Transcript athens-2005-s12

Beyond the ICD and DSM:
Diagnosis, Comorbidity, and the
Therapeutic Alliance in Severe
Personality Disorders with an
Emphasis on Borderline Personality
Allan Tasman, M.D.
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Impact of Systems of
Psychiatric Diagnosis
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DSM and ICD are still non-etiologic approaches based
on symptom clusters
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DSM revisions were designed to stimulate research, which
has occurred
No provision for role of psychological conflict or
developmental distress
No provision for symbolic meaning of symptoms
When role of empathic listening for trauma,
transference, cultural influences, and symbolic
meanings are omitted, we cannot fully understand
our patients
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Personality =
Temperament + Character
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The Five-Factor Model of Personality
Neuroticism
Agreeableness
Extraversion
Conscientiousness
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Calm – Worrying
Even-tempered – Temperamental
Self-satisfied – Self-pitying
Comfortable – Self-conscious
Unemotional – Emotional
Hardy – Vulnerable
Reserved – Affectionate
Loner – Joiner
Quiet – Talkative
Passive – Active
Sober – Fun-loving
Unfeeling – Passionate
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Ruthless – Soft-hearted
Suspicious – Trusting
Stingy – Generous
Antagonistic – Acquiescent
Critical – Lenient
Irritable – Good-natured
Negligent – Conscientious
Lazy – Hardworking
Disorganized – Well-organized
Late – Punctual
Aimless – Ambitious
Quitting – Persevering
Openness to Experience
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Down-to-earth – Imaginative
Uncreative – Creative
Conventional – Original
Prefer routine – Prefer variety
Uncurious – Curious
Conservative – Liberal
Adapted from Costa & McCrae 19864
Three Major Brain Systems Influencing
Stimulus – Response Characteristics
Brain System
(Related Personality
Dimension)
Principal
Monoamine
Neuromodulator
Relevant Stimuli
Behavioral
Response
Behavioral activation
(novelty seeking)
Dopamine
Novelty
Exploratory pursuit
Potential reward
Appetitive approach
Potential relief of
monotony or
punishment
Active avoidance,
escape
Behavioral inhibition
(harm avoidance)
Serotonin
Conditioned signals
for punishment,
novelty, or frustrative
nonreward
Passive avoidance,
extinction
Behavioral
maintenance
(reward dependence)
Norepinephrine
Conditioned signals
for reward or relief of
punishment
Resistance to
extinction
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Cloninger’s Seven-Factor Model
1.
Temperament Domains (Moderately heritable, not greatly
influenced by family environment)
a.
Novelty Seeking
b.
Harm Avoidance
c.
Reward Dependence
d.
Persistence
2. Character Domains (Moderately influenced by family
environment, only weakly heritable)
a.
Self-transcendence
b.
Cooperativeness
c.
Self-directedness
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DSM-IV Definition of Personality
Disorder
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.
2.
B.
Cognition (i.e., ways of perceiving and interpreting
self, other people, and events)
Affectivity (i.e., the range, intensity, ability,
appropriateness of emotional response)
3.
Interpersonal functioning
4.
Impulse control
The Enduring pattern is inflexible and pervasive across a
broad range of personal and social situations.
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DSM-IV Definition of Personality
Disorder
C.
D.
E.
F.
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 lease 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 of
abuse, a medication) or a general medical condition
(e.g., head trauma).
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DSM-IV Personality Disorders
A. Cluster A (odd/eccentric)
1. Paranoid
2. Schizoid
3. Schizotypal
B. Cluster B (dramatic/emotional/impulsive)
1. Antisocial
2. Borderline
3. Histrionic
4. Narcissistic
C. Cluster C (anxious/fearful)
1. Avoidant
2. Dependent
3. Obsessive-Compulsive
D. Personality Disorder Not Otherwise Specified
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Phenomenologically Corresponding Axis I & Axis II
Disorders, Potential Biological Indexes, and Characteristic
Traits (Core Vulnerabilities), Defenses and Coping
Strategies of Dimensions of Personality Disorders
Dimension
Axis I Disorder
Axis II Disorder
Biological Indexes
Characteristic Traits
Defenses and
Coping Strategies
Cognitive/
Perceptual
Organization
Schizophrenia
Odd cluster
(schizotypal PD)
Eye movement
dysfunction*, continuous
performance task,
backward masking test*,
plasma HVA*, CSF
HVA*, evoked potential
response, VBR
Disorganization,
psychotic-like
symptoms
Social isolation,
detachment,
guardedness
Impulsivity/
Aggression
Impulse
disorders
Dramatic cluster
(borderline &
antisocial PDs)
CSF 5-HIAA*, responses
to serotonergic
challenge, galvanic skin
response*, continuous
performance task
Readiness to action,
irritability/
aggression
Externalization,
dissociation,
enactment,
repression
Affective
Instability
Major affective
disorders
Dramatic cluster
(borderline &
possibly
histrionic PDs)
REM latency, responses
to cholinergic
challenges*, responses
to catecholamingeric
challenges*
Environmentally
responsive, transient
affective shifts
Exaggerated
affectivity,
“manipulativeness”,
“splitting”
Anxiety/
Inhibition
Anxiety
disorders
Anxious cluster
(avoidant PD)
Heart rate variability*,
orienting responses,
responses to lactate and
yohimbine
Autonomic arousal,
fearfulness, inhibition
Avoidant,
compulsive, and
dependent
behaviors
* Preliminary data are available in patients with personality disorder (PD)
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Impulsive Disorders
Axis II
 Borderline Personality Disorder
 Antisocial Personality Disorder
Axis I
 Psychoactive Substance Use Disorder
 Bulimia
 Paraphilias
 Impulsive Control Disorder NEC
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STPD
MDD
PTSD
Severity
of social
dysfunction
Bip-II
SPD
ASPD
BPD
NPD
AVPD
HPD
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Concepts of Borderline Disorders
Borderline
Schizophrenia (Kety)
(Schizotypal PD Rado, Meehl)
Schizophrenia
Borderline
Personality
Organization
(Kernberg)
Affective
Disorders
Atypical
Affective
Disorders
(D.Klein)
Borderline
Personality
Disorder
Borderline
Syndrome
(Grinker)
Neuroses
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Theories of Etiology of BPD
1. Affective/impulsive dysregulation (Klein, Akiskal)
2. Excessive aggression (Kernberg)
A. Primary (constitutional)
B. Secondary (reaction to frustration or trauma)
3. Maternal withdrawal (Masterson, Rinsley)
4. Introjective failure (Mahler, Kohut)
5. Neurological dysfunction (Andrulonis)
Gunderson and Zanarini
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Etiology of BPD
Type 1: Affective (Akiskal, Klein)
 **A moderately heritable “subaffective”
vulnerability, precipitated by environmental
stress
Prototypic Criteria:
 #6: affective instability due to marked
reactivity of mood (dysphoria or anxiety);
 #5: recurrent suicidal behavior, gestures or
threats, or self-mutilating behavior
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Etiology of BPD
Type 2: Impulsive (Zanarini, Hollander, Siever)
 **A moderately heritable impulse spectrum disorder,
precipitated by environmental stress
Prototypic Criteria:
 #4: impulsivity in at least two areas that are potentially
self-damaging;
 #5: recurrent suicidal behavior, gestures or threats, or
self-mutilating behavior
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Etiology of BPD
Type 3: Aggressive (Kernberg)
 **A primary moderately heritable aggressive
temperament, or a secondary reaction to early
trauma and/or abuse
Prototypic Criteria:
 #8: inappropriate, intense anger or difficulty
controlling anger;
 #6: affective instability due to marked reactivity of
mood (irritability)
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Etiology of BPD
Type 4: Dependent (Masterson and Rinsley;
Gunderson)
 **intolerance of aloneness, and impaired autonomy,
possibly secondary to parental separation-resistance
Prototypic Criteria:
 #1: frantic efforts to avoid real or imagined
abandonment;
 #6: affective instability due to marked reactivity of
mood (anxiety)
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Etiology of BPD
Type 5: Empty (Mahler; Adler and Buie)
 **failure to develop an evocative memory secondary
to lack of empathy and inconsistency in early
parenting
Prototypic Criteria:
 #7: chronic feelings of emptiness;
 #3: identity disturbance: markedly and persistently
unstable self-image or sense of self
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APA Practice Guidelines Work Group on
Borderline Personality Disorders
John Oldham, M.D. (Chair)
Glen Gabbard, M.D.
Marcia Goin, M.D., Ph.D.
John Gunderson, M.D.
Paul Soloff, M.D.
David Spiegel, M.D.
Michael Stone, M.D.
Katherine Phillips, M.D.
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Part A: Treatment Recommendations
for Patients with Borderline Personality
Disorder
II. Formulation and Implementation of a Treatment Plan
E. Specific Treatment Strategies for the Clinical
Features of Borderline Personality Disorder
1. Psychotherapy
2. Pharmacotherapy and other somatic
treatments
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Pharmacotherapy
B
P
D
T
y
p
e
Type 1
(Affective)
Type 2
(Impulsive)
Type 3
(Aggressive)
Type 4
(Dependent)
Type 5
(Empty)
Psychotherapy
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Common Features of Recommended
Psychotherapy for BPD
1.
2.
3.
4.
5.
6.
7.
8.
9.
Non-brief
Strong therapeutic alliance
Establishment of clear roles and responsibilities of
patient and therapist
Active therapist
Hierarchy of priorities
Empathic validation + need for patient to control
behavior
Flexibility
Limit-setting
Concomitant individual and group approaches
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Table 2. The Hierarchy of Priorities in Therapeutic Sessions
Dialectical Behavior Therapy
(Linehan 1993)
Psychoanalytic/Psychodynamic Therapies
(Kernberg et al. 1989; Clarkin et al. 1999)
suicidal behaviors
suicide or homicide threats
therapy-interfering behaviors
overt threats to treatment continuity
quality-of-life interfering behaviors
dishonesty or deliberate withholding
contract breaches
in-session acting out
between-session acting out
nonaffective or trivial themes
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Part A: Treatment Recommendations for
Patients with Borderline Personality Disorder
IV. Risk Management Issues in Treating Borderline Patients
A. General Considerations
1. Good collaboration and communication
2. Assessment of risk, careful documentation
3. Attention to problems in the transference or
countertransference
4. Consultations
5. Psychoeducation
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Part A: Treatment Recommendations for
Patients with Borderline Personality Disorder
IV. Risk Management Issues in Treating Borderline Patients
B. Suicide
1. Monitor for suicide risk
2. Take suicide threats seriously
3. Address chronic suicidality without acute risk,
in therapy
4. Actively treat comorbid Axis I conditions
5. Consultation
6. Involvement of family
7. Non-reliance on “suicide contract”
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Part A: Treatment Recommendations for
Patients with Borderline Personality Disorder
IV. Risk Management Issues in Treating Borderline Patients
C. Anger, Impulsivity, and Violence
1. Monitor for impulsive or violent behavior
2. Address abandonment/rejection issues, anger,
impulsivity, in therapy
3. Careful coverage arrangement and
documentation when away
4. Take action if necessary to protect self or
others
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Part A: Treatment Recommendations for
Patients with Borderline Personality Disorder
IV. Risk Management Issues in Treating Borderline Patients
D. Boundary Violations
1. Monitor counter transference
2. Be alert to deviations from standard practice
3. Avoid boundary violations
4. Consultation
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The Effectiveness of Psychodynamic Therapy and
Cognitive Behavior Therapy in the Treatment of
Personality Disorders: A Meta-Analysis
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Both psychodynamic therapy and cognitive behavior
therapy are effective treatments of personality
disorders
For psychodynamic therapy, the effect sizes indicate
long-term rather than short-term change in
personality disorders (mean follow-up period = 1.5
years [78 weeks] vs CBT mean follow-up = 13
weeks)
Leichsenring F, Leibing E, Am J
Psychiatry 2003; 160:1223-1232
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Summary
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Present diagnostic classification systems are
inadequate for severe personality disorders
Alternative models assess interaction of
temperament and developmental experience
Research evidence for borderline personality
emphasizes psychotherapeutic interventions
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Development and maintenance of an effective
therapeutic alliance is critical for success no
matter what form of psychotherapy is utilized
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