Presentation on theme: "Using Diagnoses to Improve Treatment Robert M. Gordon, Ph. D"— Presentation transcript:
1 Using Diagnoses to Improve Treatment Robert M. Gordon, Ph. D Using Diagnoses to Improve Treatment Robert M. Gordon, Ph.D. ABPP J&K Seminar 20131. How does diagnoses (DSM, ICD, PDM) affect treatment?2. How to tailor treatment to the diagnoses of personality organization and personality patterns.
2 My Eclectic Background Undergrad focus on science and epistemologyTemple’s psychology department heavily influenced by Wolpe and Lazarus. It was anti-psychoanalytic.I studied with Rosnow and Lana the artifacts and assumptions in research (applied epistemology).After my Ph.D., I studied with Albert Ellis (Rational Emotive Therapy), Salvador Manuchin, Jim Framo, and Peggy Papp (family therapy).For a while my primary identification was, “family therapist.” (AFTA, AAMFT Supervisor)Eventually, I became convinced that projections and transferences were the main issues in couples work and went on to study object relations (institute training and my psychoanalysis).
3 Paradigm Shift to Evidence Based Practice PPA Workshop Treating Neurotic and Borderline Level Personality DisordersParadigm Shift to Evidence Based Practice
4 PPA Workshop 6.20.2009 Treating Neurotic and Borderline Level Personality Disorders An Integrative Theoretical Formulation Precedes an Integrative TreatmentNeed for the best theoretical formulation that integrates research about the mind, brain, affects, cognitions, behaviors, temperament, and their interactions in an interpersonal context.Need for technical eclecticism based on the needs of the patient and EBP.
5 The New Three Core Competencies in Psychiatry Supportive Therapy (Rogerian)Cognitive- Behavioral Therapy (CBT)Long-Term Psychodynamic Psychotherapy
6 PPA Workshop 6.20.2009 Treating Neurotic and Borderline Level Personality Disorders Our Brains Guided Us for Millions of Years without Consciousness or Rationality
7 PPA Workshop 6.20.2009 Treating Neurotic and Borderline Level Personality Disorders Hypothalamic Sites that Generate Instinctual Behavioral and Affective States in Mammals Panksepp (1982)
8 PPA Workshop 6.20.2009 Treating Neurotic and Borderline Level Personality Disorders The Affective Parts of the Mammalian Brain are largely Non-Cognitive and InstinctualPeriaqueductal gray (PAG; also called the "central gray") is the gray matter located around the cerebral aqueduct within the midbrain. It plays a role in the descending modulation of pain and in defensive behaviour.
9 PPA Workshop 6.20.2009 Treating Neurotic and Borderline Level Personality Disorders Superego, Ego and Id was a First Step in Understanding a Brain in ConflictThe Amygdalae (A) are involved in the processing of emotions.The Ventromedial prefrontal cortex (VMPC) moderates emotional reactions and sends signals to the Striatum (S) with input from past experiences.If the associations are negative, the VMPC signals are inhibitory. The Striatum translates signals from the Amygdala and VMPC into body action.SVMPC Aventromedial prefrontal cortex: the rear part of the prefrontal cortexstriatum: includes the caudate nucleus and the putamen; part of the basal ganglia. Implicated in habit learning.
10 Ventromedial Prefrontal Cortex and Neurosis PPA Workshop Treating Neurotic and Borderline Level Personality DisordersVentromedial Prefrontal Cortex and NeurosisStudies with PTSD support the idea that the ventromedial prefrontal cortex is an important component for reactivating past emotional associations and events, mediating pathogenesis of PTSD.ventromedial prefrontal cortex: the rear part of the prefrontal cortex
11 PPA Workshop 6.20.2009 Treating Neurotic and Borderline Level Personality Disorders Brains of Borderlines Have Less Grey Matter in Anterior Cingulate CortexPatients with borderline personality disorder had significantly lower density of grey matter (the brain's working tissue) in the anterior cingulate cortex, an area (yellow right) that regulates the brain's fear hub (amygdala-yellow left).MRI scan data shows the difference between patients and controls.The anterior cingulate is a defined area of the cerebral cortex including parts of both the cingulate gyrus and the frontal lobe.Minzenberg MJ, Fan J, New AS, Tang CY, Siever LJ. Frontolimbic structural changes in borderline personality disorder. J Psychiatr Res Jul;42(9): Epub 2007 Sep 7. PMID:Minzenberg MJ, Fan J, New AS, Tang CY, Siever LJ. Fronto-limbic dysfunction in response to facial emotion in borderline personality disorder: an event-related fMRI study. Psychiatry Res Aug 15;155(3): Epub 2007 Jul 2. PMID:
12 Brains of Borderlines Have More Grey Matter in Amygdala PPA Workshop Treating Neurotic and Borderline Level Personality DisordersBrains of Borderlines Have More Grey Matter in AmygdalaPatients with borderline personality disorder had significantly higher density of grey matter in the brain's fear hub, the amygdala (red areas). MRI scan data shows where patients and controls differed.
13 Damasio, et al., 2002 Panksepp, J. (2003). Science, Oct 10th. PPA Workshop Treating Neurotic and Borderline Level Personality DisordersEmotions and attachment drives in mammals are similar and evolved for functional reasons. They may be affected by thoughts, but they are not created by them.Damasio, et al., 2002PAG=Periaqueductal gray;AC = anterior commisure for sure.BN likely basal nucleusPanksepp, J. (2003).Science, Oct 10th.Herman & Panksepp, 1979
14 PPA Workshop 6.20.2009 Treating Neurotic and Borderline Level Personality Disorders Attachment Security in Infancy and Early Adulthood: A Twenty-Year Longitudinal Study. Walters, E. Merrick., S.; Treboux, D.; Crowell, J. and Albersheim, L. (2000), Child Development.Researchers looked at relationship patterns in 50 young adults who were studied 20 years earlier as infants.Overall, 72% of the adults received the same secure verses insecure attachment classification they had in infancy.
15 Experimental Test of Unconscious Transference PPA Workshop Treating Neurotic and Borderline Level Personality DisordersExperimental Test of Unconscious TransferenceStudy: subjects are subliminally shown aggressive (A) or positive (B) stimuliand then rate a neutral stimulus (C)Subjects shown panel A subsequently rated the boy in panel C more negatively (Eagle, 1959)
16 Treat the Whole PersonPPA Workshop Treating Neurotic and Borderline Level Personality DisordersBlatt, (2006), Norcross (2002), Wampold (2001) have concluded that the nature of the psychotherapeutic relationship, reflecting interconnected aspects of mind and brain operating together in an interpersonal context, predicts outcome more robustly than any specific treatment approach per se.Westen, Novotny, and Thompson-Brenner (2004) have presented evidence that treatments that focus on isolated symptoms or behaviors (rather than personality, emotional, and interpersonal patterns ) are not effective in sustaining even narrowly defined changes.
17 Value of Insight into the Self PPA Workshop Treating Neurotic and Borderline Level Personality DisordersValue of Insight into the Self800 Psychologists ranked a list of 38 of the most beneficial things they got from their own psychotherapy.They listed first, “Self-understanding.”“Symptom relief” was halfway down the listIncluded in the survey were psychologists from all theoretical orientations (Behaviorists, Cognitive- Behaviorists, Psychoanalytic, etc.).Pope, K. T., B.G. (1994). Therapists as patients: A national survey of psychologists' experiences, problems, and beliefs. Professional Psychology: Research & Practice, 25(3),Pope, K. T., B.G. (1994). Therapists as patients: A national survey of psychologists' experiences, problems, and beliefs. Professional Psychology: Research & Practice, 25(3),Dattilio, F. M. (2003). To thine own self be true: Comment. Behavior Therapist, 26(5), Dattillo felt that CBT therapists became desensitized to CBT so they went to psychodynamic therapists.
18 LTPP at least 1 year (an average of 151 sessions). PPA Workshop Treating Neurotic and Borderline Level Personality DisordersEffectiveness of Long-term Psychodynamic Psychotherapy A Meta-analysis Leichsenring and Rabung (2008) JAMA, 3000,13,23 LTPP studies (11 RCT efficacy and 12 effectiveness) total of 1053 patients with personality disorders, and multiple and complex problems.LTPP at least 1 year (an average of 151 sessions).Results LTPP better than 96% of those in short term therapies (CBT, DBT, SFT, CAT, FT, STPP, etc.) with changes in not only symptoms relief but with increases in mental capacities.Leichsenring, F., & Rabung, S. (2008). Effectiveness of long-term psychodynamic psychotherapy: A meta-analysis. JAMA: Journal of the American Medical Association, 300(13),
19 Importance of Transference and Attachment with BPD PPA Workshop Treating Neurotic and Borderline Level Personality DisordersImportance of Transference and Attachment with BPDClarkin, et al. (2007): 90 BPD randomly assigned to transference-focused psychotherapy (TFT), dialectical behavior therapy (DBT), or supportive therapy (ST).Patients in all 3 treatments showed significant positive change in depression, anxiety, global functioning, and social adjustment.Both transference-focused psychotherapy and dialectical behavior therapy were significantly associated with improvement in suicidality.Only transference-focused psychotherapy and supportive treatment were associated with improvement in anger.Transference- focused psychotherapy and supportive treatment were each associated with improvement in impulsivity.Only transference-focused psychotherapy was significantly predictive of change in irritability and verbal and direct assault.Clarkin, J. F., Levy, K. N., Lenzenweger, M. F., & Kernberg, O. F. (2007). Evaluating three treatments for borderline personality disorder: A multiwave study. American Journal of Psychiatry, 164(6),The authors examined three year-long outpatient treatments for borderline personality disorder: dialectical behavior therapy, transference-focused psychotherapy, and a dynamic supportive treatment. Ninety patients who were diagnosed with borderline personality disorder were randomly assigned to transference-focused psychotherapy, dialectical behavior therapy, or supportive treatment and received medication when indicated. Prior to treatment and at 4-month intervals during a 1-year period, blind raters assessed the domains of suicidal behavior, aggression, impulsivity, anxiety, depression, and social adjustment in a multiwave study design. Individual growth curve analysis revealed that patients in all three treatment groups showed significant positive change in depression, anxiety, global functioning, and social adjustment across 1 year of treatment. Both transference-focused psychotherapy and dialectical behavior therapy were significantly associated with improvement in suicidality. Only transference-focused psychotherapy and supportive treatment were associated with improvement in anger. Transference- focused psychotherapy and supportive treatment were each associated with improvement in facets of impulsivity. Only transference-focused psychotherapy was significantly predictive of change in irritability and verbal and direct assault. Patients with borderline personality disorder respond to structured treatments in an outpatient setting with change in multiple domains of outcome. A structured dynamic treatment, transference-focused psychotherapy was associated with change in multiple constructs across six domains; dialectical behavior therapy and supportive treatment were associated with fewer changes. Future research is needed to examine the specific mechanisms of change in these treatments beyond common structures.
20 PPA Workshop 6.20.2009 Treating Neurotic and Borderline Level Personality Disorders Over-all ResearchEvidence Based short-term symptom focused treatments are all equally effective.Long-term psychodynamic therapies that focus on temperament, conflicts, affects, cognitions, behaviors, interpersonal context, child development, conscious and unconscious levels are better than symptom focused treatments in treating personality disorders.
21 PPA Workshop 6.20.2009 Treating Neurotic and Borderline Level Personality Disorders Integrative Psychotherapeutic Interventions Going From Supportive, CBT and PsychodynamicPersonal Qualities of the TherapistMaintaining the Therapeutic FrameReassuranceListeningBehavioral Mastery: Self-SoothingCognitive LearningClarificationsInterpretations of mental life that affects subjective well-being and relationships
22 Treatment of the Borderline Level Personality Disorder PPA Workshop Treating Neurotic and Borderline Level Personality DisordersTreatment of the Borderline Level Personality DisorderBehavioral Mastery: desensitization and self-soothingCognitive Learning: how to better understand thoughts, feelings, and behaviorsClarifications and Confrontations: of the patient’s confusions, distortions and consequences of judgment and impulsesInterpretations: focus on here and now defenses, transferences, enactments, and mentalization
23 Treatment of the Neurotic Level Personality Disorder PPA Workshop Treating Neurotic and Borderline Level Personality DisordersTreatment of the Neurotic Level Personality DisorderReconstructions: patients may benefit from a coherent, insightful narrative of their psychological history. Despite problems with recall and subjectivity, traumatic events can be recalled, mastered and integrated into a more cohesive identity.Interpretations: insight into unconscious resistances, defenses, transferences and enactments.
24 Neurotic Borderline Psychotic Identity +integrated - diffused - Kernberg’s Differentiation of Personality Organization That Preceded the PDMNeurotic Borderline PsychoticIdentity integrated diffusedIntegrationDefensive higher primitiveOperationsRealityTesting
30 Anaclitic vs Introjective (according to S.Blatt) Anaclitic: Borderline, Histrionic, Dependent, Avoidant, Depressive anaclitic.Introjective: Schizoid, Paranoid, Antisocial, Narcissistic, Obsessive, Depressive introjective.Reference tools: Object Relations Inventory (ORI; Blatt et al., 2006)
31 Personality Disorders P Axis Temperamental,Thematic,Affective,Cognitive, andDefense patterns
32 P101. Schizoid Personality Disorders Contributing constitutional-maturational patterns: Highly sensitive,shy, easily overstimulatedCentral tension/preoccupation: Fear of closeness/longing for closenessCentral affects: General emotional pain when overstimulated, affects so powerful they feel they must suppress themCharacteristic pathogenic belief about self: Dependency and love are dangerousCharacteristic pathogenic belief about others: The social world is impinging, dangerously engulfingCentral ways of defending: Withdrawal, both physically and into fantasy and idiosyncratic preoccupations
33 P102. Paranoid Personality Disorders Contributing constitutional-maturational patterns: Possibly irritable/aggressiveCentral tension/preoccupation: Attacking/being attacked by humiliating othersCentral affects: Fear, rage, shame, contemptCharacteristic pathogenic belief about self: Hatred, aggression and dependency are dangerousCharacteristic pathogenic belief about others: The world is full of potential attackers and usersCentral ways of defending: Projection, projective identification, denial, reaction formation
34 P103. Psychopathic (Antisocial) Personality Disorder P103 P103. Psychopathic (Antisocial) Personality Disorder P103.1 Passive/Parasitic: “con artist” P103.2 Aggressive: explosive, predatory, often violentContributing constitutional-maturational patterns: aggressiveness, high threshold for emotional stimulationCentral tension/preoccupation: Manipulating/being manipulatedCentral affects: Rage, envyCharacteristic pathogenic belief about self: I can make anything happenCharacteristic pathogenic belief about others: Everyone is selfish, manipulative, dishonestCentral ways of defending: Reaching for omnipotent control
35 Contributing constitutional-maturational patterns: No clear data P104. Narcissistic Personality Disorders P104.1 Arrogant/Entitled: devalues, vain, commanding P104.2 Depressed/Depleted: idealizing, envious, easily hurtContributing constitutional-maturational patterns: No clear dataCentral tension/preoccupation: Inflation/deflation of self-esteemCentral affects: Shame, contempt, envyCharacteristic pathogenic belief about self: I need to feel okayCharacteristic pathogenic belief about others: Others enjoy riches, beauty, power, and fame; the more I have of those, the better I will feelCentral ways of defending: Idealization/devaluation
36 Narcissistic PD: Narcissistic Injury The Doberman threw himself out the second-story window after he realized the family had indeed named him “Binky.”
37 Contributing constitutional-maturational patterns: Unknown P105. Sadistic and Sadomasochistic Personality Disorders P105.1 Intermediate Manifestation: Sadomasochistic Personality Disorders: alternate between attacking and feeling insultedContributing constitutional-maturational patterns: UnknownCentral tension/preoccupation: Suffering indignity/inflicting such sufferingCentral affects: Hatred, contempt, pleasure (sadistic glee)Characteristic pathogenic belief about self: I am entitled to hurt and humiliate othersCharacteristic pathogenic belief about others: Others exist as objects for my dominationCentral ways of defending: Detachment, omnipotent control, reversal, enactment
39 Contributing constitutional-maturational patterns: None known P106. Masochistic (Self-Defeating) Personality Disorders P106.1 Moral Masochistic: self-esteem depends on suffering P106.2 Relational Masochistic: suffer for sake of relationshipContributing constitutional-maturational patterns: None knownCentral tension/preoccupation: Suffering/losing relationship or self-esteemCentral affects: Sadness, anger, guiltCharacteristic pathogenic belief about self: By manifestly suffering, I can demonstrate my moral superiority and/or maintain my attachmentsCharacteristic pathogenic belief about others: People pay attention only when one is in troubleCentral ways of defending: Introjection, introjective identification, turning against the self, moralizing
40 Masochistic Personality Disorder “Penny for your thoughts, Arnold!”
41 P107. Depressive Personality Disorders P107 P107. Depressive Personality Disorders P107.1 Introjective: self-critical, self-worth P107.2 Anaclitic: concern with attachment issuesContributing constitutional-maturational patterns: Possible genetic predispositionCentral tension/preoccupation: Goodness/badness or aloneness/relatedness of selfCentral affects: Sadness, guilt, shameCharacteristic pathogenic belief about self: There is something essentially bad or incomplete about meCharacteristic pathogenic belief about others: People who really get to know me will reject meCentral ways of defending: Introjection, reversal, idealization of others, devaluation of self
42 Depressive Personality Disorder Lodge owner Harold Shuffle saw only the negative side of things.
43 P107.3 Converse Manifestation: Hypomanic Personality Disorder Contributing constitutional-maturational patterns: Possibly high energyCentral tension/preoccupation: Overriding grief/succumbing to griefCentral affects: Elation, rage, unconscious sadness and griefCharacteristic pathogenic belief about self: If I stop running and get close to someone, I’ll be traumatically abandoned, so I’ll leave firstCharacteristic pathogenic belief about others: Others can be charmed into not seeing the qualities that make people inevitably reject meCentral ways of defending: Denial, idealization of self, devaluation of others
44 P108. Somatizing Personality Disorders Contributing constitutional-maturational patterns: Possible physical fragility, early sickliness, early abuseCentral tension/preoccupation: Integrity/fragmentation of bodily selfCentral affects: alexithymia, inferred rage, distressCharacteristic pathogenic belief about self: I am fragile, vulnerable, in danger of dyingCharacteristic pathogenic belief about others: Others are powerful, healthy, and indifferentCentral ways of defending: Somatization, regression
45 Somatizing Personality Disorder “My brother, Tilford, had trouble with hemorrhoids and he never did anything like this!”
46 P109. Dependent Personality Disorders Contributing constitutional-maturational patterns: Possibleplacidity, sociophilaCentral tension/preoccupation: Keeping/lossing relationshipsCentral affects: Pleasure when securely attached; sadness and fear when aloneCharacteristic pathogenic belief about self: I am inadequate, needy, impotentCharacteristic pathogenic belief about others: Others are powerful and I need their careCentral ways of defending: Regression, reversal, avoidanceSubtypes: Passive-Aggressive, Counterdependent
47 Dependent PD: Others are powerful and I need their care “You’re gonna spoil that dog, Annie!”
48 P109. Dependent Personality Disorders P109 P109. Dependent Personality Disorders P109.1 Passive-Aggressive Versions of Dependent Personality Disorders Contributing constitutional-maturational patterns: Possibly irritable, aggressiveCentral tension/preoccupation: Tolerating mistreatment/getting revengeCentral affects: Anger, resentment, pleasure in hostile enactmentsCharacteristic pathogenic belief about self: I am inadequate, needy, impotentCharacteristic pathogenic belief about others: Others are powerful and I need their careCentral ways of defending: Regression, reversal, avoidance
49 Passive-Aggressive Personality Disorder “It’s almost like they do it on purpose, isn’t it, Fred?!”
50 P109. Dependent Personality Disorders P109 P109. Dependent Personality Disorders P109.2 Converse Manifestation: Counterdependent Personality DisorderContributing constitutional-maturational patterns: Possibly more aggressive than the overtly dependent typeCentral tension/preoccupation: Demonstrating lack of or shameful dependenceCentral affects: Contempt, denial of “weaker” emotionsCharacteristic pathogenic belief about self: I don’t need anyoneCharacteristic pathogenic belief about others: Others depend on me and require me to be “strong”Central ways of defending: Denial, reversal, enactment
51 P110. Phobic (Avoidant) Personality Disorders Contributing constitutional-maturational patterns: Possible anxious or timid dispositionCentral tension/preoccupation: Safety/danger relative to specific objectsCentral affects: FearCharacteristic pathogenic belief about self: I am safe if I avoid certain specific dangersCharacteristic pathogenic belief about others: More powerful people can magically keep me safeCentral ways of defending: Symbolization, displacement, projection, rationalization, avoidanceSubtypes: Counterphobic
52 P110.1 Converse Manifestation of Phobic: Counterphobic Personality Disorders Contributing constitutional-maturational patterns: UnknownCentral tension/preoccupation: Safety/dangerCentral affects: Contempt, denial of fearCharacteristic pathogenic belief about self: I can face anything without fearCharacteristic pathogenic belief about others: Others frighten easily and admire my braveryCentral ways of defending: Denial, reaction formation, projection
53 P111. Anxious Personality Disorders Contributing constitutional-maturational patterns: Anxious or timid temperamentCentral tension/preoccupation: Safety/dangerCentral affects: FearCharacteristic pathogenic belief about self: I am in constant danger from forces unknownCharacteristic pathogenic belief about others: Others are sources of either danger or protectionCentral ways of defending: Failure of defenses against anxiety, surface anxiety may mask unconscious deeper anxiety
54 P112. Obsessive-Compulsive Personality Disorders P112 P112. Obsessive-Compulsive Personality Disorders P112.1 Obsessive: Self-esteem depends on thinking,ruminative P112.2 Compulsive: Self-esteem depends on doing, meticulousContributing constitutional-maturational patterns: Possible irritability, orderlinessCentral tension/preoccupation: Submission to/rebellion against controlling authorityCentral affects: Anger, guilt, shame, fearCharacteristic pathogenic belief about self: My aggression is dangerous and must be controlledCharacteristic pathogenic belief about others: Others try to exert control, which I must resistCentral ways of defending: Isolation of affect, reaction formation, intellectualization, moralizing, undoing
55 Obsessive-Compulsive PD: Compulsive type Once again Elliot Zambini’s tidiness ruins the act.
56 Central tension/preoccupation: Power and sexuality/other gender P113. Hysterical (Histrionic) Personality Disorders P113.1 Inhibited: reserved, naiveté, somatization P113.2 Demonstrative or Flamboyant: seductive, dramaticContributing constitutional-maturational patterns: Possibly sensitivity, sociophilaCentral tension/preoccupation: Power and sexuality/other genderCentral affects: Fear, shame, guilt (over competition)Characteristic pathogenic belief about self: My gender makes me weak, castrated, vulnerableCharacteristic pathogenic belief about others: People of my own gender are of little value, people of the other gender are powerful, exciting, potentially exploitive and damagingCentral ways of defending: Repression, regression, conversion, sexualization, acting out
57 P114. Dissociative Personality Disorders (Dissociative Identity Disorder/Multiple Personality Disorder)Contributing constitutional-maturational patterns: Constitutional capacity for self-hypnosis; severe early and repeated physical and/or sexual traumaCentral tension/preoccupation: Acknowledging trauma/disavowing traumaCentral affects: Fear, rageCharacteristic pathogenic belief about self: I am small, weak, and vulnerable to recurring traumaCharacteristic pathogenic belief about others: Others are perpetrators, exploiters, or rescuersCentral ways of defending: Dissociation
58 P115. Mixed/OtherFor individuals with combinations of personality types or with particular patterns or themes
59 Implications for Treatment Depressive Personality Disorder (Most Common type in Clinical Situations) P107.1 Introjective: self-critical, preoccupied with self-worth, guilt P107.2 Anaclitic: concerned with attachment issues, relatedness, trust, inadequacy (May combine with dependent or narcissistic personality disorder)
60 Treatment for Depressive P.D. The Mood disorder responds to medication, but not the personality disorder, which requires long- term intensive treatment.The introjective type tends to respond better to interpretations and insight.The anaclitic type tends to respond better to the actual therapeutic relationship. May respond well to short term interventions.
61 P107.3 Converse Manifestation: Hypomanic Personality Disorder Relatively stable state of inflated mood, high energyLittle guiltOverly positive view of selfSuperficial relationships due to fear of being attachedHighly resistant to therapyThe mood disorder responds better to pharmacological interventions, but medication does not help the personality disorder.
62 Treatment Implications: P107 Treatment Implications: P107.3 Converse Manifestation: Hypomanic Personality DisorderThe hypomanic type often flees from commitment and therefore does not stay long enough in treatment. The PDM suggests emphasizing that the commitment to the treatment is important to improvement.People with hypomanic personality disorders are most likely to be at the borderline level favoring defenses such as denial and the idealization of self and the devaluation others, as compared to those with depressive personalities who favor defensives such as repression, and the devaluation of self and the idealization of others.
63 Personality Structure and Treatment McWilliams points out that for many neurotic level people, the best time to make interpretations is when the patient is a state of emotional arousal, so that the patient is less likely to intellectualize the affect.With borderline clients, who require a supportive approach, the opposite consideration applies, because when they are very upset, it is hard for them to take anything in.
64 Take Home Message Neurotic Level Personality Disorders PPA Workshop Treating Neurotic and Borderline Level Personality DisordersTake Home MessageNeurotic Level Personality Disordersfocus more on using insight into past traumas that need to be worked through.Borderline Level Personality Disorders focus more on using here and now interventions to help with reality testing, better self control and self soothing.
65 Take Home MessageBe technically eclectic mixing Supportive, CBT and Psychodynamic according to the needs of the patient (not according to your biases).Use a psychodynamic formulation so you will know what interventions are likely be most effective, and to communicate that you understand your patient at all levels of existence (not just seeing symptoms).
66 Consider Instruments Such as the PDC To guide your diagnostic and case formulationTo keep in your chartTo assess progress
67 Take Home Message: Use the ICD with the PDM Consider the over-all level of personality organizationConsider the personality patterns or disordersConsider the mental capacitiesConsider the subjective experience of the symptoms and use the ICD codesYou will find that your greater empathy will be felt by your patient, and this can greatly improve any treatment.