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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. Impact of Systems of Psychiatric Diagnosis. DSM and ICD are still non-etiologic approaches based on symptom clusters - PowerPoint PPT Presentation
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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
DSM and ICD are still non-etiologic approaches based on symptom clusters
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 PersonalityNeuroticism Calm – Worrying Even-tempered – Temperamental Self-satisfied – Self-pitying Comfortable – Self-conscious Unemotional – Emotional Hardy – Vulnerable
Extraversion Reserved – Affectionate Loner – Joiner Quiet – Talkative Passive – Active Sober – Fun-loving Unfeeling – Passionate
Openness to Experience Down-to-earth – Imaginative Uncreative – Creative Conventional – Original Prefer routine – Prefer variety Uncurious – Curious Conservative – Liberal
Agreeableness Ruthless – Soft-hearted Suspicious – Trusting Stingy – Generous Antagonistic – Acquiescent Critical – Lenient Irritable – Good-natured
Conscientiousness Negligent – Conscientious Lazy – Hardworking Disorganized – Well-organized Late – Punctual Aimless – Ambitious Quitting – Persevering
Adapted from Costa & McCrae 1986
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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 Seekingb. Harm Avoidancec. Reward Dependenced. Persistence
2. Character Domains (Moderately influenced by family environment, only weakly heritable)
a. Self-transcendenceb. Cooperativenessc. 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. Cognition (i.e., ways of perceiving and interpreting self, other people, and events)
2. Affectivity (i.e., the range, intensity, ability, 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.
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DSM-IV Definition of Personality Disorder
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 lease 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 (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
AffectiveInstability
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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ASPDASPD
SPDSPD
BPDBPD
AVPDAVPD
HPDHPD
NPDNPD
STPDSTPD
PTSDPTSDBip-II
MDDMDD
SeveritySeverityof socialof social
dysfunctiondysfunction
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Concepts of Borderline Disorders
SchizophreniaSchizophreniaAffective Affective DisordersDisorders
Borderline Borderline Schizophrenia (Kety)Schizophrenia (Kety)(Schizotypal PD - (Schizotypal PD - Rado, Meehl)Rado, Meehl)
Atypical Atypical Affective Affective Disorders Disorders (D.Klein)(D.Klein)
BorderlineBorderlinePersonalityPersonality
OrganizationOrganization(Kernberg)(Kernberg)
BorderlineBorderlinePersonalityPersonality
DisorderDisorder
BorderlineBorderlineSyndromeSyndrome(Grinker)(Grinker)
NeurosesNeuroses
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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. Psychotherapy2. Pharmacotherapy and other somatic
treatments
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Type 1 (Affective)
Type 2 (Impulsive)
Type 3 (Aggressive)
Type 4 (Dependent)
Type 5 (Empty)
PsychotherapyPsychotherapy
PharmacotherapyPharmacotherapy
BBPPDD TTyyppee
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Common Features of Recommended Psychotherapy for BPD
1. Non-brief 2. Strong therapeutic alliance 3. Establishment of clear roles and
responsibilities of patient and therapist 4. Active therapist 5. Hierarchy of priorities 6. Empathic validation + need for patient to
control behavior 7. Flexibility 8. Limit-setting 9. Concomitant individual and group approaches
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Table 2. The Hierarchy of Priorities in Therapeutic SessionsTable 2. The Hierarchy of Priorities in Therapeutic Sessions
Dialectical Behavior TherapyDialectical Behavior Therapy(Linehan 1993)(Linehan 1993)
Psychoanalytic/Psychodynamic TherapiesPsychoanalytic/Psychodynamic Therapies(Kernberg et al. 1989; Clarkin et al. 1999)(Kernberg et al. 1989; Clarkin et al. 1999)
suicidal behaviorssuicidal behaviors suicide or homicide threatssuicide or homicide threats
therapy-interfering behaviorstherapy-interfering behaviors overt threats to treatmentovert threats to treatment continuitycontinuity
quality-of-life interfering behaviorsquality-of-life interfering behaviors dishonesty or deliberatedishonesty or deliberate withholdingwithholding
contract breachescontract breaches
in-session acting outin-session acting out
between-session acting outbetween-session acting out
nonaffective or trivial themesnonaffective or trivial themes
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Part A: Treatment Recommendations for Patients with Borderline Personality Disorder
IV. Risk Management Issues in Treating Borderline PatientsA. General Considerations
1. Good collaboration and communication 2. Assessment of risk, careful
documentation3. Attention to problems in the transference
or countertransference4. Consultations5. Psychoeducation
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Part A: Treatment Recommendations for Patients with Borderline Personality Disorder
IV. Risk Management Issues in Treating Borderline PatientsB. Suicide
1. Monitor for suicide risk2. Take suicide threats seriously3. Address chronic suicidality without acute risk,
in therapy4. Actively treat comorbid Axis I conditions5. Consultation6. Involvement of family7. 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 PatientsC. Anger, Impulsivity, and Violence
1. Monitor for impulsive or violent behavior2. Address abandonment/rejection issues,
anger, impulsivity, in therapy3. Careful coverage arrangement and
documentation when away4. 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 PatientsD. Boundary Violations
1. Monitor counter transference2. Be alert to deviations from standard
practice3. Avoid boundary violations4. Consultation
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The Effectiveness of Psychodynamic Therapy and Cognitive Behavior Therapy in the Treatment of Personality Disorders: A Meta-Analysis
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 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 Development and maintenance of an effective
therapeutic alliance is critical for success no matter what form of psychotherapy is utilized