTICISMEXTRAVERSIONEYSENCK PSYCHOTICISMNEGATIVE EMOTIONALITY CONSTRAINTAGGRESSIVITYPOSTIVE EMOTIONALITY PSY-5 -------------NEGATIVE AFFECTIVITY CONSTRAINT----------POSITIVE AFFECTIVITY SNAPP OPENESSNEUROTICISMCONSCIENTIOUS NESS ANTAGONISMEXTRAVERSIONFFM VIVIIIIII

36 CONSTRAINT / FEAR EXTRAVERSION_AFFILIATIONEXTRAVERSION_AFFILIATION OBSESSIVE COMPULSIVE AVOIDANT DEPENDENTHISTRIONIC NARCISSISTIC PARANOID SCHIZOID BORDERLINE ANTISOCIAL HIGH LOW SCHIZOTYPAL

37 MAIN DIMENSIONS OF PERSONALITY DISORDERS AND THEIR TREATMENT NEUROBEHAVIORAL Agentic Extraversion / PEM [Dopamine] Affiliation [Opioids, Peptides] Constraint (vs. Impulsivity) [Serotonin] Neuroticism / NEM [Norepinephrine] NEUROCOGNITIVE Affect Dysregulation Impulse Dysregulation Cognitive Dysregulation Behavior Dysregulation Persistence SELF Cooperation Self-Direction Identity Diffusion Fragmentation of Self Object Relations Mentalization / Reflective Function Attachment Pathology Self-Transcendence

38 DEVELOPMENTAL FRAMEWORK

39 CAPACITIES OF THE HUMAN MIND -a developmental framework Attachment mediates: human survival ablity to live in groups Surface vs. depth understanding / diagnosis

40 CAPACITIES OF THE HUMAN MIND - a developmental framework (S. Greenspan, S. Shanker, in PDM 2006) -To perceive, attend, self-regulate, move -To form relationships and develop a capacity for sustained intimacy -To learn to interact, read social / emotional cues and express a wide range of emotions -To form a sense of self that involves many different feelings, expressions and interaction patterns -To construct a sense of self that integrates different emotional polarities (e.g. love - hate) -To create internal representations of a sense of self, feelings, wishes and impersonal ideas -To categorize internal representations in terms of: --reality vs. fantasy (reality testing), --sense of self and others (self and object representations), -- wishes and feelings, --defenses and coping capacities, judgment --peer relationships --higher level self-awareness --reflective capacities

41 DIMENSIONS OF PERSONALITY FUNCTIONING - a developmental framework (S. Greenspan, S. Shanker, in PDM 2006) SELF REGULATION (HOMEOSTASIS) [0-3 months] -Self-regulation and contact through sight, sound, smell, touch and taste -Capacity to remain calm, alert, focused, -Capacity to organize behavior, affects, thoughts -Regulation of biological / life cycles and rhythms -Regulation of arousal and physiological states: sleep-wake, hunger, satiety -Attention management -Capacity for co-regulation -Regulation of behavior (motoric) -Tolerance for / regulation of high arousal, pleasure -Affect tolerance vs. Withdrawal -Hyperarousable vs. Hypoarousable in all sensory modalities -Capacity for "autonomous ego functions" -Management of pre-wired, pre-intentional object relatedness (constitutional, reflexive, conditioned) -Differentiation of self-other, inner-outer

42 DIMENSIONS OF PERSONALITY FUNCTIONING - a developmental framework (S. Greenspan, S. Shanker, in PDM 2006) RELATIONSHIPS, ATTACHMENT, ENGAGEMENT [2-7 months] -Integrating engagement in all 5 sensory modalities / pathways -Capacity to organize and regulate comfort, dependency, pleasure, joy, assertiveness, protest and anger -Basic synchrony, connectedness, global patterns of reactivity to non-self, human and non- human objects, intentional undifferentiated symbiosis -Pleasure-seeking, protest, protest, withdrawal, rejection, preference of physical / non- human objects, hyper-affectivity (diffuse discharge of affect), active avoidance

43 DIMENSIONS OF PERSONALITY FUNCTIONING - a developmental framework (S. Greenspan, S. Shanker, in PDM 2006) SOMATOPSYCHOLOGICAL DIFFERENTIATION - TWO WAY, PURPOSEFUL COMMUNICATION [3-10 months] -Intentional, nonverbal communication / gestures -Head nod, smiles, facial expression, body language -Differentiation of own action from it's affective, somatic, interpersonal consequences basic causality - relations with inanimate objects -Use of affects for intentional communication -Expressing and responding to happiness, distress, anger, fear, surprise, disgust -Integration / coherence of sensory modalities -"proximal" [physical contact], vs "distal" modes of communication [sight, auditory] -mastery of physical space as a precursor of construction of internal representations -interpersonal synchrony vs. random reactivity -reality testing -pre-representational / behavioral representations and causality -behavioral "I" and self -fragmentation of experience - low temporal and spatial continuity -part self / part object schemas and behavior

44 DIMENSIONS OF PERSONALITY FUNCTIONING - a developmental framework (S. Greenspan, S. Shanker, in PDM 2006) BEHAVIORAL ORGANIZATION, PROBLEM SOLVING, INTERNALIZATION, COMPLEX SENSE OF SELF - [9-18 months] -Capacity for continuous, complex, organized problem-solving interactions -Formation of a pre-symbolic sense of self -Intentionality and individuation -Sequencing cause-and-effect units into an organized chain behavior patterns -Shift from proximal to distal communication patterns -Affective integration -Fragmentation - polarization - integration developmental continuum -From isolated behaviors to behavioral stance / pattern / tendency -Deficits + conflicts in affective-behavioral tendencies -Over-reactive - loss / fear -Under-reactive - assertive / aggressive

45 TREATMENT Psychoanalytic - multiple overlapping approaches Psychodynamic – Transference-Focused Therapy [TFP] (Kernberg et al.) Mentalization-Based Treatment [MBT] (Fonagy, Bateman) Dialectical Behavior Therapy (M. Linehan) Cognitive Therapy – multiple overlapping approaches

46 DIALECTICAL BEHAVIOR THERAPY PATIENT WITH BORDERLINE PD EMOTIONAL DYSREGULATION is the core dysregulation [problem] in BPD - dysphoric affect, depressed, affective lability, extremes in experience and expression of affect anger [intense experience combined with over expression or under expression] in DSM = affective instability; inappropriate anger; INTERPERSONAL DYSREGULATION [ often around abandonment] intense need for close and intense relationships idealization vs devaluation [including the therapist] in DBT- interpersonal dysregulation is believed to be a result of emotional dysregulation SELF-DYSREGULATION unstable self image / identity or fragmentation and inability to modulate it vs integrate] BEHAVIORAL DYSREGULATION impulsivity, high-risk, self-harm; suicidality – as a “resolution” to emotional; or interpersonal dysregulation, suicides, suicidal attempts, suicidal gestures, para suicidal behaviors, suicidal communication COGNITIVE DYSREGULATION – para psychotic or para-dissociative

47 DIALECTICAL BEHAVIOR THERAPY [2] DBT TREATMENT DBT = “AN INTEGRATION OF BEHAVIOR THERAPY WITH OTHER PERSPECTIVES AND PRACTICES THAT INCLUDES, MOST NOTABLY PRINCIPLES AND PRACTICES OF ZEN AND AN OVERARCHING DIALECTICAL PHILOSOPHY THAT GUIDES THE TREATMENT” M. LINEHAN in LIVESLEY 2001] GENERAL FEATURES OF DBT ROOTED IN BEHAVIOR AND COGNITIVE THERAPY EMPHASIS ON: -ONGOING SYSTEMATIC ASSESSMENT OF AND DATA COLLECTION -OPERATIONAL DEFINITIONS OF CLEARLY DEFINED TARGET BEHAVIORS -COLLABORATIVE RELATIONSHIP WITH THE THERAPIST -USE OF ALL AND ANY STANDARD BEHAVIOR AND COGNITIVE STRATEGIES UNIQUE FEATURES OF DBT -EMPHASIS ON DIALECTICS: ACCEPTANCE – CHANGE; -TWO CORE STRATEGIES: VALIDATION STRATEGIES AND PROBLEM SOLVING STRATEGIES -IRREVERENCE -FLEXIBILITY -SKILLS TRAINING

48 DIALECTICAL BEHAVIOR THERAPY [3] THEORETICAL FOUNDATIONS OF DBT Biosocial theory of BPD – its causes and maintenance Emotional dysregulation + invalidating environment – life long cycle of increasing intensity of both EMOTION DYSREGULATION inherent emotional vulnerability and difficulty in modulating emotions, genetic + temperamental variables resulting in low threshold for emotional reactions + high-level reactions chronic high arousal resulting in cognitive dysregulation + slow return to baseline levels [ results in chronic increased sensitivity to emotional stimuli] EMOTIONAL REGULATION ability to reorient attention, to inhibit mood-dependent action; to change physiological arousal, to experience emotions without escalation or blunting them, to organize behavior in the service of external not-mood-dependent goals [on a task vs on the self]

49 DIALECTICAL BEHAVIOR THERAPY [4] INVALIDATING ENVIRONMENT “PRIVATE EXPERIENCES, [EMOTIONS, THOUGHTS, ETC] AS WELL AS OVERT BEHAVIORS ARE OFTEN TAKEN AS INVALID RESPONSES TO EVENTS; ARE PUNISHED, TRIVIALIZED, DISMISSED OR DISREGARDED; AND / OR ATTRIBUTED TO SOCIALLY UNACCEPTABLE CHARACTERISTICS” [LINEHAN 1993] IN ADDITION, HIGH-LEVEL ESCALATIONS MAY RESULT IN ATTENTION, MEETING OF DEMANDS, OR OTHER TYPES OF REINFORCEMENT. CORE TREATMENT PRINCIPLES OF DBT BEHAVIOR THERAPY LEARNING THEORY: MODELING, OPERANT CONDITIONING; RESPONDENT CONDITIONING THERAPIST NEEDS TO KNOW LEARNING THEORY AND PRACTICE IT IN TREATMENT OF BPD. ZEN MINDFULNESS TRAINING, RADICAL ACCEPTANCE, LETTING GO, MIDDLE WAY = DIALECTICS, CAPACITY FOR ENLIGHTENMENT AND TRUTH = WISE MIND, SELF REGULATION, EMOTION REGULATION, IMPULSE CONTROL DIALECTICS – SYNTHESIS OF OPPOSING ELEMENTS DBT = LEARNING THEORY + ZEN + DIALECTICAL PHILOSOPHY

50 PSYCHOANALYTIC TREATMENT – TFP [1] BASIC CONCEPTS Observable behaviors, traits, symptoms and subjective disturbances reflect specific pathological features of underlying psychological structures Treatment that alters psychological structures and mental organization will result in overt / subjective changes Descriptive features – observable behaviors + subjective states Model of mind Combined Dimensional [severity] + categorical [specific PD] model [see next slide] Psychological structure = a stable and enduring configuration of mental functions and processes that organizes the individual’s behavior and subjective experience [Kernebrg 2005] “Surface” + “deep” structures

51 INTROVERTEDEXTRAVERTED OBSESSIVE COMPULSIV E NEUROTIC LEVEL HIGH BORDERLINE LEVEL LOW BORDERLINE LEVEL PSYCHOTIC LEVEL DEPRESSIVE MASOCHISTIC HYSTERICAL AVOIDANT DEPENDENT HISTRIONIC NARCISSISTICSADO- MASOCHISTIC PARANOID SCHIZOTYPAL HYPOCHONDRIACALSCHIZOIDBORDERLINE HYPOMANIC ANTISOCIAL MALIGNANT NARCISSISTIC

52 PSYCHOANALYTIC TREATMENT – TFP [2] BASIC CONCEPTS Internal object relations are THE basic building blocks = affect state linked to an image of specific person / interaction between self and other. Include BOTH actual AND fantasized interactions with other as well as defenses in relation to both. Can be dyadic or triadic [a sexual / loving couple + a third party who is excluded] Identity is a central concept Healthy – stable + consolidated, integrated realistic sense of self and others, combined with positive affect states and defenses based on repression. Pathological - unstable, polarized, unrealistic, with affects which are crude, intense, poorly modulated, predominately aggressive and primitive defenses based on splitting. DSM criteria list observable behaviors, internal states, or symptoms

53 PSYCHOANALYTIC TREATMENT – TFP [3] PERSONALITY – BASIC TERMS Temperament – constitutionally given, largely genetically determined, inborn disposition to particular reactions – such as, intensity, rhythm, threshold of affective responses. Thresholds for activation positive pleasurable, rewarding affects vs negative, painful, aggressive affects. Also, inborn dispositions to perceptual organization, motor reactivity and to control of motor reactivity. Constitutionally determined aspects of cognition, especially as they interact with affects and development and modulation of affects. Representational aspects of affect activation and modulation. Capacity for “effortful control” / modulation of affects Character – dynamic organization of enduring behavior patterns, including ways of perceiving and relating to the world, that are characteristic of the individual. Degree of flexibility vs rigidity, Identity Character is a behavioral manifestation of identity. System of internalized values [ formerly superego]

54 PSYCHOANALYTIC TREATMENT – TFP [4] NORMAL PERSONALITY Integrated concept of self and significant others, identity, coherence capacity for broad spectrum of affects mature, integrated internalized values satisfactory management of sexual, dependent and aggressive motivations low affect activation states peak affect activation states integration of positive vs negative domains of psychological experiences [vs splitting into all good vs all bad] object constancy repression of high affect unintegrated self-states – dynamic unconscious

55 PSYCHOANALYTIC TREATMENT – TFP [5] PERSONALITY DISORDERS Neurotic level High borderline level Severe borderline level Psychotic level Pathology of aggression and the severe Personality Disorders Chronic physical pain in the first year of life Physical abuse + trauma affective instability – adrenergic + cholinergic systems – nor adrenaline + acetylcholine psychotic symptoms = dopaminergic impulsive aggression – serotonin amygdala Pathology of sexuality in higher level, “neurotic’ Personality Disorders Oedipal conflicts, inhibitions, guilt Hysterical, O-C PD, Paraphilias / perversions – fusion of aggressive and sexual motivations

56 PSYCHOANALYTIC TREATMENT – TFP [6] TREATMENT 2-6 YEARS EXPLORATION OF INTERNAL OBJECT RELATIONS TRANSFERENCE-FOCUSED PSYCHOTHERAPY – TFP-B / TFP-N DYADIC ANALYSIS / EXPLORATION / CONFRONTATION OF TRANSFERENCE FOR BORDERLINE LEVEL AMELIORATION OF IDENTITY DIFFUSION IDENTITY CONSOLIDATION INTEGRATION OF SPLIT OFF FRAGMENTS OF THE SELF FOR NEUROTIC LEVEL REDUCTION OF CHARACTER RIGIDITY

57 Mentalization Based Therapy The model takes into account constitutional vulnerability and is rooted in attachment theory and its elaboration by contemporary developmental psychologists. The model suggests that disruption of the attachment relationship early in development in combination with later traumatic experiences in an attachment context interacts with neurobiological development. The combination leads to hyper-responsiveness of the attachment system which makes mentalizing, the capacity to make sense of ourselves and others in terms of mental states, unstable during emotional arousal. The emergence of earlier modes of psychological function at these times accounts for the symptoms of (B)PD. The model has clinical implications and suggests that the aim of treatment is not only to encourage development of mentalizing but also to facilitate its maintenance when the attachment system is stimulated.

58 The term reflective function (RF) refers to the psychological processes underlying the capacity to mentalize. Mentalizing refers to the capacity to perceive and understand oneself and others in terms of mental states (feelings, beliefs, intentions and desires). It also refers to the capacity to reason about one’s own and others’ behaviour in terms of mental states, i.e. reflection. Reflective functioning or mentalization is the active expression of this psychological capacity intimately related to the representation of the self. RF involves both a self-reflective and an interpersonal component that ideally provides the individual with a well-developed capacity to distinguish inner from outer reality, pretend from ‘real’ modes of functioning, intra-personal mental and emotional processes from interpersonal communications. This formulation differs from most developmentalists in considering RF not to be a maturational cognitive capacity but rather a developmental achievement which is never fully acquired and is not consistently maintained across situations. It is important that RF is not conflated with introspection. Introspection or self reflection is quite different from RF as the latter is an automatic procedure, unconsciously invoked in interpreting human action. Procedural knowledge of minds in general, rather than declarative self knowledge, is the defining feature. Mentalization Based Therapy

59 MAIN DIMENSIONS OF PERSONALITY DISORDERS AND THEIR TREATMENT NEUROBEHAVIORAL Agentic Extraversion / PEM [Dopamine] Affiliation [Opioids, Peptides] Constraint (vs. Impulsivity) [Serotonin] Neuroticism / NEM [Norepinephrine] NEUROCOGNITIVE Affect Dysregulation Impulse Dysregulation Cognitive Dysregulation Behavior Dysregulation Persistence SELF Cooperation Self-Direction Identity Diffusion Fragmentation of Self Object Relations Mentalization / Reflective Function Attachment Pathology Self-Transcendence

60 MULTIDIMENSIONAL / MULTIVARIABLE TREATMENT (MMT) The Multidimensional / Multivariable Treatment (MMT) is an innovative and arguably more efficacious than other approaches treatment model for "difficult to engage and treat patients with severe personality disorders". The model is "multidimensional" and "multivariable" - multiple dimensions of a personality disorder are treated simultaneously by multiple treatment variables within an Intensive Outpatient Program (IOP) setting. Personality disorders are conceptualized as "enduring disturbances of neurocognitive system regulating patterns of internal experience, behavior and interpersonal adaptation", reflecting a life-long developmental dysregulation of three basic domains of functioning: body (neurobiology), mind (cognition / psychodynamics) behavior (interpersonal relating).

61 MULTIDIMENSIONAL / MULTIVARIABLE TREATMENT (MMT) Main dimensions of a personality disorder targeted in MMT are: the attachment system neurobehavioral circuits underlying personality neurocognitve regulation of affects, mood and impulses psychodynamics of object relations and ego-functions cognition interpersonal behavior and patterns of relating consciousness, self and subjectivity

62 MULTIDIMENSIONAL / MULTIVARIABLE TREATMENT (MMT) the attachment system An innate evolutionarily hardwired neurobiological system regulating human bonding, originally regulating mother-newborn bonding to enhance survival of the offspring. The system involves contact seeking (sucking reflex, licking, nursing, etc.), intense distress in both mother and the infant at separation and danger (fight- flight [mother], distress cry, increased arousal and activity [newborn]. Later in life, the attachment system regulates the formation of interpersonal / intimate bonds, friendships and romantic relationships. Abandonment, separation, relational loss, romantic break-up and any other rupture of the attachment bond(s) re-activates the hardwired emergency distress reactions (flight-fight), intense, often unbearable distress, (fear, anger, hyper arousal) which, if prolonged, can result in despair, hopelessness, helplessness, depression, melancholy and, in most dramatic cases, a full psychotic regression / decompensation.

63 MULTIDIMENSIONAL / MULTIVARIABLE TREATMENT (MMT) neurobehavioral circuits underlying personality Genetically determined, biological circuits in the brain and the nervous system regulating temperament (reactivity, sensitivity, response threshold, etc.), including anatomical structures (limbic system, frontal cortex, brain stem), neurotransmitters (dopamine, serotonin, norepinephrine, etc), autonomic nervous system, hormones, sensory organs and muscle structures (?). Some of the most central ones include:

64 MULTIDIMENSIONAL / MULTIVARIABLE TREATMENT (MMT) neurocognitve regulation of affects, mood and impulses Temperament and learning (conditioning) based, activation / inhibition of affects, mood-states and impulses. Involves complex interactions among cortical and sub- cortical / peripheral components of the CNS, subject to classical and operant conditioning, prenatally and throughout lifespan. Develops, via maturation and learning, from instinct-based reflexes to progressively more central and complex volitional, cognitive regulation

65 MULTIDIMENSIONAL / MULTIVARIABLE TREATMENT (MMT) psychodynamics of object relations and ego-functions Psychodynamic organization and functioning of unconscious (primary process) and conscious aspects of object relations and object choices, defenses and ego functions, including wish-defense configurations, internal conflicts, displacement and condensation, symbolization and configurations of signifiers, dreams, identity and desires

66 MULTIDIMENSIONAL / MULTIVARIABLE TREATMENT (MMT) Cognition All aspects of perception and cognitive functioning including cognitive styles,/ biases and distortions, learning and information processing, procedural / declarative, semantic / episodic memory (knowledge, skills, etc.), language processing, schemata and representations of self and others, mentalization, personal theory / construction of meaning, mind and reality.

67 MULTIDIMENSIONAL / MULTIVARIABLE TREATMENT (MMT) Interpersonal behavior and patterns of relating All and any observable aspects of action and behavior, including physiological manifestations of internal states regulated by the autonomic nervous system, observable aspects of cognition, psychodynamics and internal experience (e.g. attention, emotions, mood states), patterns of interpersonal relating, appearance, speech and vocalizations.

68 MULTIDIMENSIONAL / MULTIVARIABLE TREATMENT (MMT) Consciousness, self and subjectivity Moment-to-moment changes of one’s consciousness and its dialectical mutuality with the experience of subjectivity and the self. All and any contents and states of consciousness experienced by a person, including the in-the-moment experience of one’s existence.The phenomenological center of one’s being and subjectivity.

69 MULTIDIMENSIONAL / MULTIVARIABLE TREATMENT (MMT) Main clusters of treatment variables are Theory Structure and modalities –Environmental / milieu –Individual vs. Group –Contingencies and consequences [IF…….Then……] Technical interventions –Language / speech transactions –Environmental transactions –Relational transactions –Psychodynamic / cognitive –Behavioral / relational –Special assignments New learning and conditioning –New skill acquisition –Classical re-conditioning Therapist –Demographics –Theoretical / clinical stance –Personality / self / consciousness –Countertransference Peer group dynamics

70 MULTIDIMENSIONAL / MULTIVARIABLE TREATMENT (MMT) theoretical approach Personality Disorders are approached as a life-long neurocognitive disturbance of consciousness and self-states manifested by dysregulation of mood, impulses, affects, perception, cognition and interpersonal behavior. Consciousness and the self are user-defined, subject to an ongoing analysis and transformation, by the therapist and the patient, in the course of MMT. The treatment involves a non-integrative application of psychoanalytic and neurocognitive theories of mind and brain in the analysis and transformation of the moment-to-moment flow of states of consciousness, subjective experience and observable behaviors both in maladaptive symptom-formation and in curative change.

71 TREATMENT OF PERSONALITY DISORDERS PSYCHOTHERAPY – DEFINITIONS, OUTCOMES, METAPHORS PERSONAL METAPHORS AND SELF-PARADIGMS PSYCHOANALYTIC / PSYCHODYNAMIC APPROACHES COGNITIVE & BEHAVIORAL APPROACHES DBT - DIALECTICAL BEHAVIOR THERAPY ATTACHMENT – BASED APPROACHES INTERPERSONAL APPROACHES OTHER APPROACHES AND MODELS GENERAL, INTEGRATED MODEL MULTIDIMENSIONAL / MULTIVARIABLE MODEL

72 PSYCHOTHERAPY Psychotherapy is a process of changing one’s mind, brain and behavior to alleviate psychological symptoms and / or to improve functioning. It is a transformation of several biopsychosocial functions which typically affects one’s: personality, including the conscious and unconscious components of the Self, ego, character organization, emotions, wishes and desires, inhibitions, conflicts brain, including neurocognitive activity of neuronal associative networks, memory, language, information processing, neurotransmitters, molecular biochemistry and global integrative functions behavior, including one's observable actions, interactions and relationships with others It is not a set of procedures or techniques applied to a person by the therapist. It is a change in the subjective experience which begins in the therapy office and then is not only carried outside of it but also continues to unfold during the time between sessions.

73 PSYCHOTHERAPY [2] Psychotherapy involves dialectical use of spoken language between the therapist and the patient. It necessitates a unique kind of a dialogue, narrative or a conversation between the therapist and the patient, whereby spoken language, ranging from simple words and instructions to intensely personal, infinitely complex narratives and dialogues, becomes the main medium of personal change within and beyond the psychotherapy office. On the most fundamental level, is a process of examining, exploring, changing and re-constructing the moment-to-moment flow of one’s subjective experience.

74 PSYCHOTHERAPY [3] Psychotherapy typically brings about at least one of the following outcomes: cure of a mental disorder symptoms reduction (i.e. decrease in their intensity, frequency, range or scope of interference with functioning) reduction of subjectively experienced distress or suffering insight - improved understanding of oneself and others conflict(s) resolution wellness - improved psychological, emotional and interpersonal functioning improved performance / efficacy of actions ability to work, play and love personal development improved capacity for compassion improved capacity for happiness

75 PSYCHOTHERAPY [4] The Western culture’s attempt to alleviate and remedy human suffering, over the centuries, it has been a realm of gods, magic, shamanism, religion, spiritual practice, art, philosophy, social activism and, most recently, of science. METAPHORS FOR PSYCHOTHERAPY Medical ones - healing, cure, treatment, recovery, remission, rehabilitation – suggesting restoration of health from sickness, disease, disorder, illness, disability, impairment. Exploratory ones – self-discovery, journey, insight – emphasizing a search for a new or hidden territory, place, secret. Aesthetic ones – (re)-creating a state of harmony, balance, grace and, ultimately, beauty Religious / spiritual ones – transcendence, higher power, finding God, enlightenment, Technological ones – mastery of control, power, efficacy, outcomes Scientific ones – mastery of knowledge, explanation, control, prediction, learning Interpersonal ones – intimacy, autonomy, interdependency, love,

76 PSYCHOTHERAPY [5] CHANGE DISCOVERY JOURNEY ANALYSIS RECONSTRUCTION HEALING REPARENTING EXPLORATION KNOWLEDGE INSIGHT LEARNING NEW NARRATIVE TRUTH CONDITIONING SKILLS ACQUISITION GROWTH NEW LEARNING DESENSITIZATION MODIFICATION OF SCHEMATA OF SELF AND OTHERS CONSTRUCTION OF NEW NARRATIVE ABOUT SELF AND OTHERS SYSTEMS CHANGE MAKING UNCONSCIOUS CONSCIOUS BEHAVIORAL REHEARSAL ACCEPTANCE OF SELF AND OTHERS, POSITIVE REGARD NEW LIFE STYLE OTHER?

77 PERSONAL METAPHORS & LIFE PARADIGMS WHY PEOPLE WITH PDs CAN’T OR WON’T GET BETTER Psychotherapy & medicine represent a “health / cure” paradigm Alternative metaphors / paradigms more important than “health / cure”: PLEASURE – HEDONISM, SELF-INDULGENCE POWER – WEALTH, POLITICS, CONTROL, MILITARY BEAUTY – ART CREATIVITY ROMANTIC LOVE TRANSCENDENCE - GREATER CAUSE / OTHERS TRANSCENDENCE - GOD / RELIGION / SPIRITUALITY TRANSCENDENCE – MARTYRDOM ESCAPISM OTHER

78 TREATMENT – MAIN APPROACHES SUPPORTIVE PSYCHOTHERAPY PSYCHOANALYSIS PSYCHOANALYTIC / PSYCHODYNAMIC THERAPY MENTALIZATION-BASED THERAPY - Fonagy COGNITIVE THERAPY SCHEMA THERAPY DIALECTICAL BEHAVIOR THERAPY – M. Linehan COGNITIVE ANALYTIC THERAPY - Anthony Ryle INTERPERSONAL THEORY – L. Benjamin PSYCHOPHARMACOLOGY

79 GENERAL GUIDELINES FOR TREATMENT NO SINGLE APPROACH HAS MONOPOLY DIFFERENT INTERVENTIONS ARE EFFECTIVE FOR DIFFERENT SYMPTOMS DIVERSE, EVIDENCE-BASED INTEGRATIVE TREATMENT IS NEEDED PSYCHOTHERAPY INTEGRATION: TECHNICAL ECLECTICISM  SELECTING THE BEST COMBINATION OF INTERVENTIONS MATCHING THE PERSON OR PROBLEM / SYMPTOM THEORETICAL INTEGRATION  BASIC CONCEPTS: NEUROCOGNITIVE STRUCTURE / CIRCUIT REPRESENTATION OF SELF AND OTHERS OBJECT RELATIONS SCHEMA / WORKING MODELS. COMMON FACTORS APPROACH: RELATIONSHIP / SUPPORTIVE FACTORS + TECHNICAL FACTORS [ NEW LEARNING]

80 TREATMENT – MAIN PRINCIPLES [1] [1] TREATMENT OF PDS REQUIRES MULTIDIMENSIONAL / MULTIVARIABLE INTERVENTIONS BASIC DIMENSIONS / VARIABLES ARE: MIND / COGNITION [PSYCHODYNAMIC, SCHEMA, COGNITIVE] BRAIN / CNS [PSYCHOPHARMACOLOGY] BEHAVIOR [DBT / INTERPERSONAL] MOOD AFFECTS PSYCHOTIC RANGE SYMPTOMS SELF HARM / SUICIDE SUBSTANCE ABUSE SELF-REGULATION IMPULSE CONTROL ATTACHMENT PROBLEMS RELATIONSHIPS / INTIMACY SELF / OTHER REPRESENTATIONS,

81 TREATMENT – MAIN PRINCIPLES [2] [2] CORE FEATURES [COMMON TO ALL PDs] + SPECIFIC SYMPTOMS [SPECIFIC TO A SPECIFIC PD] CORE FEATURES: 1. SELF / OTHER REPRESENTATIONS + INTERPERSONAL FUNCTIONING + SELF-REGULATION - BUT EACH IS MANIFESTED DIFFERENTLY IN EACH PD [E.G. SCHIZOID vs BPD] 2. IMPORTANCE OF THERAPEUTIC RELATIONSHIP – IT ADDRESSES THE CORE PROBLEM – RELATIONSHIPS / INTIMACY 3. EMPATHIC / SUPPORTIVE vs CONFRONTATIVE --- INTERPRETATIVE CONTINUUM [3] PDs ARE COMPLEX BIOPSYCHOSOCIAL SYNDROMES 1. BIOLOGICAL / GENETIC FACTORS – SEE BEFORE 2. BASIC PERSONALITY TRAITS, BIOLOGY / TEMPERAMENT-BASED ARE DIFFICULT TO CHANGE - WHAT NEEDS TO CHANGE IS HOW THEY BECOME MORE ADAPTIVE / EFFECTIVE 3. THE GOAL OF TREATMENT IS TO ENHANCE ADAPTATION BY BUILDING COMPETENCE

82 TREATMENT – MAIN PRINCIPLES [3] [4] THE ROLE OF PSYCHOSOCIAL ADVERSITY / TRAUMA IN THE FORMATION OF PDs TRAUMATIC EXPERIENCES NEED TO BE ADDRESSED / RESOLVED FIRST

83 UNDERSTANDING CHANGE METAPHORS FOR THERAPEUTIC CHANGE [SEE EARLIER] METAPHORS FOR PSYCHOTHERAPY SHOULD MATCH PATIENT’S METAPHORS / LIFE PARADIGMS WHENEVER POSSIBLE RESULTING IN “COLLABORATIVE DESCRIPTION / CONVERSATIONAL ELABORATION” MAIN STAGES OF CHANGE IN THERAPY REFERRAL -> INITIAL CONTACT -> ENGAGEMENT -> READINESS / PREPARATION -> THERAPY PROPER -> MAINTENANCE -> TERMINATION

84 UNDERSTANDING CHANGE [1] [1] PROBLEM RECOGNITION / CONTRACT [2] EXPLORATION MICRO-ANALYSIS OF SUBJECTIVE EXPERIENCE SYMPTOM ANALYSIS BEHAVIOR ANALYSIS SUBJECTIVE EXPERIENCE ANALYSIS INTERPERSONAL ANALYSIS DIARIES MAKING CONNECTIONS WITHIN DESCRIPTION - ANTECEDENTS, TRIGGERS, CONSEQUENCES, ETC. DESCRIPTIVE REFRAMING FOCUSING ON GENERAL THEMES / PATTERNS AND SPECIFICS PROMOTING SELF-OBSERVATION, SELF AWARENESS, SELF-MONITORING IDENTIFYING MAINTENANCE FACTORS, SYMPTOMATIC RELAPSE PREVENTION ADDRESSING / CHALLENGING OBSTACLES TO CHANGE

85 UNDERSTANDING CHANGE [2] [3] ACQUISITION OF ALTERNATIVE SKILLS AND BEHAVIORS GENERATING ALTERNATIVES / PROBLEM SOLVING MAINTAINING MOTIVATION TO CHANGE ENCOURAGING NEW BEHAVIORS INHIBITING OLD PATTERNS – CONTRACTS, DISTRACTIONS, CONTINGENCIES MANAGEMENT TEACHING NEW SKILLS [4] CONSOLIDATION AND GENERALIZATION APPLYING NEW LEARNING TO SPECIFIC SITUATIONS REHEARSAL DEVELOPING MAINTENANCE STRATEGIES ATTRIBUTION OF CHANGE

86 GENERAL THERAPEUTIC STRATEGIES [1] [LIVESLEY 2001] [1] BUILD AND MAINTAIN A COLLABORATIVE RELATIONSHIP BUILD CREDIBILITY GENERATE OPTIMISM AND HOPE COMMUNICATE UNDERSTANDING AND ACCEPTANCE INDICATE SUPPORT FOR THE GOALS OF THERAPY RECOGNIZE PROGRESS ACKNOWLEDGE THE USE OF SKILLS & KNOWLEDGE LEARNED USE RELATIONSHIP LANGUAGE REFER TO SHARED EXPERIENCES IN THERAPY ENGAGE IN COLLABORATIVE SEARCH FOR UNDERSTANDING MONITOR ALLIANCE AND MANAGE RUPTURES

87 GENERAL THERAPEUTIC STRATEGIES [2] [2] ESTABLISH AND MAINTAIN A CONSISTENT TREATMENT PROCESS ESTABLISH A CONSISTENT FRAME TREATMENT CONTRACT THERAPEUTIC STANCE TREATMENT CONTEXT MAINTAIN CONSISTENCY

88 GENERAL THERAPEUTIC STRATEGIES [3] [3] VALIDATION RECOGNIZE, ACKNOWLEDGE, ACCEPT BEHAVIOR AND EXPERIENCE AVOID PREMATURE FOCUSING ON POSITIVE / NEGATIVE COLLABORATIVE SEARCH FOR MEANING COUNTERACT SELF - INVALIDATION RECOGNIZE AREAS OF COMPETENCE REDUCE SELF-DEROGATION MANAGE VALIDATION RUPTURES

89 GENERAL THERAPEUTIC STRATEGIES [4] [4] BUILD AND MAINTAIN MOTIVATION USING DISCONTENTMENT CREATING OPTIONS FOCUS ON SMALL STEPS CHALLENGING INCENTIVES FOR NOT CHANGING MANAGING AMBIVALENCE [5] CONSOLIDATION, TRANSFER, GENERALIZATION, RELAPSE PREVENTION

90 SPECIFIC THERAPEUTIC STRATEGIES [1] SYMPTOMS AND CRISES MANAGEMENT CONTAINMENT MEDICATION COGNITIVE – BEHAVIORAL INTERVENTIONS [2] PROMOTING MORE ADAPTIVE EXPRESSION OF BASIC TRAITS INCREASE TOLERANCE AND ACCEPTANCE ATTENUATE TRAIT EXPRESSION SUBSTITUTE MORE ADAPTIVE TRAIT EXPRESSION [3] SELF / INTERPERSONAL PROBLEMS REPETITIVE BEHAVIOR PATTERNS SELF / OTHER SCHEMATA SELF PATHOLOGY / DISJUNCTIONS MANAGING FRAGMENTATION / INTEGRATION CONSTRUCT A NEW ‘THEORY’ OF THE SELF

91

92 BUDDHIST MEDITATION TO STUDY THE BUDDHA WAY IS TO STUDY THE SELF. TO STUDY THE SELF IS TO FORGET THE SELF. TO FORGET THE SELF IS TO BE REALIZED BY THE ENTIRE UNIVERSE. WHEN REALIZED BY THE UNIVERSE THE BODY-AND-MIND AND THE ENTIRE UNIVERSE DROP AWAY. Eihei Dogen (1200-1253) Shobogenzo

93 Definitions: MEDITATION RG-VEDA / UPANISHADAS DHI OR DHYA => TO THINK => INQUIRY, EXAMINATION OR INTROSPECTION SANSCRIT DHYANA => THOUGHT, REFLECTION, PROFOUND AND ABSTRACT RELIGIOUS PRACTICE, MENTAL REPRESENTATION OF THE PERSONAL ATTRIBUTES OF A DEITY, TRANCE STATE, MEDITATION, DHAYANA IS ONE OF 8 MAIN STAGES OF PRACTICE OF YOGA Yama, Niyama, Asana, Pranayama, Pratyahara, Dharana, Dhyana and Samadhi. YOGA=> UNION, YOKE, APPLICATION; MEANS, ART, MAGIC, WORK, RELATION, CONTACT, PURSUIT, ORDER, FITNESS, EFFORT, ATTENTION, CONCENTRATION, MEDITATION, CONTEMPLATION DHYANA BUDDHISM => [CHINESE] CH’AN BUDDHISM = > [ JAPANESE] ZEN – “MEDITATION” BUDDHISM

94 Definitions: MEDITATION HEBREW [OLD TESTAMENT] HAGAH => TO "PONDER, IMAGINE, MOURN, SPEAK, STUDY, TALK, UTTER, MEDITATE” GREEK MELETAO => TO CARE FOR, TO ATTEND TO, PRACTICE, BE DILIGENT IN, TO PONDER, IMAGINE LATIN MEDITATIO => TO STUDY, TO PRACTICE, PREPARATION, GETTING READY / CONSIDERATION, PONDERING, TO REFLECT UPON ENGLISH MEDITATION => SERIOUS CONSIDERATION, AS OF UNDERTAKING A COURSE OF ACTION OR OF IMPLEMENTING A PLAN; DEEP REFLECTION, PRAYER, CONTEMPLATION ORIGINAL MEANING IN MODERN TERMS: REFLECTION + INTROSPECTION + CONTEMPLATION + SELF-HELP + HEALING+ SELF-ACTUALIZATION + PSYCHOTHERAPY + SPIRITUALITY

95 Definitions: MINDFULNESS SITA [PALI] MINDFULNESS - AN INTENTIONAL FOCUSED AWARENESS – A WAY OF PAYING ATTENTION ON PURPOSE IN THE PRESENT MOMENT, NON-JUDGMENTALLY MINDFULNESS TRAINING – [1] LEARNING HOW TO BE PRESENT, AWARE, ATTENTIVE AND, [2] LEARNING TO PERCEIVE THE FLOW OF EXPERIENCE IN A NEW UNBIASED, WAY, TO EXPERIENCE THE REALITY AS IT “REALLY” IS. VIPASSANA [IN-SIGHT] MEDITATION IS A DIRECT AND GRADUAL CULTIVATION OF MINDFULNESS OR AWARENESS RESULTING IN A NEW WAY OF PERCEIVING SELF, OTHERS AND ALL PHENOMENA. MINDFULNESS IS ONE OF KEY COMPONENTS OF MEDITATION MINDFULNESS TRAINING IS NOT MEDITATION TRAINING

96 BUDDHIST MEDITATION A CONTINUUM OF PRACTICES AND INTENDED OUTCOMES GUIDED BY FOUR NOBLE TRUTHS AND EIGHTFOLD PATH The Four Noble Truths The truth of suffering The truth of origins of suffering The truth of cessation of suffering The truth of the Way to cessation of suffering The Eightfold Path Right Understanding Right Thought Right Speech Right Action Right Livelihood Right Effort Right Mindfulness Right Concentration “MEDITATION IS THE ABSENCE OF THE MEDITATOR”

97 MEDITATION TRAINING IN BUDDHISM MULTIPLE COMPLEMENTARY MODELS OF TRAINING The ‘Arhat’ [‘saint / ascetic’] model – Theravada The ‘Boddhisatva’ [compassion] model - Mahayana Finding the path – peak – returning to marketplace Realization + Actualization [‘insight + working through’] Zen - mindfulness training –> Kensho(s) – Dai Kensho Mindfulness training vs. Emptiness [formlessness] training Relative [consensual] vs. Absolute [quantum] Realities Most of the self / characterological changes occur in the advanced ‘actualization’ stage

98 Definitions: MEDITATION A CONTINUUM OF PRACTICES & INTENEDED OUTCOMES RESPITE / RELAXATION ------------------------------------------------- ENLIGHTENMENT MAIN ASPECTS / STAGES: 1.RELAXATION, REST, CALM 2.MINDFULNESS, CONCENTRATION, ABSORPTION 3.INSIGHT, KENSHO, SELF-TRANSCENDENCE 4.ENLIGHTENMENT, WISDOM, COMPASSION

99 SITTING MEDITATION BASIC ZAZEN INSTRUCTION PAUSE – STOP ALL HABITUAL ACTIVITY POSTURE - BE STILL BECOME AWARE OF YOUR BODY, BREATH, SENSES CLOSE YOUR EYES BREATHE NATURALLY THROUGH NOSE COUNT EACH BREATH FROM 1 TO 10 CONCENTRATE FOCUS ATTENTION ON JUST COUNTING 1-10 LET GO OF ALL THOUGHTS AND IMAGES RESISIT ANY AND ALL IMPULSES TO MOVE RESIST ANY AND ALL URGES TO ANALYZE, INTROSPECT, THINK, REMEMBER, PLAN, ANTICIPATE, WORRY, COMPARE, REMAIN IN THE PRESENT, DO NOT INVOKE PAST OR FUTURE LET GO OF THE OBSERVING MEDITATOR

100 EFFECTS OF MEDITATION Effective for treating a variety of stress-related, somatically based problems A preventive or rehabilitative strategy in treatment of addictions, hypertension, fears, phobias, asthma, insomnia, and stress Subjects using meditation change more than control groups in the direction of positive mental health, positive personality change, self-actualization, increased spontaneity self-regard and inner directedness and self-perceived increase in the capacity for intimate contact Influence on personality scores - on self-esteem and self-concept, depression, psychosomatic symptomatology, self-actualization, locus of control, and introversion / extroversion.

101 PERCEPTUAL AND COGNITIVE ABILITIES Perceptual ability Reaction time and perceptual motor skill Deautomatization Field independence Concentration and attention Memory and intelligence Rorschach shifts Regression in the service of the ego Empathy Creativity and self-actualization Hypnotic suggestibility

102 MECHANISMS OF ACTION Zen training is an agency of character change, a program designed to point the whole personality in the direction of increasing selflessness and enhanced awareness. (J. Austin, Zen Brain Reflections, 2008) The nervous system undergoes a series of fundamental changes. "In Zen you let your frontal lobes to rest" (Dainin Katagiri Roshi) Relaxation / physiological variables Cognitive / behavioral variables Psychodynamic variables Interpersonal variables Spiritual / transcendental variables

103 RELAXATION / PHYSIOLOGICAL VARIABLES Changes in the brain Changes in CNS & autonomic responses Reduction in stress / anxiety / dysphoric states Improved wellness “Flow” / “Zone” experience

104 COGNITIVE / BEHAVIORAL VARIABLES Retraining of habitual patterns of attention, perception, cognition, and response. “Deautomatization" of consciousness & behavior New competeing responses Impulse / reactivity management Freeing up of working memory capacity Creating / remembering / re-learning of pleasurable experience Behavioral stillness instead of enactment / acting out Self-regulation skills Radical acceptance & hope

105 PSYCHODYNAMIC VARIABLES Self-observation / observing ego Free associations Re-organization of defenses Return of the repressed material Curative regression to earlier traumatic experiences Re-experiencing of “primitive” mental states / affects and impulses Re-experience of pre-verbal aspects of loss, deprivation, abandonment, pain Positive corrective experiences Self-soothing and containment Maturation / transcendence of the self

106 MAIN DIMENSIONS OF PERSONALITY DISORDERS AND THEIR TREATMENT NEUROBEHAVIORAL Agentic Extraversion / PEM [Dopamine] Affiliation [Opioids, Peptides] Constraint (vs. Impulsivity) [Serotonin] Neuroticism / NEM [Norepinephrine] NEUROCOGNITIVE Affect Dysregulation Impulse Dysregulation Cognitive Dysregulation Behavior Dysregulation Persistence SELF Cooperation Self-Direction Identity Diffusion Fragmentation of Self Object Relations Mentalization / Reflective Function Attachment Pathology Self-Transcendence

107 I RELAXATION II MINDFULNESS III INSIGHT IV ENLIGHTENMENT AGENTIC EXTRAVERSION - PEM+++ AFFILIATION vs ANTAGONISM+++ CONSTRAINT vs. IMPULSIVITY--- / ++++++--- NEUROTICISM - NEM+++ AFFECT / IMPULSE DYSREGULATION+++ COGNITIVE DYSREGULATION+++ ?? BEHAVIOR DYSREGULATION--- / ++++++?? PERSISTENCE+ COOPERATION+++ SELF-DIRECTION+? IDENTITY DIFFUSION- / + FRAGMENTATION OF SELF- / +?--- OBJECT RELATIONS++++ MENTALIZATION+++ ATTACHMENT PROBLEMS+++ SELF-TRANSCENDENCE+++ EFFECTS OF BUDDHIST MEDITATION ON DISORDERS OF PERSONALITY

108 BUDDHIST MEDITATION AND PERSONALITY DISORDERS Different instruction and techniques used for different types of personality organization during meditation DSM CLUSTER “A” Mindfulness training used to increase capacity for being present and grounded in the sensory / consensual / interpersonal reality vs. Schizotypal, Paranoid, Schizoid ideation / cognition DSM CLUSTER “B” Impulsivity / anger management, behavioral / affective / cognitive containment / soothing; reduced reactivity, observing ego, self- regulation, insight, integration DSM CLUSTER “C” Anxiety / fear reduction, relaxation, self-soothing, PEM:NEM, capacity for sensory experience vs worry, obsessive ideation, phobias, disinhibition, being present in the here-now

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110 Mentalization Based Therapy Attachment categories Secure: "It is relatively easy for me to become emotionally close to others. I am comfortable depending on others and having others depend on me. I don't worry about being alone or having others not accept me. Dismissive-Avoidant "I am comfortable without close emotional relationships. It is very important to me to feel independent and self-sufficient, and I prefer not to depend on others or have others depend on me." Fearful-Avoidant "I am somewhat uncomfortable getting close to others. I want emotionally close relationships, but I find it difficult to trust others completely, or to depend on them. I sometimes worry that I will be hurt if I allow myself to become too close to others." Preoccupied "I want to be completely emotionally intimate with others, but I often find that others are reluctant to get as close as I would like. I am uncomfortable being without close relationships, but I sometimes worry that others don't value me as much as I value them."

111 Mentalization Based Therapy Attachment styles: CHILDREN: Bolwby-Ainsworth [Strange Situation paradigm] Secure, Anxious / Avoidant, Anxious / Resistant (Ambivalent), Disorganized / Disoriented Secure,Insecure,Unresolved, Fearful, Preoccupied ADULTS [Romantic Relationships] Secure, Preoccupied, Dismissive [ARS, Hazan, Shaver 2002] Secure, Preoccupied, Fearful, Dismissive [RQ, RSQ] Secure, Anxious-Preoccupied, Dismissive-Avoidant, Fearful-Avoidant PARENTS-CHILDREN: Autonomous Secure; Dismissive Avoidant; Preoccupied Ambivalent / Resistant; Unresolved Disorganized

112 Mentalization Based Therapy Brain abnormalities identified in borderline patients are consistent with the suggestion that a failure of representation of self-states is a key dysfunction in BPD. Anterior cingulate cortex - mentalizing the self & emotional states. Dorsal anterior cingulate -implicit self-representations (i.e., phenomenal self-awareness) Rostral anterior cingulate -explicit self-representations (i.e., reflection) Medial prefrontal cortex - a wide range of mentalization inferences, in both visual and verbal domains. Prefrontal cortex - representing the mental states of others. Mesial prefrontal cortex parieto-temporal junction temporal poles

113 Mentalization Based Therapy Prementalistic ways of representing subjectivity Psychic equivalence - there is no experience of “as if” and the internal experience becomes “real.” Pretend mode - thoughts and feelings are dissociated to the point of near meaninglessness. In these states patients can discuss experiences without contextualizing them in any kind of physical or material reality.

114 Buddhist Meditation and Disorders of Personality Heart Rate / Respiration - lower rates, relaxation via parasympathetic and limbic systems, possible release of GABA and opioids Cortisol - regular meditative practice can reduce blood cortisone and NE and ACTH levels. Reduction in "stress response" ["calming of the brain"] - regular meditation reduces firing in amygdala, hippocampus and hypothalamus, locus ceruleus, anterior pituitary gland. Changes in melatonin levels [sleep, immune system regulation] - direction needs to be studied Brain waves Delta 0.7-4 cps, Theta 4-7 cps, Alpha 8-12 cps, Beta 13-29 cps, Gamma 30-70 cps Transcortical synchronization of brain waves in specific parts of the brain and throughout many structures. Changes in the pre-frontal lobes and thalamus.


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