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DISORDERS OF PERSONALITY. 2011. 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).

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DISORDERS OF PERSONALITY


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  1. DISORDERS OF PERSONALITY 2011

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

  33. P. D. PEM : NEM CONSTRAINT AFFILIATION FEAR HISTRIONIC 85-100 0-20 25-100 20-100 Depue - Lezenweger’s ModelHypothetical ranges for PDs on four dimensions ANTISOCIAL 60-100 0-20 0-25 0-20 NARCISSISTIC 60-80 25-45 15-45 0-100 BORDERLINE 0-30 0-30 30-100 70-100 COMPULSIVE 10-40 85-100 15-100 0-100 DEPENDENT 0-70 30-85 0-100 85-100 AVOIDANT 0-15 30-85 20-100 0-100 SCHIZOID 45-55 0-100 0-10 0-100

  34. I II III IV V FFM EXTRAVERSION ANTAGONISM CONSCIENTIOUSNESS NEUROTICISM OPENESS DABB-BQ (-) INHIBITION DISSOCIAL IMPULSIVITY EMOTIONAL DYSREGULATION -------------- SNAPP POSITIVE AFFECTIVITY ---------- CONSTRAINT NEGATIVE AFFECTIVITY ------------- PSY-5 POSTIVE EMOTIONALITY AGGRESSIVITY CONSTRAINT NEGATIVE EMOTIONALITY PSYCHOTICISM EYSENCK EXTRAVERSION PSYCHOTICISM NEUROTICISM --------------- SIEVER / DAVIS (-) INHIBITION AGGRESSIVITY / IMPULSIVITY AFFECTIVE INSTABILITY COGNITIVE / PERCEPTUAL DISTORTION TCI CLONIGER NOVELTY SEEKING (-) COOPERATIVENESS PERSISTENCE HARM AVOIDANCE TRANSCENDENCE REWARD DEPENDANCE SELF-DIRECTIVENESS? DEPUE-LEZENWEGER AGENTIC EXTRAVERSION (-) AFFILIATION CONSTRAINT NEUROTICISM / FEAR

  35. HIGH HISTRIONIC DEPENDENT E X T R A V E R S I O N _ A F F I L I A T I O N BORDERLINE AVOIDANT ANTISOCIAL SCHIZOTYPAL NARCISSISTIC PARANOID OBSESSIVE COMPULSIVE SCHIZOID LOW HIGH CONSTRAINT / FEAR

  36. 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

  37. DEVELOPMENTAL FRAMEWORK

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

  39. 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

  40. 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

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

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

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

  44. 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

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

  46. 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

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

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

  49. 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