Transcript Using Diagnoses to Improve Treatment Robert M. Gordon, Ph.D

Using Diagnoses to Improve
Treatment
Robert M. Gordon, Ph.D. ABPP
J&K Seminar 2013
1. How does diagnoses (DSM, ICD, PDM) affect
treatment?
2. How to tailor treatment to the diagnoses of
personality organization and personality
patterns.
1
My Eclectic Background
• Undergrad focus on science and epistemology
• Temple’s psychology department heavily influenced by Wolpe
and Lazarus. It was anti-psychoanalytic.
• I studied with Rosnow and Lana the artifacts and assumptions in
research (applied epistemology).
• After my Ph.D., I studied with Albert Ellis (Rational Emotive
Therapy), Salvador Manuchin, Jim Framo, and Peggy Papp
(family therapy).
• For a while my primary identification was, “family therapist.”
(AFTA, AAMFT Supervisor)
• Eventually, I became convinced that projections and
transferences were the main issues in couples work and went
on to study object relations (institute training and my
psychoanalysis).
2
Paradigm Shift to Evidence Based Practice
3
An Integrative Theoretical
Formulation Precedes an
Integrative Treatment
• Need for the best theoretical formulation that
integrates research about the mind, brain,
affects, cognitions, behaviors, temperament,
and their interactions in an interpersonal
context.
• Need for technical eclecticism based on the
needs of the patient and EBP.
4
The New Three Core Competencies in
Psychiatry
• Supportive Therapy (Rogerian)
• Cognitive- Behavioral Therapy (CBT)
• Long-Term Psychodynamic
Psychotherapy
5
Our Brains Guided Us for Millions of Years without
Consciousness or Rationality
6
Hypothalamic Sites that Generate Instinctual Behavioral and
Affective States in Mammals
Panksepp (1982)
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The Affective Parts of the Mammalian Brain
are largely Non-Cognitive and Instinctual
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Superego, Ego and Id was a First Step in
Understanding a Brain in Conflict
S
VMPC
A
•The Amygdalae (A) are involved
in the processing of emotions.
•The Ventromedial prefrontal
cortex (VMPC) moderates
emotional reactions and sends
signals to the Striatum (S) with
input from past experiences.
•If the associations are negative,
the VMPC signals are inhibitory.
The Striatum translates signals
from the Amygdala and VMPC
into body action.
9
Ventromedial Prefrontal Cortex and
Neurosis
Studies with PTSD
support the idea that
the ventromedial
prefrontal cortex is
an important
component for
reactivating past
emotional
associations and
events, mediating
pathogenesis of
PTSD.
10
Brains of Borderlines Have Less Grey Matter in
Anterior Cingulate Cortex
Patients with borderline
personality disorder
had significantly lower
density of grey matter
(the brain's working
tissue) in the anterior
cingulate cortex, an
area (yellow right) that
regulates the brain's
fear hub (amygdalayellow left).
MRI scan data shows the
difference between patients
and controls.
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Brains of Borderlines Have More Grey Matter
in Amygdala
Patients with
borderline personality
disorder had
significantly higher
density of grey matter
in the brain's fear hub,
the amygdala (red
areas). MRI scan data shows
where patients and controls
differed.
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Emotions and attachment drives in mammals are similar and evolved for functional reasons. They may
be affected by thoughts, but they are not created by them.
Damasio, et al., 2002
Herman & Panksepp, 1979
Panksepp, J. (2003).
Science, Oct 10th. 13
Attachment Security in Infancy and Early
Adulthood: A Twenty-Year Longitudinal Study.
Walters, E. Merrick., S.; Treboux, D.; Crowell, J. and Albersheim, L. (2000), Child Development.
• Researchers looked at relationship patterns
in 50 young adults who were studied 20 years
earlier as infants.
• Overall, 72% of the adults received the same
secure verses insecure attachment
classification they had in infancy.
14
Experimental Test of Unconscious Transference
•
Study: subjects are subliminally shown aggressive (A) or positive (B) stimuli
– and then rate a neutral stimulus (C)
– Subjects shown panel A subsequently rated the boy in panel C more negatively
(Eagle, 1959)
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Treat the Whole Person
• Blatt, (2006), Norcross (2002), Wampold (2001) have
concluded that the nature of the psychotherapeutic
relationship, reflecting interconnected aspects of mind and
brain operating together in an interpersonal context, predicts
outcome more robustly than any specific treatment approach
per se.
• Westen, Novotny, and Thompson-Brenner (2004) have
presented evidence that treatments that focus on isolated
symptoms or behaviors (rather than personality, emotional,
and interpersonal patterns ) are not effective in sustaining
even narrowly defined changes.
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Value of Insight into the Self
• 800 Psychologists ranked a list of 38 of the most
beneficial things they got from their own
psychotherapy.
• They listed first, “Self-understanding.”
• “Symptom relief” was halfway down the list
• Included in the survey were psychologists from all
theoretical orientations (Behaviorists, CognitiveBehaviorists, Psychoanalytic, etc.).
•
Pope, K. T., B.G. (1994). Therapists as patients: A national survey of psychologists' experiences, problems, and beliefs. Professional Psychology: Research &
Practice, 25(3), 247-258.
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Effectiveness of Long-term Psychodynamic Psychotherapy A
Meta-analysis
Leichsenring and Rabung (2008) JAMA, 3000,13,1551-1565.
• 23 LTPP studies (11 RCT efficacy and 12 effectiveness) total of
1053 patients with personality disorders, and multiple and
complex problems.
• LTPP at least 1 year (an average of 151 sessions).
• Results LTPP better than 96% of those in short term therapies
(CBT, DBT, SFT, CAT, FT, STPP, etc.) with changes in not only
symptoms relief but with increases in mental capacities.
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Importance of Transference and Attachment with BPD
• Clarkin, et al. (2007): 90 BPD randomly assigned to transferencefocused psychotherapy (TFT), dialectical behavior therapy (DBT), or
supportive therapy (ST).
• Patients in all 3 treatments showed significant positive change in
depression, anxiety, global functioning, and social adjustment.
• Both transference-focused psychotherapy and dialectical behavior
therapy were significantly associated with improvement in suicidality.
• Only transference-focused psychotherapy and supportive treatment
were associated with improvement in anger.
• Transference- focused psychotherapy and supportive treatment were
each associated with improvement in impulsivity.
• Only transference-focused psychotherapy was significantly predictive
of change in irritability and verbal and direct assault.
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Over-all Research
• Evidence Based short-term symptom focused
treatments are all equally effective.
• Long-term psychodynamic therapies that focus on
temperament, conflicts, affects, cognitions,
behaviors, interpersonal context, child development,
conscious and unconscious levels are better than
symptom focused treatments in treating personality
disorders.
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Integrative Psychotherapeutic Interventions
Going From Supportive, CBT and Psychodynamic
• Personal Qualities of the Therapist
• Maintaining the Therapeutic Frame
• Reassurance
• Listening
• Behavioral Mastery: Self-Soothing
• Cognitive Learning
• Clarifications
• Interpretations of mental life that affects subjective wellbeing and relationships
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Treatment of the Borderline Level Personality Disorder
• Behavioral Mastery: desensitization and self-soothing
• Cognitive Learning: how to better understand thoughts, feelings,
and behaviors
• Clarifications and Confrontations: of the patient’s confusions,
distortions and consequences of judgment and impulses
• Interpretations: focus on here and now defenses, transferences,
enactments, and mentalization
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Treatment of the Neurotic Level Personality Disorder
• Reconstructions: patients may benefit from a coherent,
insightful narrative of their psychological history. Despite
problems with recall and subjectivity, traumatic events can be
recalled, mastered and integrated into a more cohesive
identity.
• Interpretations: insight into unconscious resistances,
defenses, transferences and enactments.
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Kernberg’s Differentiation of Personality Organization
That Preceded the PDM
•Identity
Integration
Neurotic
Borderline
+integrated
- diffused
Psychotic
-
•Defensive
Operations
+higher
-primitive
-
•Reality
Testing
+
+
-
Borderline Personality Organization
Basic Characteristics- Kernberg
Identity Diffusion
No integrated concept of self
No integrated concept of significant others
Primitive Defenses
– Splitting
– Idealization/devaluation
– Projective identification
– Omnipotent control
– Denial
Variable Reality Testing
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Healthy Defense Mechanisms
Anticipation
Affiliation
Altruism
Humor
Self-Assertion
Self-Observation
Sublimation
Suppression
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Neurotic Level Defenses
Displacement
Dissociation
Intellectualization
Rationalization
Isolation of Affect
Reaction Formation
Repression
Undoing
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Borderline level Defenses
Idealization / Devaluation
Omnipotence and Omnipotent control
Denial
Projective identification
Splitting of self-image or image of others
Acting out
Projection
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Psychotic Level
Delusional projection
Psychotic denial
Psychotic distortion
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Anaclitic vs Introjective
(according to S.Blatt)
•Anaclitic: Borderline, Histrionic, Dependent, Avoidant,
Depressive anaclitic.
•Introjective: Schizoid, Paranoid, Antisocial, Narcissistic,
Obsessive, Depressive introjective.
•Reference tools: Object Relations Inventory (ORI; Blatt
et al., 2006)
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Personality Disorders
P Axis
Temperamental,
Thematic,
Affective,
Cognitive, and
Defense patterns
P101. Schizoid Personality Disorders
•
Contributing constitutional-maturational patterns: Highly sensitive,shy,
easily overstimulated
•
Central tension/preoccupation: Fear of closeness/longing for closeness
•
Central affects: General emotional pain when overstimulated, affects so
powerful they feel they must suppress them
•
Characteristic pathogenic belief about self: Dependency and love are
dangerous
•
Characteristic pathogenic belief about others: The social world is
impinging, dangerously engulfing
•
Central ways of defending: Withdrawal, both physically and into fantasy and
idiosyncratic preoccupations
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P102. Paranoid Personality Disorders
• Contributing constitutional-maturational patterns: Possibly
irritable/aggressive
• Central tension/preoccupation: Attacking/being attacked by
humiliating others
• Central affects: Fear, rage, shame, contempt
• Characteristic pathogenic belief about self: Hatred, aggression and
dependency are dangerous
• Characteristic pathogenic belief about others: The world is full of
potential attackers and users
• Central ways of defending: Projection, projective identification,
denial, reaction formation
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P103. Psychopathic (Antisocial) Personality Disorder
P103.1 Passive/Parasitic: “con artist”
P103.2 Aggressive: explosive, predatory, often violent
• Contributing constitutional-maturational patterns: aggressiveness,
high threshold for emotional stimulation
• Central tension/preoccupation: Manipulating/being manipulated
• Central affects: Rage, envy
• Characteristic pathogenic belief about self: I can make anything
happen
• Characteristic pathogenic belief about others: Everyone is selfish,
manipulative, dishonest
• Central ways of defending: Reaching for omnipotent control
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P104. Narcissistic Personality Disorders
P104.1 Arrogant/Entitled: devalues, vain, commanding
P104.2 Depressed/Depleted: idealizing, envious, easily hurt
• Contributing constitutional-maturational patterns: No clear data
• Central tension/preoccupation: Inflation/deflation of self-esteem
• Central affects: Shame, contempt, envy
• Characteristic pathogenic belief about self: I need to feel okay
• Characteristic pathogenic belief about others: Others enjoy riches,
beauty, power, and fame; the more I have of those, the better I will feel
• Central ways of defending: Idealization/devaluation
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Narcissistic PD: Narcissistic Injury
The Doberman threw himself out the second-story window
after he realized the family had indeed named him “Binky.”
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P105. Sadistic and Sadomasochistic Personality Disorders
P105.1 Intermediate Manifestation: Sadomasochistic Personality Disorders:
alternate between attacking and feeling insulted
• Contributing constitutional-maturational patterns: Unknown
• Central tension/preoccupation: Suffering indignity/inflicting such
suffering
• Central affects: Hatred, contempt, pleasure (sadistic glee)
• Characteristic pathogenic belief about self: I am entitled to hurt and
humiliate others
• Characteristic pathogenic belief about others: Others exist as
objects for my domination
• Central ways of defending: Detachment, omnipotent control,
reversal, enactment
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Sadistic PD: I am entitled to hurt others
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P106. Masochistic (Self-Defeating) Personality Disorders
P106.1 Moral Masochistic: self-esteem depends on suffering
P106.2 Relational Masochistic: suffer for sake of relationship
•
Contributing constitutional-maturational patterns: None known
•
Central tension/preoccupation: Suffering/losing relationship or selfesteem
•
Central affects: Sadness, anger, guilt
•
Characteristic pathogenic belief about self: By manifestly suffering, I
can demonstrate my moral superiority and/or maintain my attachments
•
Characteristic pathogenic belief about others: People pay attention only
when one is in trouble
•
Central ways of defending: Introjection, introjective identification,
turning against the self, moralizing
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Masochistic Personality Disorder
“Penny for your thoughts, Arnold!”
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P107. Depressive Personality Disorders
P107.1 Introjective: self-critical, self-worth
P107.2 Anaclitic: concern with attachment issues
•
Contributing constitutional-maturational patterns: Possible genetic
predisposition
•
Central tension/preoccupation: Goodness/badness or
aloneness/relatedness of self
•
Central affects: Sadness, guilt, shame
•
Characteristic pathogenic belief about self: There is something
essentially bad or incomplete about me
•
Characteristic pathogenic belief about others: People who really get to
know me will reject me
•
Central ways of defending: Introjection, reversal, idealization of others,
devaluation of self
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Depressive Personality Disorder
Lodge owner Harold Shuffle saw only the negative side
of things.
P107.3 Converse Manifestation: Hypomanic Personality Disorder
• Contributing constitutional-maturational patterns: Possibly high
energy
• Central tension/preoccupation: Overriding grief/succumbing to grief
• Central affects: Elation, rage, unconscious sadness and grief
• Characteristic pathogenic belief about self: If I stop running and get
close to someone, I’ll be traumatically abandoned, so I’ll leave first
• Characteristic pathogenic belief about others: Others can be
charmed into not seeing the qualities that make people inevitably reject
me
• Central ways of defending: Denial, idealization of self, devaluation
of others
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P108. Somatizing Personality Disorders
• Contributing constitutional-maturational patterns: Possible
physical fragility, early sickliness, early abuse
• Central tension/preoccupation: Integrity/fragmentation of bodily self
• Central affects: alexithymia, inferred rage, distress
• Characteristic pathogenic belief about self: I am fragile, vulnerable,
in danger of dying
• Characteristic pathogenic belief about others: Others are powerful,
healthy, and indifferent
• Central ways of defending: Somatization, regression
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Somatizing Personality Disorder
“My brother, Tilford, had trouble with hemorrhoids and he never
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did anything like this!”
P109. Dependent Personality Disorders
• Contributing constitutional-maturational patterns: Possible
placidity, sociophila
• Central tension/preoccupation: Keeping/lossing relationships
• Central affects: Pleasure when securely attached; sadness and fear
when alone
• Characteristic pathogenic belief about self: I am inadequate, needy,
impotent
• Characteristic pathogenic belief about others: Others are powerful
and I need their care
• Central ways of defending: Regression, reversal, avoidance
• Subtypes: Passive-Aggressive, Counterdependent
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Dependent PD: Others are powerful and I need their care
“You’re gonna spoil that dog, Annie!”
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P109. Dependent Personality Disorders
P109.1 Passive-Aggressive Versions of Dependent Personality Disorders
•
Contributing constitutional-maturational patterns: Possibly irritable, aggressive
•
Central tension/preoccupation: Tolerating mistreatment/getting revenge
•
Central affects: Anger, resentment, pleasure in hostile enactments
•
Characteristic pathogenic belief about self: I am inadequate, needy, impotent
•
Characteristic pathogenic belief about others: Others are powerful and I need
their care
•
Central ways of defending: Regression, reversal, avoidance
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Passive-Aggressive Personality Disorder
“It’s almost like they do it on purpose, isn’t it, Fred?!”
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P109. Dependent Personality Disorders
P109.2 Converse Manifestation: Counterdependent Personality Disorder
• Contributing constitutional-maturational patterns: Possibly more
aggressive than the overtly dependent type
• Central tension/preoccupation: Demonstrating lack of or shameful
dependence
• Central affects: Contempt, denial of “weaker” emotions
• Characteristic pathogenic belief about self: I don’t need anyone
• Characteristic pathogenic belief about others: Others depend on me and
require me to be “strong”
• Central ways of defending: Denial, reversal, enactment
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P110. Phobic (Avoidant) Personality Disorders
• Contributing constitutional-maturational patterns: Possible
anxious or timid disposition
• Central tension/preoccupation: Safety/danger relative to specific
objects
• Central affects: Fear
• Characteristic pathogenic belief about self: I am safe if I avoid
certain specific dangers
• Characteristic pathogenic belief about others: More powerful
people can magically keep me safe
• Central ways of defending: Symbolization, displacement, projection,
rationalization, avoidance
• Subtypes: Counterphobic
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P110.1 Converse Manifestation of Phobic: Counterphobic Personality Disorders
•
Contributing constitutional-maturational patterns: Unknown
•
Central tension/preoccupation: Safety/danger
•
Central affects: Contempt, denial of fear
•
Characteristic pathogenic belief about self: I can face anything without fear
•
Characteristic pathogenic belief about others: Others frighten easily and
admire my bravery
•
Central ways of defending: Denial, reaction formation, projection
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P111. Anxious Personality Disorders
•
Contributing constitutional-maturational patterns: Anxious or timid
temperament
•
Central tension/preoccupation: Safety/danger
•
Central affects: Fear
•
Characteristic pathogenic belief about self: I am in constant danger from
forces unknown
•
Characteristic pathogenic belief about others: Others are sources of either
danger or protection
•
Central ways of defending: Failure of defenses against anxiety, surface
anxiety may mask unconscious deeper anxiety
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P112. Obsessive-Compulsive Personality Disorders
P112.1 Obsessive: Self-esteem depends on thinking,ruminative
P112.2 Compulsive: Self-esteem depends on doing, meticulous
•
Contributing constitutional-maturational patterns: Possible irritability,
orderliness
•
Central tension/preoccupation: Submission to/rebellion against controlling
authority
•
Central affects: Anger, guilt, shame, fear
•
Characteristic pathogenic belief about self: My aggression is dangerous and
must be controlled
•
Characteristic pathogenic belief about others: Others try to exert control,
which I must resist
•
Central ways of defending: Isolation of affect, reaction formation,
intellectualization, moralizing, undoing
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Obsessive-Compulsive PD: Compulsive type
Once again Elliot Zambini’s tidiness ruins the act.
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P113. Hysterical (Histrionic) Personality Disorders
P113.1 Inhibited: reserved, naiveté, somatization
P113.2 Demonstrative or Flamboyant: seductive, dramatic
•
Contributing constitutional-maturational patterns: Possibly sensitivity,
sociophila
•
Central tension/preoccupation: Power and sexuality/other gender
•
Central affects: Fear, shame, guilt (over competition)
•
Characteristic pathogenic belief about self: My gender makes me weak,
castrated, vulnerable
•
Characteristic pathogenic belief about others: People of my own
gender are of little value, people of the other gender are powerful, exciting,
potentially exploitive and damaging
•
Central ways of defending: Repression, regression, conversion,
sexualization, acting out
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P114. Dissociative Personality Disorders (Dissociative
Identity Disorder/Multiple Personality Disorder)
•
Contributing constitutional-maturational patterns: Constitutional
capacity for self-hypnosis; severe early and repeated physical and/or
sexual trauma
•
Central tension/preoccupation: Acknowledging trauma/disavowing
trauma
•
Central affects: Fear, rage
•
Characteristic pathogenic belief about self: I am small, weak, and
vulnerable to recurring trauma
•
Characteristic pathogenic belief about others: Others are perpetrators,
exploiters, or rescuers
•
Central ways of defending: Dissociation
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P115. Mixed/Other
• For individuals with combinations of
personality types or with particular patterns
or themes
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Implications for Treatment
Depressive Personality Disorder
(Most Common type in Clinical Situations)
P107.1 Introjective: self-critical, preoccupied with
self-worth, guilt
P107.2 Anaclitic: concerned with attachment issues,
relatedness, trust, inadequacy (May combine with
dependent or narcissistic personality disorder)
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Treatment for Depressive P.D.
• The Mood disorder responds to medication, but
not the personality disorder, which requires longterm intensive treatment.
• The introjective type tends to respond better to
interpretations and insight.
• The anaclitic type tends to respond better to the
actual therapeutic relationship. May respond well
to short term interventions.
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P107.3 Converse Manifestation: Hypomanic Personality Disorder
•
•
•
•
Relatively stable state of inflated mood, high energy
Little guilt
Overly positive view of self
Superficial relationships due to fear of being
attached
• Highly resistant to therapy
• The mood disorder responds better to
pharmacological interventions, but medication
does not help the personality disorder.
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Treatment Implications:
P107.3 Converse Manifestation: Hypomanic Personality Disorder
• The hypomanic type often flees from commitment
and therefore does not stay long enough in
treatment. The PDM suggests emphasizing that the
commitment to the treatment is important to
improvement.
• People with hypomanic personality disorders are
most likely to be at the borderline level favoring
defenses such as denial and the idealization of self
and the devaluation others, as compared to those
with depressive personalities who favor defensives
such as repression, and the devaluation of self and
the idealization of others.
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Personality Structure and Treatment
• McWilliams points out that for many neurotic
level people, the best time to make
interpretations is when the patient is a state
of emotional arousal, so that the patient is
less likely to intellectualize the affect.
• With borderline clients, who require a
supportive approach, the opposite
consideration applies, because when they are
very upset, it is hard for them to take anything
in.
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Take Home Message
• Neurotic Level Personality Disorders
focus more on using insight into past
traumas that need to be worked through.
• Borderline Level Personality Disorders focus
more on using here and now interventions
to help with reality testing, better self
control and self soothing.
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Take Home Message
• Be technically eclectic mixing Supportive,
CBT and Psychodynamic according to the
needs of the patient (not according to your
biases).
• Use a psychodynamic formulation so you
will know what interventions are likely be
most effective, and to communicate that
you understand your patient at all levels of
existence (not just seeing symptoms).
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Consider Instruments Such as the PDC
• To guide your diagnostic and case
formulation
• To keep in your chart
• To assess progress
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Take Home Message:
Use the ICD with the PDM
1. Consider the over-all level of personality
organization
2. Consider the personality patterns or
disorders
3. Consider the mental capacities
4. Consider the subjective experience of the
symptoms and use the ICD codes
You will find that your greater empathy will
be felt by your patient, and this can
greatly improve any treatment.
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