disorders of personality 2011. definitions: personality persona – “mask” in greek "...the...

DISORDERS OF

PERSONALITY

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]

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 individualPhenotype = 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]

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.

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

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 preservationACTIVITY-PASSIVITY – mode of adaptationSELF-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).

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

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

• 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

• 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

• 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

• 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).

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.

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).

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.

DSM-IV-TR

Categorical [Prototypal / Polythetic] model

• CLUSTER A Paranoid, Schizotypal, Schizoid

• CLUSTER BNarcissistic, Borderline, Histrionic, Antisocial

• CLUSTER CObsessive-Compulsive, Dependent, Avoidant

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

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)

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

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

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

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

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

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

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

DEPUE - LEZENWEGER’S MODEL

MULTIDIMENSIONAL , MULTIPLE NEUROTRANSMITTER-NEUROPEPTIDE MODEL

Basic dimensions:

• AGENTIC EXTRAVERSION : NEUROTICISM [Positive Emotionality PEM : NEM Negative Emotionality]

• CONSTRAINT

• AFFILIATION

• FEAR

AGENTIC EXTRAVERSION

Extraversion = Affiliation + Agency

Social dominance, positive emotional feelings, sociability, achievement, motor activityPositive 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

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

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,

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

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

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

Depue - Lezenweger’s Model

Hypothetical ranges for PDs on four dimensions

0-1000-100-10045-55 SCHIZOID

0-10020-10030-850-15 AVOIDANT

85-1000-10030-850-70 DEPENDENT

0-10015-10085-10010-40 COMPULSIVE

70-10030-1000-300-30 BORDERLINE

0-10015-4525-4560-80 NARCISSISTIC

0-200-250-2060-100 ANTISOCIAL

20-10025-1000-2085-100 HISTRIONIC

FEARAFFILIATIONCONSTRAINTPEM : NEM P. D.

--------------EMOTIONAL

DYSREGULATIONIMPULSIVITYDISSOCIAL (-) INHIBITIONDABB-BQ

NEUROTICISM / FEAR

CONSTRAINT(-) AFFILIATIONAGENTIC EXTRAVERSION

DEPUE-LEZENWEGER

REWARD DEPENDANCESELF-DIRECTIVENESS?

TRANSCENDENCEHARM AVOIDANCE

PERSISTENCE(-) COOPERATIVENE

NOVELTY SEEKING

TCICLONIGER

COGNITIVE / PERCEPTUALDISTORTION

AFFECTIVE INSTABILITY

AGGRESSIVITY / IMPULSIVITY(-) INHIBITIONSIEVER / DAVIS

---------------NEUROTICISMPSYCHOTICISMEXTRAVERSIONEYSENCK

PSYCHOTICISMNEGATIVE EMOTIONALITY

CONSTRAINTAGGRESSIVITYPOSTIVE EMOTIONALITY

-------------NEGATIVE AFFECTIVITY

CONSTRAINT----------POSITIVE AFFECTIVITY

OPENESSNEUROTICISMCONSCIENTIOUSNESS

ANTAGONISMEXTRAVERSIONFFM

VIVIIIIII

CONSTRAINT / FEAR

EXTRAVERSION_

AFFILIATION

OBSESSIVE COMPULSIVE

AVOIDANT

DEPENDENTHISTRIONIC

NARCISSISTIC

PARANOID

SCHIZOID

BORDERLINE

ANTISOCIAL

HIGHLOW

SCHIZOTYPAL

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

DEVELOPMENTAL FRAMEWORK

CAPACITIES OF THE HUMAN MIND -a developmental framework

Attachment mediates:• human survival • ablity to live in groups

Surface vs. depth understanding / diagnosis

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

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

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

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 consequencesbasic 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

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

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

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 affectanger [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 relationshipsidealization vs devaluation [including the therapist]in DBT- interpersonal dysregulation is believed to be a result of emotional dysregulation

• SELF-DYSREGULATIONunstable self image / identity or fragmentation and inability to modulate it vs integrate]

• BEHAVIORAL DYSREGULATIONimpulsivity, 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

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

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]

• 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 CONDITIONINGTHERAPIST 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

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

INTROVERTED EXTRAVERTED

OBSESSIVE COMPULSIVE

NEUROTICLEVEL

HIGH BORDERLINE

LOW BORDERLINE

PSYCHOTICLEVEL

DEPRESSIVE MASOCHISTIC

HYSTERICAL

AVOIDANT

DEPENDENT

HISTRIONIC

NARCISSISTICSADO-MASOCHISTIC

PARANOID

SCHIZOTYPAL

HYPOCHONDRIACAL SCHIZOID BORDERLINE

HYPOMANIC

ANTISOCIAL

MALIGNANTNARCISSISTIC

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

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]

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

• 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

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

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.

•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 theindividual with a well-developed capacity to distinguish inner from outer reality, pretend from‘real’ modes of functioning, intra-personal mental and emotional processes from interpersonalcommunications.

•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.

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).

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

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.

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:

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

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

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.

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.•

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.

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

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.

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

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.

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.

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

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,

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?

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

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

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 / CIRCUITREPRESENTATION OF SELF AND OTHERSOBJECT RELATIONS SCHEMA / WORKING MODELS.

• COMMON FACTORS APPROACH: RELATIONSHIP / SUPPORTIVE FACTORS + TECHNICAL FACTORS [ NEW LEARNING]

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,

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 / INTIMACY3. EMPATHIC / SUPPORTIVE vs CONFRONTATIVE --- INTERPRETATIVE CONTINUUM

[3] PDs ARE COMPLEX BIOPSYCHOSOCIAL SYNDROMES

1. BIOLOGICAL / GENETIC FACTORS – SEE BEFORE2. 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

TREATMENT – MAIN PRINCIPLES [3]

[4] THE ROLE OF PSYCHOSOCIAL ADVERSITY / TRAUMA IN THE FORMATION OF PDs

TRAUMATIC EXPERIENCES NEED TO BE ADDRESSED / RESOLVED FIRST

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

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

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

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

GENERAL THERAPEUTIC STRATEGIES [2]

[2] ESTABLISH AND MAINTAIN A CONSISTENT TREATMENT PROCESS

• ESTABLISH A CONSISTENT FRAME• TREATMENT CONTRACT• THERAPEUTIC STANCE• TREATMENT CONTEXT• MAINTAIN CONSISTENCY

[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

[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

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

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

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 YOGAYama, 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

• 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

• ENGLISHMEDITATION => 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

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

BUDDHIST MEDITATION

A CONTINUUM OF PRACTICES AND INTENDED OUTCOMESGUIDED BY FOUR NOBLE TRUTHS AND EIGHTFOLD PATH

The Four Noble Truths

The truth of sufferingThe truth of origins of suffering

The truth of cessation of sufferingThe truth of the Way to cessation of suffering

The Eightfold Path

Right Understanding Right Thought Right SpeechRight Action Right Livelihood

Right EffortRight Mindfulness

Right Concentration

“MEDITATION IS THE ABSENCE OF THE MEDITATOR”

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

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

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

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.

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

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

RELAXATION / PHYSIOLOGICAL VARIABLES

• Changes in the brain

• Changes in CNS & autonomic responses

• Reduction in stress / anxiety / dysphoric states

• Improved wellness

• “Flow” / “Zone” experience

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

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

IRELAXATION

IIMINDFULNESS

IIIINSIGHT

IVENLIGHTENMENT

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

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

Attachment categoriesSecure: "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."

Attachment styles: CHILDREN: Bolwby-Ainsworth [Strange Situation paradigm] Secure, Anxious / Avoidant, Anxious / Resistant (Ambivalent), Disorganized / DisorientedSecure,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

Brain abnormalities identified in borderline patients are consistent withthe suggestion that a failure of representation of self-states is a key dysfunction in

•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

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.

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.

disorders of personality 2011. definitions: personality persona – “mask” in greek "...the...

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