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Personality disorders (Antisocial & Borderline)

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Personality disorders
DSM – IV. General Criteria
An enduring pattern of inner experience and behaviour the deviates
marked...

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Antisocial Personality Disorder
DSM IV. Criteria (APA, 2000)
There is a pervasive pattern of disregard for and violation o...

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(DSM IV. Continue):
 The individual is at least age 18 years.
 There is evidence of Conduct Disorder with onset before a...

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Personality disorders (Antisocial & Borderline)

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exam preparation slide that includes DSM IV and V. diagnostic criterias, therapeutic interventions and recent research findings

exam preparation slide that includes DSM IV and V. diagnostic criterias, therapeutic interventions and recent research findings

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Personality disorders (Antisocial & Borderline)

  1. 1. Personality disorders DSM – IV. General Criteria An enduring pattern of inner experience and behaviour the deviates markedly from the expectations of the individual's culture. This pattern is manifested in two (or more) of the following areas:  Cognition (i.e., ways of perceiving and interpreting self, other people and events)  Affectivity (i.e., the range, intensity, liability, and appropriateness of emotional response)  Interpersonal functioning  Impulse control  The enduring pattern is inflexible and pervasive across a broad range of personal and social situations.  The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning.  The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood.  The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder.  The enduring pattern is not due to the direct physiological effects of a substance (e.g., a drug abuse, a medication) or a general medical condition (e.g., head trauma). DSM-V. General Criteria  The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose a personality disorder, the following criteria must be met:  Significant impairments in self (identity or self-direction) and interpersonal (empathy or intimacy) functioning.  One or more pathological personality trait domains or trait facets.  The impairments in personality functioning and the individual‟s personality trait expression are relatively stable across time and consistent across situations.  The impairments in personality functioning and the individual‟s personality trait expression are not better understood as normative for the individual‟s developmental stage or socio-cultural environment.  The impairments in personality functioning and the individual‟s personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma).
  2. 2. Antisocial Personality Disorder DSM IV. Criteria (APA, 2000) There is a pervasive pattern of disregard for and violation of the rights of others occurring since age 15 years, as indicated by three (or more) of the following: having hurt, mistreated, or stolen from another.  Failure to conform to social norms with respect to lawful behaviours as indicated by repeatedly performing acts that are grounds for arrest.  Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure.  Impulsivity or failure to plan ahead.  Irritability and aggressiveness, as indicated by repeated physical fights or assaults.  Reckless disregard for safety of self or others.  Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behaviour or honour financial obligations.  Lack of remorse, as indicated by being indifferent to or rationalizing. DSM V. Criteria (APA, 2011) The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose antisocial personality disorder, the following criteria must be met: Significant impairments in personality functioning manifest by:  Impairments in self functioning (a or b):  Identity: Ego-centrism; self-esteem derived from personal gain, power, or pleasure.  Self-direction: Goal-setting based on personal gratification; absence of prosocial internal standards associated with failure to conform to lawful or culturally normative ethical behaviour. AND  Impairments in interpersonal functioning (a or b):  Empathy: Lack of concern for feelings, needs, or suffering of others; lack of remorse after hurting or mistreating another.  Intimacy: Incapacity for mutually intimate relationships, as exploitation is a primary means of relating to others, including by deceit and coercion; use of dominance or intimidation to control others.
  3. 3. (DSM IV. Continue):  The individual is at least age 18 years.  There is evidence of Conduct Disorder with onset before age 15 years.  The occurrence of antisocial behaviour is not exclusively during the course of Schizophrenia or a Manic Episode. (DSM V. Continue):  counter boredom; lack of concern for one's limitations and denial of the reality of personal danger  C. The impairments in personality functioning and the individual's personality trait expression are relatively stable across time and consistent across situations.  D. The impairments in personality functioning and the individual‟s personality trait expression are not better understood as normative for the individual‟s developmental stage or socio-cultural environment.  E. The impairments in personality functioning and the individual's personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma).  F. The individual is at least age 18 years. (DSM V. Continue) Pathological personality traits in the following domains: Antagonism, characterized by:  Manipulativeness: Frequent use of subterfuge to influence or control others; use of seduction, charm, glibness, or ingratiation to achieve one„s ends.  Deceitfulness: Dishonesty and fraudulence; misrepresentation of self; embellishment or fabrication when relating events.  Callousness: Lack of concern for feelings or problems of others; lack of guilt or remorse about the negative or harmful effects of one„s actions on others; aggression; sadism.  Hostility: Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults; mean, nasty, or vengeful behavior. Disinhibition, characterized by:  Irresponsibility: Disregard for – and failure to honour – financial and other obligations or commitments; lack of respect for – and lack of follow through on – agreements and promises.  Impulsivity: Acting on the spur of the moment in response to immediate stimuli; acting on a momentary basis without a plan or consideration of outcomes; difficulty establishing and following plans.  Risk taking: Engagement in dangerous, risky, and potentially self- damaging activities, unnecessarily and without regard for consequences; boredom proneness and thoughtless initiation of activities to
  4. 4. Borderline Personality Disorder DSM IV. Criteria A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:  Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behaviour covered in Criterion 5.  A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.  Identity disturbance: markedly and persistently unstable self image or sense of self.  Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behaviour covered in Criterion 5.  Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour.  Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).  Chronic feelings of emptiness.  Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).  Transient, stress-related paranoid ideation or severe dissociative symptoms. DSM V. Criteria The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose borderline personality disorder, the following criteria must be met: Significant impairments in personality functioning manifest by:  Impairments in self functioning (a or b):  Identity: Markedly impoverished, poorly developed, or The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose borderline personality disorder, the following criteria must be met:  Significant impairments in personality functioning manifest by:  Impairments in self functioning (a or b):  Identity: Markedly impoverished, poorly developed, or Separation insecurity: Fears of rejection by – and/or separation from – significant others, associated with fears of excessive dependency and complete loss of autonomy.  Depressivity: Frequent feelings of being down, miserable, and/or hopeless; difficulty recovering from such moods; pessimism about the future; pervasive shame; feeling of inferior self-worth; thoughts of suicide and suicidal behaviour.
  5. 5. DSM V. Continue Disinhibition, characterized by:  Impulsivity: Acting on the spur of the moment in response to immediate stimuli; acting on a momentary basis without a plan or consideration of outcomes; difficulty establishing or following plans; a sense of urgency and self-harming behavior under emotional distress.  Risk taking: Engagement in dangerous, risky, and potentially self-damaging activities, unnecessarily and without regard to consequences; lack of concern for one’s limitations and denial of the reality of personal danger. Antagonism, characterized by:  Hostility: Persistent or frequent angry feelings; anger or irritability in response to minor slights and insults.  The impairments in personality functioning and the individual’s personality trait expression are relatively stable across time and consistent across situations.  The impairments in personality functioning and the individual’s personality trait expression are not better understood as normative for the individual's developmental stage or socio-cultural environment.  The impairments in personality functioning and the individual's personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma)
  6. 6. Treatments for Borderline Personality Disorder I. Cognitive Behaviour Therapy CBT can help Borderline patients to identify and change core beliefs/behaviours that underlie inaccurate perceptions of themselves and others and problems interacting with others. CBT may help to reduce anxiety and mood symptoms and reduce the number of suicidal and self- harming behaviours. Dialectical Behaviour Therapy This type of therapy focuses on mindfulness, or being aware of / attentive to the current situation. DBT teaches skills to control intense emotions, reduces self- destructive behaviours and improves relationships. This therapy differs from CBT in that it seeks a balance between changing and accepting beliefs and behaviours Schema focused therapy This type of therapy combines elements of CBT with other forms of therapy that focus on reframing schemas (a mental concept that informs a person about what to expect from a variety of experiences and situations), or the way people view themselves. This approach is based on the idea that borderline personality disorder stems from dysfunctional self- image – possibly brought on by negative childhood experiences- that affect how people react to their environment, interact with others, and cope with problems or stress.  Psychodynamic therapy  Mentalization therapy (Davidson et al, 2006, McMain, 2007)
  7. 7. Borderline Disorder treatments II.CBT:  Place emphasis on the observable behaviours and on the psychic schemata or “inner scripts” (habitual patterns of thought about the self and the interpersonal world, built up during one’s developmental years)  therapy is based on the assumption that behaviours and their underlying schemata have become maladaptive for variety of causative factors: hereditary predisposition, humiliations and other psychological hurts experiences from the caretakers or in some cases trauma due to physical or sexual abuse.  Important cognitive distortions of BPD patients; polarized all-or-none attitudes or dichotomous thinking.  CBT focuses on decreasing the tendency to dichotomous thinking, helping the patient to develop better control over his emotions and impulses, and strengthening the patient’s sense of identity. (Stone, 2006)  Treatment can be divided into 5 stages; 1. construction of working relationship 2. symptom management 3. correction of thinking errors 4. trauma processing and schema changes 5. termination Challenges in stage 1:  constructing working relationship with BPD patients is difficult, as strong ambivalence dominates the contact; on one hand there is a desire for help and acceptance, on the other there is fear of rejection.  In crisis periods demands on the therapist for immediate relief of despair can be great. Typical BPDs mistrust others very strongly, therefore much of the help offered by the therapist is rejected.  Therapists may feel themselves facing and impossible task thus may let themselves easily be provoked into rejecting situations.  Physical proximity, confrontation (telling the patient “you don’t want to change”), lack of clarity (long silence, or no answer, returning the question) will increase the level of fear in the patient.  However, attempts to offer clarity, consistency and prescribing strict standard programs, or directive approach by the therapist will not meet success because the patient does not dare relinquish control. (Arntz,1994)
  8. 8. Challenges in Stage 2:  The goal of this stage is not the banishing of symptoms, but making life more bearable and evening the path towards the next stages of therapy.  For example, crises periods, self mutilation and self- threatening behaviour (that normally is the expression of despair, severe feelings of fear and aggression) can be changed to an alternative behaviour that is harmless to the patient, such as placing hands on ice, dancing to music, cold showers.  Frequent misunderstanding occurs that the patient thinks the therapist has told them they MUST behave differently. However the goal of the therapy is to increase the freedom of choice pertaining to the expression of emotions. Therefore the patient choses an alternative – the therapist does not prescribe this.  In the long term the goal is to cope with emotions in a more adequate fashion: gradually the focus of therapy is replaced from the problem behaviour to the motive. (Leibenluft et al, 1987) Challenges in stage 3:  The aim of this stage is to change dichotomous thinking in the patient. (According to Jean Piaget’s theory dichotomous thinking is characteristic of children and distinguishes itself from more adult thinking, which is multidimensional and more nuanced)  Other frequent thinking factors in BPD are; personalization (blaming themselves excessively), double standard ( strict rules they judge themselves by do not apply to others). Egocentric thinking (inability to distinguish one’s own interpretations or wishes from those of others). Catastropihizing (fear of catastrophes if they do not fulfil other’s wishes and expectations).  Approaching these patterns with standard cognitive techniques may not be enough. Intellectually the patient understands the arbitraty character of his / her thinking, but claims that “it just feels this way” (Westen, 1991)
  9. 9. Challenges in Stage 4:  Changing thinking errors is not easy in borderlines: the core schemas are deeply anchored. Moreover, the patients fear the consequences of letting these assumptions go.  At this stage the aim of therapy is to modify representation of traumatic childhood experiences which led to the development of the faulty assumptions (thinking errors)  Exposure to traumatic memories and emotions thereby incurred may cause the patient to withdraw, therefore therapy at this stage must proceed slowly, gradually and predictably, and must be controlled by the patient.  It is also important that previous childlike interpretations are reconstructed. (it has to be made clear to the patient that their assumption were reasonable then, but do not necessarily apply to the present situation.  Mostly however, more is needed: the change has to take place at the child- level, so to speak; thereto, use can be made of imagination techniques or of psychodrama. ( Edwards, 1990)  BPD patients commonly possess other comorbid disorders as well such as, depressive episodes, eating disorders (anorexia, bulimia), panic and other anxiety disorders, alcohol / substance abuse, dissociative disorder, PTSD
  10. 10. Psychodynamic treatments  Psychodynamic methods are based on the assumption that unconscious forces and conflict are buffeting the borderline patient and are responsible for the sharply polarized attitudes and often wildly osciallting behavioural patterns seen in BPD.  This approach aims to integrate the disparate elements of personality that have been disintegrated by splitting defence mechanism (Splitting is a very common ego defense mechanism. It can be defined as the division or polarization of beliefs, actions, objects, or persons into good and bad by focusing selectively on their positive or negative attributes)  This approach strives to promote psychic integration through the careful examination of the polarized attitudes (that are outside awareness), transference.  In early stages of work, the therapist may be confronted with all manner of life- threatening or self- mutilative behaviours, interpersonal crises, disruptions in the treatment. (Stone, 2006) In recent years a number of treatment guidelines have been developed:  Transference Focused Psychotherapy (Kernberg et al. 2002)  Mentalization- Based treatment (Mentalization: ability to read mental states of others and self more accurately, so to develop a more coherent sense of self and better regulated set of emotions in relation to the external world) (Bateman & Fonagy, 2004)  Self psychology (borderline state is not analysable, therefore converts such patients over time into an “analysable narcissistic personality”) (Kohut, 1971)  However, Kernberg and Bateman & Fonagy made the case in numerous publications of efficacy of psychodynamic approach in a respectably high proportion of borderline patients. The presumption is that the important dynamic constellations in the borderline patient’s everyday life will eventually play themselves out within the transference relationship, there to be brought to light, clarified, and modulated along more adaptive paths.
  11. 11. APD treatments Family Therapy:  Parent management training, structured family therapy have been shown to be effective in children with conduct disorder. There is no published research however on family therapy with adults with APD.  Severely psychopathic patient with APD or severely psychopathic person who does not meet the criteria for APD is not advised; information learned by the patient from both the therapist and other family members is likely to be used to hurt or control in the service of sadism and omnipotent fantasy (Meloy, 1992)  However, reductions in criminal recidivism as a result of family therapy have been reported (Gendreau and Ross, 1987) Milieu and Residential Therapy:  The term Milieu is used to describe any treatment method in which control of the environment surrounding the antisocial environment is the primary agent for change.  1. approach token economy program: empirically found to shape patient and staff behaviour within institutions. Although effective, such programs may be legally challenged by patients with APD on the basis of an arguable constitutional right to unwanted therapy (Rice et al, 1990)  2. approach therapeutic community: Members of the community care for one another, follow the rules, submit to the autihority of the community, and rewarded or disciplined by the group. The primary intervention is the daily group meeting that functions as psychotherapeutic and policy- making body. Peer problemsolving is encouraged, and staff are the facilitators of this largely democratic group culture.  Few controlled studies of therapeutic communities have been done, they have shown modest positive effects (Harris & Rice, 1994)
  12. 12. CBT  Cognitive behavioural and social learning techniques are the most frequently used methods for treating APD. Clear and unambiguous rules, clearly established and enforced consequences, teaching life skills and cognitive skills that are congruent with the patient’s developmental level, identification and modification of cognitive distortions and cirimnal lifestyle patterns, addressing effects of patient’s behaviours on others is highly recommended in therapy (Gacono et al, 2000)  Patients with APD are likely to respond to this method of treatment if they are motivated to change and it is used in a milieu or residential setting.  This is most predictable in the mild to moderately psychopathic patient with APD, who normatively respond to aversive consequences and has felt the emotional and practical pain of his or her antisocial acts.  It is however highly unlikely to have any effect on severely psychopathic patient with APD, because of deficits in passive avoidance learning (inhibiting new behaviour when faced with punishment), the inability to foresee the long- term consequences of his or her actions and the lack of capacity to reflect on the past.  The cognitive deficits of the psychopathic patient such as moderate formal thought disorder and impairments in understanding the connotative meaning of words would also interfere with the success achieved with this mode of therapy (Hare, 2003) Psychodynamic Approaches:  There is no clinical evidence that psychopathic or APD patients will benefit from any form of psychodynamic therapy, including the expressive or supportive psychotherapies or any psychodynamically based group therapies.
  13. 13. Challenges in APD treatment Anxiety and Attachment:  Anxiety is a necessary correlate of any successful mental health treatment that debepnd on interpersonal methods, because it marks a capacity for internalized object relations. As the severity of psychopathi increseas in patients with APD anxiety likely lessens and with it the personal discomfort that can motivate a patient to change.  The ability to form an alliance with a therapist, a behaviour related to attachment, has been shown to be positive prognostic marker in the psychotherapeutic treatment of males with ADP  Without attachment capacity, any treatment that depends on the emotional relationship with the psychotherapist will fail and may pose an explicitdanger to the professional because a lack of empathy for the therapist will not inhibit aggression. (Gerstley et al, 1989) Narcissism:  Psychopathic patients can be conceptualized as aggressive narcissists.  In clinical and treatment setting, the more severe the psychopathic disturbance in the patient with APD the greater the likelihood that aggressive devaluation will be used to shore up feelings of grandiosity and repair emotional wounds.  In addition to the devaluation of others, the severity of psychopathy will determine the degree of control the patient will try to control other patients and the staff. (This “omnipotent control” often felt by the staff as “being under the patient’s thumb” and usually serves the purpose of stimulating the patient’s grandiose fatnasies and waring off his fears of being controlled be others around him)  When the grandiosity of the mild and moderately psychopathic patient with APD is challenged by failure, there will be clinical manifestations of anxiety or depression - both which are positive prognostic predictors (Gabbard & Coye, 1987)
  14. 14. Psychological Defences:  APD patients with severe psychopathy most predictably use the following psychological defences: projective identification, devaluation, denial, omnipotence, splitting  For instance, projective identification is most apparent in treatment when the psychopathic patient attributes certain negative characteristics to the clinician and then attempts to control the clinician.  If neurotic defences are present in patient with APD they suggest amenability of the treatment. Internal experience will more likely be expressed with thought rather than just trough feeling and impulse. (Hare, 2003) Object relations:  The severely psychopathic patient’s internal representations of self are aggressive and larger than life – he is a legend in his on mind. At the same time he does not represent others as a whole, real, and meaningful individuals deserving of respect and empathy but as objects to dominate and exploit.  Unlike patients with BPD, in whom impulses to aggress against the self or others may be frightening, the psycho[athic patient may wholly identify with the aggressor and have no inhibitions.  A histort of violence, coupled with predatory nature of their violence, makes APD patients with severe psychopathy very dangerous in a hospital milieu without appropriate security (Gacono et al, 1997)
  15. 15. Affects:  The emotions of the patient with APD lack the subtlety, depth and modulation of normal individuals.  The APD patient with severe psychopathy appears to live in “presocialized” emotional world, where feelings are experienced in relation to the self but not to others.  The patient’s emotional life instead is dominated by feelings of anger, sensitiveness to shame or humiliation, envy, boredom, contempt and pleasure through dominance.  Both male and felmale adults with APD apper to modulate affect about as well as a 5 to 7 year old child.  These factors pose difficult treatment problems, as these factors predict treatment failure for modalities that depend on emotional access to the patient, such as cognitive- behavioural relapse prevention or psychodynamic approaches that require capacity to feel emotion in relation to the psychotherapist and talk about it.  Most troublesome and difficult to detect is the patient who imitates certain emotional states for secondary gain or to manipulate the psychotherapist. (Gacono & Meloy, 1994)
  16. 16. APD treatment challenges II. Nature of APD pose additional threats to treatment success due to Clinician’s reactions to the patient:  Common countertransference reactions, that are likely to occur regardless of the treatment modality being applied and ill be felt more intensely when psychopathy is more severe in the APD patient.  Therapeutic Nihilism (rejection of all patients with APD as being completely untreatable)  Illusory Treatment Alliance (the illusion that there is treatment alliance when in fact there is none. Such alliance should be viewed with clinical suspicion and may actually be imitations to please and manipulate the psychotherapist)  Fear of Assault or Harm (Obvious)  Helplessness and Guilt (especially prevalent among novice clinicians; feeling og quilt and helplessness when the patient with APD does not change despite treatment efforts)  Devaluation and loss of professional identity (patient with APD is source of continuous professional disappointment. In long term- treatment the APD patient’s resistance to change may compel the clinician to question his or her own professional value and identity) (Gabbard et al, 2005)
  17. 17. General treatment findings  There is yet no body of controlled empirical research concerning the treatment of APD or psychopathy. No demonstrateably effective treatment is available  Meta- analytic studies of the effectiveness of treatment in juvenile delinquents, however, have consistently found a modest overall positive effect.  The most useful treatments are skills- based and behavioural, targeting higher risk offenders in the community  A review of the research on the treatment of APD indicates that these patients have a poor response to hospitalization. The prognosis may be improved, however, if a treatable anxiety or depression is present. (Lipsey, 1992, Hare, 2003)

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