DISORDERS
OF
PERSONALITY
2011
Definitions: PERSONALITY
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Persona – “mask” in Greek
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"...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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“...a dynamic organization, inside the person, of psychophysical systems that create
the person's characteristic patterns of behavior, thoughts and feelings" (G. Allport,
1961).
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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)
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Personality refers to enduring patterns of cognition, emotion, motivation and behavior
that are activated in particular circumstances (D. Westen 2005)
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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]
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]
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
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Innate identity - absolute uniqueness, singularity, can be concealed but cannot be erased
DNA (genotype), time / place of birth, names, ID #, temperament,
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Acquired identity - unique personal episodic memory / narrative about oneself
gender identity, character, personality, Self, endophenotype
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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.
Definitions: TEMPERAMENT, CHARACTER
TEMPERAMENT: Constitutional, genetic-biological foundations of personality regulating:
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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:
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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.
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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
Definition: PERSONALITY DISORDERS
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Chronic interpersonal dysfunction and problems with self and identity [Livesley 2001]
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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]
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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
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Maladaptive exaggeration of nonpathological personality styles and traits (Oldham 2005)
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Personality disorders are " pathologically amplified traits" (J.Paris 2005)
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Problems with self and / or others resulting in persistent interpersonal dysfunction(s), not
accounted for by other DSM disorder(s).
Definition: DISORDERS OF PERSONALITY
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A disorder of personality is an enduring disturbance of the neurocognitive system
regulating patterns of internal experience, behavior and interpersonal
adaptation.(Twardon 2008)
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“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
ICD-10 Classification of Mental and Behavioural Disorders
F60-F69 Disorders of adult personality and behaviour (1)
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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
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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
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ICD-10 Classification of Mental and Behavioural Disorders
F60-F69 Disorders of adult personality and behaviour
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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
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F63 Habit and impulse disorders
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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
(2)
ICD-10 Classification of Mental and Behavioural Disorders
F60-F69 Disorders of adult personality and behaviour
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(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
ICD-10 Classification of Mental and Behavioural Disorders
F60-F69 Disorders of adult personality and behaviour
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(4)
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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
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F69 Unspecified disorder of adult personality and behaviour
ICD-10 Classification of Mental and Behavioural Disorders
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F21 SCHIZOTYPAL DISORDER
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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).
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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.
Definition: DISORDERS OF PERSONALITY: ICD-10
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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.
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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).
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G3. There is personal distress, or adverse impact on the social environment, or both,
clearly attributable to the behaviour referred to under G2.
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G4. There must be evidence that the deviation is stable and of long duration, having its
onset in late childhood or adolescence.
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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.
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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).
PERSONALITY DISORDERS
CATEGORIES vs DIMENSIONS
Categorical models [Fuzzy concepts]
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Monothetic [necessary and sufficient attributes] [Yes / No]
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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
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theory and observation]
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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.
DSM-IV-TR
Categorical [Prototypal / Polythetic] model
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Paranoid, Schizotypal, Schizoid
• CLUSTER B
Narcissistic, Borderline, Histrionic, Antisocial
• CLUSTER C
Obsessive-Compulsive, Dependent, Avoidant
PERSONALITY DISORDERS
CATEGORIES vs DIMENSIONS: PROBLEMS & ALTERNATIVES
Problems with Categorical models:
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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:
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Develop alternative categorical diagnostic system
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Use multidimensional personality profile (e.g. MCMI-III)
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Identify dimensions underlying personality disorders
DIMENSIONAL MODELS OF PERSONALITY DISORDERS
Factor analytic models
• FFM - the Five Factors Model (McCrae & Costa 1999)
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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)
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.
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Neuroticism (vs. Emotional Stability)
Anxiety, Angry hostility, Depression, Self-consciousness, Impulsiveness, Vulnerability
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Extraversion (vs. Introversion)
Warmth, Gregariousness, Assertiveness, Activity, Excitement-seeking, Positive emotion
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Openness to experience (vs. Closedness to experiences)
Fantasy, Aesthetics, Feelings, Actions, Ideas, Values
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Agreeableness ( vs. Antagonism)
Trust, Straightforwardness, Altruism, Compliance, Modesty, Tender-mindedness
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Conscientiousness (vs. Lack of conscientiousness)
Competence, Order, Dutifulness, Achievement striving, Self-discipline, Deliberation
Dimensional Assessment of Personality Pathology - Basic Questionnaire
DAPP-BQ
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Emotional Dysregulation [Neuroticsm]
affective instability, submissiveness, cognitive distortions, anxiousness, diffidence,
self-harm, identity problems, suspiciousness, insecure attachment, avoidance, narcissism
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Dissocial Behavior [Disagreeableness]
conduct problems, stimulus seeking, callousness, rejection, suspiciousness,
passive oppositionality,
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Inhibition [Constraint]
restricted expression, intimacy problems
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Compulsivity
compulsivity
SNAP - Schedule for Nonadaptive and Adaptive Personality
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Positive Affectivity / Temperament
Exhibitionism, Entitlement, Detachment
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Negative Affectivity / Temperament
Distrust, Manipulativeness, Aggression, Self-harm, Eccentric Perceptions, ependency
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Disinhibition vs Constraint
Impulsivity, Propriety, Workoholism
SIEVERS & DAVIS - GENERAL MODEL
DIMENSIONS FOR THE DSM-IV AXIS I AND AXIS II DISORDERS
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Cognitive / Perceptual Organization – Dopaminergic
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Impulsivity / Aggression Regulation – Serotonergic
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Affective Instability – Noradrenergic-cholinergic
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Anxiety/ Inhibition – Dopamine + Serotonin
EYSENCK’S MODEL
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[E] - Extraversion – sociable, lively, active, assertive, sensation-seeking, carefree,
dominant, surgent, venturesome
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[N] – Neuroticism – anxious, depressed, guilt feelings, low self-esteem, tense, shy,
irrational, moody, emotional
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[P] – Psychoticism – aggressive, cold, egocentric, impersonal, impulsive, antisocial,
unempathic, creative, tough-minded
EYSENCK’S MODEL (2)
Biological basis for each of the three dimensions
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Eysenck (1967; 1990) proposes that there is a biological basis for introversionextraversion: introverts have higher levels of activity in the cortico-reticular
loop, and thus are chronically more cortically aroused, than extraverts.
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Neuroticism is based on a separate biological system related to the “visceral”
brain (the hippocampus-amygdala, singulum, septum, and hypothalamus) that
produces autonomic arousal.
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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.“
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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
CLONINGER'S MODEL
TEMPERAMENT DIMENSIONS
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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]
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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]
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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
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Persistence
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Self-Direction
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Cooperation
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Self-Transcendence
DEPUE - LEZENWEGER’S MODEL
MULTIDIMENSIONAL , MULTIPLE NEUROTRANSMITTER-NEUROPEPTIDE MODEL
Basic dimensions:
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AGENTIC EXTRAVERSION : NEUROTICISM
[Positive Emotionality PEM : NEM Negative Emotionality]
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CONSTRAINT
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AFFILIATION
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FEAR
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].
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Affiliation - Warmth, sociability, agreeableness
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Agency - Social dominance, assertiveness, exhibitionism, sense of potency, efficacy,
endurance, persistence, energy, assuredness, dominance
Affiliation and Agentic Extraversion are two different neurobiological systems / circuits.
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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
AGENTIC EXTRAVERSION (2)
NEUROBEHAVIORAL AREAS / CIRCUITS
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Ventral Tegmental Area (VTA) dopamine (DA) projections to the caudiomedial
shell region of the NAS [individual differences in VTA-NAS DA pathway]
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Incentive Stimulation Magnitude + State / Trait DA Receptor Activation
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Main structures: Basolateral and extended amygdala + hippocampus + posterior
medial orbital prefrontal cortical area 13
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Glutamatergic excitatory afferents to VTA-NAS systems
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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
NEUROTICISM
Anxiety + Fear
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Correlation between fear and anxiety = 0
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Gray: neuroticism= general amplifier of reactivity to both reward and
punishment signals
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Different neuroanatomy of fear and anxiety
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NE involved in two nonspecific systems: peripheral [cortex to spine-muscle]
and central [EEG activation].
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Both interrupt ongoing behavior, reset cognition, increase sensory input,
initiate selective attention,
NEUROTICISM (2)
FEAR [harm avoidance]
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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]
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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
NONAFFECTIVE CONSTRAINT
LOW IMPULSIVITY / HIGH CONSCIENTIOUSNESS
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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
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Control of emotion, sensation-seeking, risk-taking, novelty-seeking, boldness,
adventuresomeness, boredom susceptibility, unreliability, unorderliness.
Serotonin [5-HT] modulation of a Response Threshold
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Gray: Impulsivity = interaction of Extraversion, Neuroticism and Psychoticism
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Cloninger: Impulsivity is related to ‘Novelty Seeking’
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Depue-Lenzenweger: Impulsivity / sensation seeking lies between orthogonal High
Extraversion and Low Constraint
AFFILIATION
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Warmth, sociability, agreeableness
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Sexual / social contact, cohesion. Approach / interaction of sociosexual behaviors.
Facilitation of: positive reinforcement, sensory processing, social memories, feelings
of warmth, affection, caring, nurturance, mating
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Gonadal Steroids [ estrogen, progesterone, testosterone]
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Neuropetides [ oxytocin OT; vasopressin VP] involve the limbic system and have a
facilitative role in behavior and memory formation
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Opiates and opiate receptors [ mu, delta, kappa], in the cortico-limbic structures; Bendorphines – interpersonal warmth, euphoria, peaceful calmness [ naltrexone blocks
those effects], co-localization with DA receptors
Depue - Lezenweger’s Model
Hypothetical ranges for PDs on four dimensions
P. D.
PEM : NEM
CONSTRAINT
AFFILIATION
FEAR
HISTRIONIC
85-100
0-20
25-100
20-100
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
I
II
III
IV
V
FFM
EXTRAVERSION
ANTAGONISM
CONSCIENTIOUS
NESS
NEUROTICISM
OPENESS
DABB-BQ
(-) INHIBITION
DISSOCIAL
IMPULSIVITY
EMOTIONAL
DYSREGULATION
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SNAPP
POSITIVE
AFFECTIVITY
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CONSTRAINT
NEGATIVE
AFFECTIVITY
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PSY-5
POSTIVE
EMOTIONALITY
AGGRESSIVITY
CONSTRAINT
NEGATIVE
EMOTIONALITY
PSYCHOTICISM
EYSENCK
EXTRAVERSION
PSYCHOTICISM
NEUROTICISM
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SIEVER / DAVIS
(-) INHIBITION
AGGRESSIVITY / IMPULSIVITY
AFFECTIVE
INSTABILITY
COGNITIVE /
PERCEPTUAL
DISTORTION
TCI
CLONIGER
NOVELTY
SEEKING
PERSISTENCE
HARM
AVOIDANCE
TRANSCENDENCE
CONSTRAINT
NEUROTICISM /
FEAR
(-)
COOPERATIVENE
SS
REWARD DEPENDANCE
SELF-DIRECTIVENESS?
DEPUELEZENWEGER
AGENTIC
EXTRAVERSION
(-) AFFILIATION
HIGH
HISTRIONIC
E
X
T
R
A
V
E
R
S
I
O
N
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DEPENDENT
BORDERLINE
AVOIDANT
ANTISOCIAL
A
F
F
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L
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A
T
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O
N
SCHIZOTYPAL
NARCISSISTIC
PARANOID
OBSESSIVE
COMPULSIVE
SCHIZOID
LOW
CONSTRAINT / FEAR
HIGH
MAIN DIMENSIONS OF PERSONALITY DISORDERS AND THEIR TREATMENT
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NEUROBEHAVIORAL
Agentic Extraversion / PEM [Dopamine]
Affiliation [Opioids, Peptides]
Constraint (vs. Impulsivity) [Serotonin]
Neuroticism / NEM [Norepinephrine]
NEUROCOGNITIVE
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Affect Dysregulation
Impulse Dysregulation
Cognitive Dysregulation
Behavior Dysregulation
Persistence
SELF
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Cooperation
Self-Direction
Identity Diffusion
Fragmentation of Self
Object Relations
Mentalization / Reflective Function
Attachment Pathology
Self-Transcendence
DEVELOPMENTAL FRAMEWORK
CAPACITIES OF THE HUMAN MIND -a developmental framework
Attachment mediates:
• human survival
• ablity to live in groups
Surface vs. depth understanding / diagnosis
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
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
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 nonhuman objects, intentional undifferentiated symbiosis
-Pleasure-seeking, protest, protest, withdrawal, rejection, preference of physical / nonhuman objects, hyper-affectivity (diffuse discharge of affect), active avoidance
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
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
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
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
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
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]
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
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
INTROVERTED
NEUROTIC
LEVEL
EXTRAVERTED
OBSESSIVE
COMPULSIV
E
HYSTERICAL
DEPRESSIVE
MASOCHISTIC
AVOIDANT
HISTRIONIC
DEPENDENT
HIGH
BORDERLINE
LEVEL
SADOMASOCHISTIC
NARCISSISTIC
PARANOID
LOW
BORDERLINE
LEVEL
HYPOCHONDRIACAL
HYPOMANIC
SCHIZOID
BORDERLINE
MALIGNANT
NARCISSISTIC
SCHIZOTYPAL
ANTISOCIAL
PSYCHOTIC
LEVEL
PSYCHOANALYTIC TREATMENT – TFP
[2]
BASIC CONCEPTS
•
•
Internal object relations are THE basic building blocks = affect state linked to an
image of specific person / interaction between self and other.
Include BOTH actual AND fantasized interactions with other as well as defenses in
relation to both.
Can be dyadic or triadic [a sexual / loving couple + a third party who is excluded]
•
Identity is a central concept
•
•
Healthy – stable + consolidated, integrated realistic sense of self and others,
combined with positive affect states and defenses based on repression.
Pathological - unstable, polarized, unrealistic, with affects which are crude, intense,
poorly modulated, predominately aggressive and primitive defenses based on
splitting.
•
DSM criteria list observable behaviors, internal states, or symptoms
•
PSYCHOANALYTIC TREATMENT – TFP
[3]
PERSONALITY – BASIC TERMS
Temperament – constitutionally given, largely genetically determined, inborn disposition
to particular reactions – such as, intensity, rhythm, threshold of affective responses.
• Thresholds for activation positive pleasurable, rewarding affects vs negative, painful,
aggressive affects.
• Also, inborn dispositions to perceptual organization, motor reactivity and to control of
motor reactivity.
• Constitutionally determined aspects of cognition, especially as they interact with
affects and development and modulation of affects.
• Representational aspects of affect activation and modulation.
• Capacity for “effortful control” / modulation of affects
Character – 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,
Identity
•
Character is a behavioral manifestation of identity.
System of internalized values [ formerly superego]
PSYCHOANALYTIC TREATMENT – TFP [4]
NORMAL PERSONALITY
•
Integrated concept of self and significant others, identity, coherence
•
capacity for broad spectrum of affects
•
mature, integrated internalized values
•
satisfactory management of sexual, dependent and aggressive motivations
•
low affect activation states
•
peak affect activation states
•
integration of positive vs negative domains of psychological experiences [vs splitting
into all good vs all bad]
•
object constancy
•
repression of high affect unintegrated self-states – dynamic unconscious
PSYCHOANALYTIC TREATMENT – TFP [5]
PERSONALITY DISORDERS
•
•
•
•
Neurotic level
High borderline level
Severe borderline level
Psychotic level
•
•
•
•
Pathology of aggression and the severe Personality Disorders
Chronic physical pain in the first year of life
Physical abuse + trauma
affective instability – adrenergic + cholinergic systems – nor adrenaline +
acetylcholine
psychotic symptoms = dopaminergic
impulsive aggression – serotonin
amygdala
Pathology of sexuality in higher level, “neurotic’ Personality Disorders
Oedipal conflicts, inhibitions, guilt
Hysterical, O-C PD,
Paraphilias / perversions – fusion of aggressive and sexual motivations
•
•
•
•
•
•
•
PSYCHOANALYTIC TREATMENT – TFP [6]
TREATMENT
•
2-6 YEARS
•
EXPLORATION OF INTERNAL OBJECT RELATIONS
•
•
TRANSFERENCE-FOCUSED PSYCHOTHERAPY – TFP-B / TFP-N
DYADIC ANALYSIS / EXPLORATION / CONFRONTATION OF TRANSFERENCE
FOR BORDERLINE LEVEL
•
•
•
AMELIORATION OF IDENTITY DIFFUSION
IDENTITY CONSOLIDATION
INTEGRATION OF SPLIT OFF FRAGMENTS OF THE SELF
FOR NEUROTIC LEVEL
•
REDUCTION OF CHARACTER RIGIDITY
Mentalization Based Therapy
•The model takes into account constitutional vulnerability and is rooted in attachment theory
and its elaboration by contemporary developmental psychologists.
•The model suggests that disruption of the attachment relationship early in development in
combination with later traumatic experiences in an attachment context interacts with
neurobiological development.
•The combination leads to hyper-responsiveness of the attachment system which makes
mentalizing, the capacity to make sense of ourselves and others in terms of mental states,
unstable during emotional arousal.
•The emergence of earlier modes of psychological function at these times accounts for the
symptoms of (B)PD.
•The model has clinical implications and suggests that the aim of treatment is not only to
encourage development of mentalizing but also to facilitate its maintenance when the
attachment system is stimulated.
Mentalization Based Therapy
•The term reflective function (RF) refers to the psychological processes underlying the capacity
to mentalize.
•Mentalizing refers to the capacity to perceive and understand oneself and others in terms of
mental states (feelings, beliefs, intentions and desires). It also refers to the capacity to reason
about one’s own and others’ behaviour in terms of mental states, i.e. reflection.
•Reflective functioning or mentalization is the active expression of this psychological capacity
intimately related to the representation of the self.
•RF involves both a self-reflective and an interpersonal component that ideally provides the
individual with a well-developed capacity to distinguish inner from outer reality, pretend from
‘real’ modes of functioning, intra-personal mental and emotional processes from interpersonal
communications.
•This formulation differs from most developmentalists in considering RF not to be a
maturational cognitive capacity but rather a developmental achievement which is never fully
acquired and is not consistently maintained across situations.
•It is important that RF is not conflated with introspection. Introspection or self reflection is quite
different from RF as the latter is an automatic procedure, unconsciously invoked in interpreting
human action. Procedural knowledge of minds in general, rather than declarative self
knowledge, is the defining feature.
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
MULTIDIMENSIONAL / MULTIVARIABLE TREATMENT (MMT)
The Multidimensional / Multivariable Treatment (MMT) is an innovative and
arguably more efficacious than other approaches treatment model for "difficult to
engage and treat patients with severe personality disorders". The model is
"multidimensional" and "multivariable" - multiple dimensions of a personality
disorder are treated simultaneously by multiple treatment variables within an
Intensive Outpatient Program (IOP) setting.
Personality disorders are conceptualized as "enduring disturbances of
neurocognitive system regulating patterns of internal experience, behavior
and interpersonal adaptation", reflecting a life-long developmental dysregulation
of three basic domains of functioning:
• body (neurobiology),
• mind (cognition / psychodynamics)
• behavior (interpersonal relating).
MULTIDIMENSIONAL / MULTIVARIABLE TREATMENT (MMT)
Main dimensions of a personality disorder targeted in MMT are:
•
the attachment system
•
neurobehavioral circuits underlying personality
•
neurocognitve regulation of affects, mood and impulses
•
psychodynamics of object relations and ego-functions
•
cognition
•
interpersonal behavior and patterns of relating
•
consciousness, self and subjectivity
MULTIDIMENSIONAL / MULTIVARIABLE TREATMENT (MMT)
the attachment system
An innate evolutionarily hardwired neurobiological system regulating human
bonding, originally regulating mother-newborn bonding to enhance survival of the
offspring. The system involves contact seeking (sucking reflex, licking, nursing,
etc.), intense distress in both mother and the infant at separation and danger (fightflight [mother], distress cry, increased arousal and activity [newborn]. Later in life,
the attachment system regulates the formation of interpersonal / intimate bonds,
friendships and romantic relationships.
Abandonment, separation, relational loss, romantic break-up and any other rupture
of the attachment bond(s) re-activates the hardwired emergency distress reactions
(flight-fight), intense, often unbearable distress , (fear, anger, hyper arousal) which,
if prolonged, can result in despair, hopelessness, helplessness, depression,
melancholy and, in most dramatic cases, a full psychotic regression /
decompensation.
MULTIDIMENSIONAL / MULTIVARIABLE TREATMENT (MMT)
neurobehavioral circuits underlying personality
Genetically determined, biological circuits in the brain and the nervous system
regulating temperament (reactivity, sensitivity, response threshold, etc.), including
anatomical structures (limbic system, frontal cortex, brain stem), neurotransmitters
(dopamine, serotonin, norepinephrine, etc), autonomic nervous system, hormones,
sensory organs and muscle structures (?). Some of the most central ones include:
MULTIDIMENSIONAL / MULTIVARIABLE TREATMENT (MMT)
neurocognitve regulation of affects, mood and impulses
Temperament and learning (conditioning) based, activation / inhibition of affects,
mood-states and impulses. Involves complex interactions among cortical and subcortical / peripheral components of the CNS, subject to classical and operant
conditioning, prenatally and throughout lifespan. Develops, via maturation and
learning, from instinct-based reflexes to progressively more central and complex
volitional, cognitive regulation
MULTIDIMENSIONAL / MULTIVARIABLE TREATMENT (MMT)
psychodynamics of object relations and ego-functions
Psychodynamic organization and functioning of unconscious (primary process) and
conscious aspects of object relations and object choices, defenses and ego
functions, including wish-defense configurations, internal conflicts, displacement
and condensation, symbolization and configurations of signifiers, dreams, identity
and desires
MULTIDIMENSIONAL / MULTIVARIABLE TREATMENT (MMT)
Cognition
All aspects of perception and cognitive functioning including cognitive styles,/
biases and distortions, learning and information processing, procedural /
declarative, semantic / episodic memory (knowledge, skills, etc.), language
processing, schemata and representations of self and others, mentalization,
personal theory / construction of meaning, mind and reality.
MULTIDIMENSIONAL / MULTIVARIABLE TREATMENT (MMT)
Interpersonal behavior and patterns of relating
All and any observable aspects of action and behavior, including physiological
manifestations of internal states regulated by the autonomic nervous system,
observable aspects of cognition, psychodynamics and internal experience (e.g.
attention, emotions, mood states), patterns of interpersonal relating, appearance,
speech and vocalizations.
•
MULTIDIMENSIONAL / MULTIVARIABLE TREATMENT (MMT)
Consciousness, self and subjectivity
Moment-to-moment changes of one’s consciousness and its dialectical mutuality
with the experience of subjectivity and the self. All and any contents and states of
consciousness experienced by a person, including the in-the-moment experience of
one’s existence .The phenomenological center of one’s being and subjectivity.
MULTIDIMENSIONAL / MULTIVARIABLE TREATMENT (MMT)
Main clusters of treatment variables are
•
•
Theory
Structure and modalities
–
–
–
•
Technical interventions
–
–
–
–
–
–
•
New skill acquisition
Classical re-conditioning
Therapist
–
–
–
–
•
Language / speech transactions
Environmental transactions
Relational transactions
Psychodynamic / cognitive
Behavioral / relational
Special assignments
New learning and conditioning
–
–
•
Environmental / milieu
Individual vs. Group
Contingencies and consequences [IF…….Then……]
Demographics
Theoretical / clinical stance
Personality / self / consciousness
Countertransference
Peer group dynamics
MULTIDIMENSIONAL / MULTIVARIABLE TREATMENT (MMT)
theoretical approach
Personality Disorders are approached as a life-long neurocognitive disturbance of
consciousness and self-states manifested by dysregulation of mood, impulses,
affects, perception, cognition and interpersonal behavior. Consciousness and the
self are user-defined, subject to an ongoing analysis and transformation, by the
therapist and the patient, in the course of MMT.
The treatment involves a non-integrative application of psychoanalytic and
neurocognitive theories of mind and brain in the analysis and transformation of the
moment-to-moment flow of states of consciousness, subjective experience and
observable behaviors both in maladaptive symptom-formation and in curative
change.
TREATMENT
OF PERSONALITY DISORDERS
•
•
•
•
•
•
•
•
•
•
PSYCHOTHERAPY – DEFINITIONS, OUTCOMES, METAPHORS
PERSONAL METAPHORS AND SELF-PARADIGMS
PSYCHOANALYTIC / PSYCHODYNAMIC APPROACHES
COGNITIVE & BEHAVIORAL APPROACHES
DBT - DIALECTICAL BEHAVIOR THERAPY
ATTACHMENT – BASED APPROACHES
INTERPERSONAL APPROACHES
OTHER APPROACHES AND MODELS
GENERAL, INTEGRATED MODEL
MULTIDIMENSIONAL / MULTIVARIABLE MODEL
PSYCHOTHERAPY
Psychotherapy is a process of changing one’s mind, brain and behavior to
alleviate psychological symptoms and / or to improve functioning.
It is a transformation of several biopsychosocial functions which typically affects
one’s:
•
personality, including the conscious and unconscious components of the Self,
ego, character organization, emotions, wishes and desires, inhibitions, conflicts
•
brain, including neurocognitive activity of neuronal associative networks,
memory, language, information processing, neurotransmitters, molecular
biochemistry and global integrative functions
•
behavior, including one's observable actions, interactions and relationships
with others
•
It is not a set of procedures or techniques applied to a person by the therapist. It is a
change in the subjective experience which begins in the therapy office and then is
not only carried outside of it but also continues to unfold during the time between
sessions.
PSYCHOTHERAPY [2]
• Psychotherapy involves dialectical use of spoken language between
the therapist and the patient. It necessitates a unique kind of a
dialogue, narrative or a conversation between the therapist and the
patient , whereby spoken language, ranging from simple words and
instructions to intensely personal, infinitely complex narratives and
dialogues, becomes the main medium of personal change within and
beyond the psychotherapy office.
• On the most fundamental level, is a process of examining, exploring,
changing and re-constructing the moment-to-moment flow of one’s
subjective experience.
PSYCHOTHERAPY [3]
Psychotherapy typically brings about at least one of the following outcomes:
•
•
•
•
•
•
•
•
•
•
•
cure of a mental disorder
symptoms reduction (i.e. decrease in their intensity, frequency, range or scope
of interference with functioning)
reduction of subjectively experienced distress or suffering
insight - improved understanding of oneself and others
conflict(s) resolution
wellness - improved psychological, emotional and interpersonal functioning
improved performance / efficacy of actions
ability to work, play and love
personal development
improved capacity for compassion
improved capacity for happiness
PSYCHOTHERAPY [4]
The Western culture’s attempt to alleviate and remedy human suffering, over the
centuries, it has been a realm of gods, magic, shamanism, religion, spiritual
practice, art, philosophy, social activism and, most recently, of science.
METAPHORS FOR PSYCHOTHERAPY
•
•
•
•
•
•
•
Medical ones - healing, cure, treatment, recovery, remission, rehabilitation –
suggesting restoration of health from sickness, disease, disorder, illness,
disability, impairment.
Exploratory ones – self-discovery, journey, insight – emphasizing a search for
a new or hidden territory, place, secret.
Aesthetic ones – (re)-creating a state of harmony, balance, grace and,
ultimately, beauty
Religious / spiritual ones – transcendence, higher power, finding God,
enlightenment,
Technological ones – mastery of control, power, efficacy, outcomes
Scientific ones – mastery of knowledge, explanation, control, prediction,
learning
Interpersonal ones – intimacy, autonomy, interdependency, love,
PSYCHOTHERAPY [5]
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
CHANGE
DISCOVERY
JOURNEY
ANALYSIS
RECONSTRUCTION
HEALING
REPARENTING
EXPLORATION
KNOWLEDGE
INSIGHT
LEARNING
NEW NARRATIVE
TRUTH
CONDITIONING
SKILLS ACQUISITION
GROWTH
•
•
•
•
•
•
•
•
•
•
NEW LEARNING
DESENSITIZATION
MODIFICATION OF SCHEMATA
OF SELF AND OTHERS
CONSTRUCTION OF NEW
NARRATIVE ABOUT SELF AND
OTHERS
SYSTEMS CHANGE
MAKING UNCONSCIOUS
CONSCIOUS
BEHAVIORAL REHEARSAL
ACCEPTANCE OF SELF AND
OTHERS, POSITIVE REGARD
NEW LIFE STYLE
OTHER?
PERSONAL METAPHORS &
LIFE PARADIGMS
WHY PEOPLE WITH PDs CAN’T OR WON’T GET BETTER
Psychotherapy & medicine represent a “health / cure” paradigm
Alternative metaphors / paradigms more important than “health / cure”:
•
•
•
•
•
•
•
•
•
•
PLEASURE – HEDONISM, SELF-INDULGENCE
POWER – WEALTH, POLITICS, CONTROL, MILITARY
BEAUTY – ART
CREATIVITY
ROMANTIC LOVE
TRANSCENDENCE - GREATER CAUSE / OTHERS
TRANSCENDENCE - GOD / RELIGION / SPIRITUALITY
TRANSCENDENCE – MARTYRDOM
ESCAPISM
OTHER
TREATMENT – MAIN APPROACHES
•
•
•
•
•
•
•
•
•
•
SUPPORTIVE PSYCHOTHERAPY
PSYCHOANALYSIS
PSYCHOANALYTIC / PSYCHODYNAMIC THERAPY
MENTALIZATION-BASED THERAPY - Fonagy
COGNITIVE THERAPY
SCHEMA THERAPY
DIALECTICAL BEHAVIOR THERAPY – M. Linehan
COGNITIVE ANALYTIC THERAPY - Anthony Ryle
INTERPERSONAL THEORY – L. Benjamin
PSYCHOPHARMACOLOGY
GENERAL GUIDELINES FOR TREATMENT
•
NO SINGLE APPROACH HAS MONOPOLY
•
DIFFERENT INTERVENTIONS ARE EFFECTIVE FOR DIFFERENT SYMPTOMS
•
DIVERSE, EVIDENCE-BASED INTEGRATIVE TREATMENT IS NEEDED
•
•
PSYCHOTHERAPY INTEGRATION:
TECHNICAL ECLECTICISM  SELECTING THE BEST COMBINATION OF
INTERVENTIONS MATCHING THE PERSON OR PROBLEM / SYMPTOM
•
THEORETICAL INTEGRATION  BASIC CONCEPTS:
NEUROCOGNITIVE STRUCTURE / CIRCUIT
REPRESENTATION OF SELF AND OTHERS
OBJECT RELATIONS
SCHEMA / WORKING MODELS.
•
COMMON FACTORS APPROACH: RELATIONSHIP / SUPPORTIVE FACTORS +
TECHNICAL FACTORS [ NEW LEARNING]
TREATMENT – MAIN PRINCIPLES [1]
[1] TREATMENT OF PDS REQUIRES MULTIDIMENSIONAL / MULTIVARIABLE
INTERVENTIONS
•
BASIC DIMENSIONS / VARIABLES ARE:
•
•
•
•
•
•
•
•
•
•
•
•
•
MIND / COGNITION [PSYCHODYNAMIC, SCHEMA, COGNITIVE]
BRAIN / CNS [PSYCHOPHARMACOLOGY]
BEHAVIOR [DBT / INTERPERSONAL]
MOOD
AFFECTS
PSYCHOTIC RANGE SYMPTOMS
SELF HARM / SUICIDE
SUBSTANCE ABUSE
SELF-REGULATION
IMPULSE CONTROL
ATTACHMENT PROBLEMS
RELATIONSHIPS / INTIMACY
SELF / OTHER REPRESENTATIONS,
TREATMENT – MAIN PRINCIPLES [2]
[2] CORE FEATURES [COMMON TO ALL PDs] + SPECIFIC SYMPTOMS [SPECIFIC TO A
SPECIFIC PD]
•
CORE FEATURES:
1. SELF / OTHER REPRESENTATIONS + INTERPERSONAL FUNCTIONING
+ SELF-REGULATION - BUT EACH IS MANIFESTED DIFFERENTLY IN
EACH PD [E.G. SCHIZOID vs BPD]
2. IMPORTANCE OF THERAPEUTIC RELATIONSHIP – IT ADDRESSES
THE CORE
PROBLEM – RELATIONSHIPS / INTIMACY
3. EMPATHIC / SUPPORTIVE vs CONFRONTATIVE --- INTERPRETATIVE
CONTINUUM
[3] PDs ARE COMPLEX BIOPSYCHOSOCIAL SYNDROMES
1. BIOLOGICAL / GENETIC FACTORS – SEE BEFORE
2. BASIC PERSONALITY TRAITS , BIOLOGY / TEMPERAMENT-BASED
ARE
DIFFICULT TO CHANGE - WHAT NEEDS TO CHANGE IS
HOW THEY
BECOME MORE ADAPTIVE / EFFECTIVE
3. THE GOAL OF TREATMENT IS TO ENHANCE ADAPTATION BY
BUILDING
COMPETENCE
TREATMENT – MAIN PRINCIPLES [3]
[4] THE ROLE OF PSYCHOSOCIAL ADVERSITY / TRAUMA IN THE FORMATION OF PDs
TRAUMATIC EXPERIENCES NEED TO BE ADDRESSED / RESOLVED FIRST
UNDERSTANDING CHANGE
METAPHORS FOR THERAPEUTIC CHANGE
[SEE EARLIER]
• METAPHORS FOR PSYCHOTHERAPY SHOULD MATCH
PATIENT’S METAPHORS / LIFE PARADIGMS WHENEVER
POSSIBLE RESULTING IN “COLLABORATIVE DESCRIPTION /
CONVERSATIONAL ELABORATION”
MAIN STAGES OF CHANGE IN THERAPY
• REFERRAL -> INITIAL CONTACT -> ENGAGEMENT ->
• READINESS / PREPARATION -> THERAPY PROPER ->
• MAINTENANCE -> TERMINATION
UNDERSTANDING CHANGE [1]
[1] PROBLEM RECOGNITION / CONTRACT
[2] EXPLORATION
•
•
•
•
•
•
•
•
•
•
•
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MICRO-ANALYSIS OF SUBJECTIVE EXPERIENCE
SYMPTOM ANALYSIS
BEHAVIOR ANALYSIS
SUBJECTIVE EXPERIENCE ANALYSIS
INTERPERSONAL ANALYSIS
DIARIES
MAKING CONNECTIONS WITHIN DESCRIPTION - ANTECEDENTS, TRIGGERS,
CONSEQUENCES, ETC.
DESCRIPTIVE REFRAMING
FOCUSING ON GENERAL THEMES / PATTERNS AND SPECIFICS
PROMOTING SELF-OBSERVATION, SELF AWARENESS, SELF-MONITORING
IDENTIFYING MAINTENANCE FACTORS, SYMPTOMATIC RELAPSE
PREVENTION
ADDRESSING / CHALLENGING OBSTACLES TO CHANGE
UNDERSTANDING CHANGE [2]
[3] ACQUISITION OF ALTERNATIVE SKILLS AND BEHAVIORS
•
•
•
•
•
GENERATING ALTERNATIVES / PROBLEM SOLVING
MAINTAINING MOTIVATION TO CHANGE
ENCOURAGING NEW BEHAVIORS
INHIBITING OLD PATTERNS – CONTRACTS, DISTRACTIONS,
CONTINGENCIES MANAGEMENT
TEACHING NEW SKILLS
[4] CONSOLIDATION AND GENERALIZATION
•
•
•
•
APPLYING NEW LEARNING TO SPECIFIC SITUATIONS
REHEARSAL
DEVELOPING MAINTENANCE STRATEGIES
ATTRIBUTION OF CHANGE
GENERAL THERAPEUTIC STRATEGIES [1]
[LIVESLEY 2001]
[1] BUILD AND MAINTAIN A COLLABORATIVE RELATIONSHIP
•
•
•
•
•
•
•
•
•
•
BUILD CREDIBILITY
GENERATE OPTIMISM AND HOPE
COMMUNICATE UNDERSTANDING AND ACCEPTANCE
INDICATE SUPPORT FOR THE GOALS OF THERAPY
RECOGNIZE PROGRESS
ACKNOWLEDGE THE USE OF SKILLS & KNOWLEDGE LEARNED
USE RELATIONSHIP LANGUAGE
REFER TO SHARED EXPERIENCES IN THERAPY
ENGAGE IN COLLABORATIVE SEARCH FOR UNDERSTANDING
MONITOR ALLIANCE AND MANAGE RUPTURES
GENERAL THERAPEUTIC STRATEGIES [2]
[2] ESTABLISH AND MAINTAIN A CONSISTENT TREATMENT PROCESS
•
•
•
•
•
ESTABLISH A CONSISTENT FRAME
TREATMENT CONTRACT
THERAPEUTIC STANCE
TREATMENT CONTEXT
MAINTAIN CONSISTENCY
GENERAL THERAPEUTIC STRATEGIES [3]
[3] VALIDATION
•
•
•
•
•
•
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RECOGNIZE, ACKNOWLEDGE, ACCEPT BEHAVIOR AND EXPERIENCE
AVOID PREMATURE FOCUSING ON POSITIVE / NEGATIVE
COLLABORATIVE SEARCH FOR MEANING
COUNTERACT SELF - INVALIDATION
RECOGNIZE AREAS OF COMPETENCE
REDUCE SELF-DEROGATION
MANAGE VALIDATION RUPTURES
GENERAL THERAPEUTIC STRATEGIES [4]
[4] BUILD AND MAINTAIN MOTIVATION
•
•
•
•
•
USING DISCONTENTMENT
CREATING OPTIONS
FOCUS ON SMALL STEPS
CHALLENGING INCENTIVES FOR NOT CHANGING
MANAGING AMBIVALENCE
[5] CONSOLIDATION, TRANSFER, GENERALIZATION, RELAPSE PREVENTION
SPECIFIC THERAPEUTIC STRATEGIES
[1] SYMPTOMS AND CRISES MANAGEMENT
•
•
•
CONTAINMENT
MEDICATION
COGNITIVE – BEHAVIORAL INTERVENTIONS
[2] PROMOTING MORE ADAPTIVE EXPRESSION OF BASIC TRAITS
•
•
•
INCREASE TOLERANCE AND ACCEPTANCE
ATTENUATE TRAIT EXPRESSION
SUBSTITUTE MORE ADAPTIVE TRAIT EXPRESSION
[3] SELF / INTERPERSONAL PROBLEMS
• REPETITIVE BEHAVIOR PATTERNS
• SELF / OTHER SCHEMATA
• SELF PATHOLOGY / DISJUNCTIONS
• MANAGING FRAGMENTATION / INTEGRATION
• CONSTRUCT A NEW ‘THEORY’ OF THE SELF
BUDDHIST MEDITATION
TO STUDY THE BUDDHA WAY IS TO STUDY THE SELF.
TO STUDY THE SELF IS TO FORGET THE SELF.
TO FORGET THE SELF IS TO BE REALIZED BY THE ENTIRE UNIVERSE.
WHEN REALIZED BY THE UNIVERSE THE BODY-AND-MIND AND THE
ENTIRE UNIVERSE DROP AWAY.
Eihei Dogen (1200-1253)
Shobogenzo
Definitions: MEDITATION
RG-VEDA / UPANISHADAS
DHI OR DHYA => TO THINK => INQUIRY, EXAMINATION OR INTROSPECTION
SANSCRIT
DHYANA => THOUGHT , REFLECTION , PROFOUND AND ABSTRACT RELIGIOUS
PRACTICE, MENTAL REPRESENTATION OF THE PERSONAL ATTRIBUTES OF A
DEITY, TRANCE STATE, MEDITATION ,
DHAYANA IS ONE OF 8 MAIN STAGES OF PRACTICE OF YOGA
Yama, Niyama, Asana, Pranayama, Pratyahara, Dharana, Dhyana and Samadhi.
YOGA=> UNION, YOKE, APPLICATION; MEANS, ART, MAGIC, WORK, RELATION,
CONTACT, PURSUIT, ORDER, FITNESS, EFFORT, ATTENTION, CONCENTRATION,
MEDITATION, CONTEMPLATION
DHYANA BUDDHISM => [CHINESE] CH’AN BUDDHISM = > [ JAPANESE] ZEN –
“MEDITATION” BUDDHISM
Definitions: MEDITATION
•
HEBREW [OLD TESTAMENT]
HAGAH => TO "PONDER, IMAGINE, MOURN, SPEAK, STUDY, TALK,
UTTER, MEDITATE”
•
GREEK
MELETAO => TO CARE FOR, TO ATTEND TO, PRACTICE, BE DILIGENT IN,
TO PONDER, IMAGINE
•
LATIN
MEDITATIO => TO STUDY, TO PRACTICE, PREPARATION, GETTING
READY / CONSIDERATION, PONDERING, TO REFLECT UPON
•
ENGLISH
MEDITATION => SERIOUS CONSIDERATION, AS OF UNDERTAKING A COURSE
OF ACTION OR OF IMPLEMENTING A PLAN; DEEP REFLECTION,
PRAYER, CONTEMPLATION
ORIGINAL MEANING IN MODERN TERMS:
REFLECTION + INTROSPECTION + CONTEMPLATION + SELF-HELP + HEALING+
SELF-ACTUALIZATION + PSYCHOTHERAPY + SPIRITUALITY
Definitions: MINDFULNESS
SITA [PALI]
MINDFULNESS - AN INTENTIONAL FOCUSED AWARENESS – A WAY OF PAYING
ATTENTION ON PURPOSE IN THE PRESENT MOMENT, NON-JUDGMENTALLY
MINDFULNESS TRAINING –
[1] LEARNING HOW TO BE PRESENT, AWARE, ATTENTIVE AND,
[2] LEARNING TO PERCEIVE THE FLOW OF EXPERIENCE IN A NEW UNBIASED,
WAY, TO EXPERIENCE THE REALITY AS IT “REALLY” IS.
VIPASSANA [IN-SIGHT] MEDITATION IS A DIRECT AND GRADUAL CULTIVATION
OF MINDFULNESS OR AWARENESS RESULTING IN A NEW WAY OF PERCEIVING
SELF, OTHERS AND ALL PHENOMENA.
MINDFULNESS IS ONE OF KEY COMPONENTS OF MEDITATION
MINDFULNESS TRAINING IS NOT MEDITATION TRAINING
BUDDHIST MEDITATION
A CONTINUUM OF PRACTICES AND INTENDED OUTCOMES
GUIDED BY FOUR NOBLE TRUTHS AND EIGHTFOLD PATH
The Four Noble Truths
The truth of suffering
The truth of origins of suffering
The truth of cessation of suffering
The truth of the Way to cessation of suffering
The Eightfold Path
Right Understanding
Right Thought
Right Speech
Right Action
Right Livelihood
Right Effort
Right Mindfulness
Right Concentration
“MEDITATION IS THE ABSENCE OF THE MEDITATOR”
MEDITATION TRAINING IN BUDDHISM
MULTIPLE COMPLEMENTARY MODELS OF TRAINING
•
The ‘Arhat’ [‘saint / ascetic’] model – Theravada
•
The ‘Boddhisatva’ [compassion] model - Mahayana
Finding the path – peak – returning to marketplace
Realization + Actualization [‘insight + working through’]
•
Zen - mindfulness training –> Kensho(s) – Dai Kensho
•
Mindfulness training vs. Emptiness [formlessness] training
Relative [consensual] vs. Absolute [quantum] Realities
Most of the self / characterological changes occur in the advanced ‘actualization’ stage
Definitions: MEDITATION
A CONTINUUM OF PRACTICES & INTENEDED OUTCOMES
RESPITE / RELAXATION ------------------------------------------------- ENLIGHTENMENT
MAIN ASPECTS / STAGES:
1.
RELAXATION, REST, CALM
2.
MINDFULNESS, CONCENTRATION, ABSORPTION
3.
INSIGHT, KENSHO, SELF-TRANSCENDENCE
4.
ENLIGHTENMENT, WISDOM, COMPASSION
SITTING MEDITATION
BASIC ZAZEN INSTRUCTION
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PAUSE – STOP ALL HABITUAL ACTIVITY
POSTURE - BE STILL
BECOME AWARE OF YOUR BODY, BREATH, SENSES
CLOSE YOUR EYES
BREATHE NATURALLY THROUGH NOSE
COUNT EACH BREATH FROM 1 TO 10
CONCENTRATE
FOCUS ATTENTION ON JUST COUNTING 1-10
LET GO OF ALL THOUGHTS AND IMAGES
RESISIT ANY AND ALL IMPULSES TO MOVE
RESIST ANY AND ALL URGES TO ANALYZE, INTROSPECT, THINK,
REMEMBER, PLAN, ANTICIPATE, WORRY, COMPARE,
• REMAIN IN THE PRESENT, DO NOT INVOKE PAST OR FUTURE
• LET GO OF THE OBSERVING MEDITATOR
EFFECTS OF MEDITATION
•
Effective for treating a variety of stress-related, somatically based problems
•
A preventive or rehabilitative strategy in treatment of addictions, hypertension,
fears, phobias, asthma, insomnia, and stress
•
Subjects using meditation change more than control groups in the direction of
positive mental health, positive personality change, self-actualization,
increased spontaneity self-regard and inner directedness and self-perceived
increase in the capacity for intimate contact
•
Influence on personality scores - on self-esteem and self-concept, depression,
psychosomatic symptomatology, self-actualization, locus of control, and
introversion / extroversion.
PERCEPTUAL AND COGNITIVE ABILITIES
•
Perceptual ability
•
Reaction time and perceptual motor skill
•
Deautomatization
•
Field independence
•
Concentration and attention
•
Memory and intelligence
•
Rorschach shifts
•
Regression in the service of the ego
•
•
•
Empathy
•
Hypnotic suggestibility
Creativity and self-actualization
MECHANISMS OF ACTION
Zen training is an agency of character change, a program designed to point the whole
personality in the direction of increasing selflessness and enhanced awareness.
(J. Austin, Zen Brain Reflections, 2008)
The nervous system undergoes a series of fundamental changes.
"In Zen you let your frontal lobes to rest"
(Dainin Katagiri Roshi)
•
Relaxation / physiological variables
•
Cognitive / behavioral variables
•
Psychodynamic variables
•
Interpersonal variables
•
Spiritual / transcendental variables
RELAXATION / PHYSIOLOGICAL VARIABLES
•
Changes in the brain
•
Changes in CNS & autonomic responses
•
Reduction in stress / anxiety / dysphoric states
•
Improved wellness
•
“Flow” / “Zone” experience
COGNITIVE / BEHAVIORAL VARIABLES
•
Retraining of habitual patterns of attention, perception, cognition, and
response.
•
“Deautomatization" of consciousness & behavior
•
New competeing responses
•
Impulse / reactivity management
•
Freeing up of working memory capacity
•
Creating / remembering / re-learning of pleasurable experience
•
Behavioral stillness instead of enactment / acting out
•
Self-regulation skills
•
Radical acceptance & hope
PSYCHODYNAMIC VARIABLES
•
Self-observation / observing ego
•
Free associations
•
Re-organization of defenses
•
Return of the repressed material
•
Curative regression to earlier traumatic experiences
•
Re-experiencing of “primitive” mental states / affects and impulses
•
Re-experience of pre-verbal aspects of loss, deprivation, abandonment, pain
•
Positive corrective experiences
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Self-soothing and containment
•
Maturation / transcendence of the self
MAIN DIMENSIONS OF PERSONALITY DISORDERS AND THEIR TREATMENT
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NEUROBEHAVIORAL
Agentic Extraversion / PEM [Dopamine]
Affiliation [Opioids, Peptides]
Constraint (vs. Impulsivity) [Serotonin]
Neuroticism / NEM [Norepinephrine]
NEUROCOGNITIVE
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Affect Dysregulation
Impulse Dysregulation
Cognitive Dysregulation
Behavior Dysregulation
Persistence
SELF
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Cooperation
Self-Direction
Identity Diffusion
Fragmentation of Self
Object Relations
Mentalization / Reflective Function
Attachment Pathology
Self-Transcendence
EFFECTS OF BUDDHIST MEDITATION ON DISORDERS OF PERSONALITY
I
RELAXATION
AGENTIC EXTRAVERSION - PEM
+++
AFFILIATION vs ANTAGONISM
+++
CONSTRAINT vs. IMPULSIVITY
--- / +++
II
MINDFULNESS
III
INSIGHT
IV
ENLIGHTENMENT
+++
+++
+++
+++
---
---
+++
+++
NEUROTICISM - NEM
+++
AFFECT / IMPULSE DYSREGULATION
+++
COGNITIVE DYSREGULATION
+++
+++
?
?
BEHAVIOR DYSREGULATION
--- / +++
+++
?
?
+++
+++
PERSISTENCE
+
COOPERATION
+++
SELF-DIRECTION
+
IDENTITY DIFFUSION
FRAGMENTATION OF SELF
-/+
OBJECT RELATIONS
MENTALIZATION
ATTACHMENT PROBLEMS
SELF-TRANSCENDENCE
+++
?
-/+
-/+
?
---
---
+
+++
+++
+++
+++
+++
+++
+++
BUDDHIST MEDITATION AND PERSONALITY DISORDERS
Different instruction and techniques used for different types of personality organization
during meditation
•
DSM CLUSTER “A”
Mindfulness training used to increase capacity for being present and grounded in the
sensory / consensual / interpersonal reality vs. Schizotypal, Paranoid, Schizoid
ideation / cognition
•
DSM CLUSTER “B”
Impulsivity / anger management, behavioral / affective / cognitive containment /
soothing; reduced reactivity, observing ego, self- regulation, insight, integration
•
DSM CLUSTER “C”
Anxiety / fear reduction, relaxation, self-soothing, PEM:NEM, capacity for sensory
experience vs worry, obsessive ideation, phobias, disinhibition, being present in the
here-now
Mentalization Based Therapy
Attachment categories
Secure:
"It is relatively easy for me to become emotionally close to others. I am comfortable
depending on others and having others depend on me. I don't worry about being alone or
having others not accept me.
Dismissive-Avoidant
"I am comfortable without close emotional relationships. It is very important to me to feel
independent and self-sufficient, and I prefer not to depend on others or have others
depend on me."
Fearful-Avoidant
"I am somewhat uncomfortable getting close to others. I want emotionally close
relationships, but I find it difficult to trust others completely, or to depend on them. I
sometimes worry that I will be hurt if I allow myself to become too close to others."
Preoccupied
"I want to be completely emotionally intimate with others, but I often find that others are
reluctant to get as close as I would like. I am uncomfortable being without close
relationships, but I sometimes worry that others don't value me as much as I value them."
Mentalization Based Therapy
Attachment styles:
CHILDREN: Bolwby-Ainsworth [Strange Situation paradigm]
Secure, Anxious / Avoidant, Anxious / Resistant (Ambivalent),
Disorganized / Disoriented
Secure,Insecure,Unresolved, Fearful, Preoccupied
ADULTS [Romantic Relationships]
Secure, Preoccupied, Dismissive [ARS, Hazan, Shaver 2002]
Secure, Preoccupied, Fearful, Dismissive [RQ, RSQ]
Secure, Anxious-Preoccupied, Dismissive-Avoidant, Fearful-Avoidant
PARENTS-CHILDREN:
Autonomous<->Secure; Dismissive<->Avoidant; Preoccupied<>Ambivalent / Resistant; Unresolved<->Disorganized
Mentalization Based Therapy
Brain abnormalities identified in borderline patients are consistent with
the suggestion that a failure of representation of self-states is a key dysfunction in
BPD.
•Anterior cingulate cortex - mentalizing the self & emotional states.
•Dorsal anterior cingulate -implicit self-representations (i.e., phenomenal self-awareness)
•Rostral anterior cingulate -explicit self-representations (i.e., reflection)
•
•Medial prefrontal cortex - a wide range of mentalization inferences, in both visual and verbal
domains.
•Prefrontal cortex - representing the mental states of others.
•Mesial prefrontal cortex
•parieto-temporal junction
•temporal poles
Mentalization Based Therapy
Prementalistic ways of representing subjectivity
•Psychic equivalence - there is no experience of “as if” and the internal experience becomes
“real.”
•Pretend mode - thoughts and feelings are dissociated to the point of near meaninglessness.
In these states patients can discuss experiences without contextualizing them in any
kind of physical or material reality.
Buddhist Meditation and Disorders of Personality
•Heart Rate / Respiration - lower rates, relaxation via parasympathetic and limbic systems,
possible release of GABA and opioids
•Cortisol - regular meditative practice can reduce blood cortisone and NE and ACTH levels.
•Reduction in "stress response" ["calming of the brain"] - regular meditation reduces firing in
amygdala, hippocampus and hypothalamus, locus ceruleus, anterior pituitary gland.
•Changes in melatonin levels [sleep, immune system regulation] - direction needs to be studied
•Brain waves
Delta 0.7-4 cps, Theta 4-7 cps, Alpha 8-12 cps, Beta 13-29 cps, Gamma 30-70 cps
•Transcortical synchronization of brain waves in specific parts of the brain and throughout many
structures.
•Changes in the pre-frontal lobes and thalamus.