Prelim 3- Personality Disorders pt. 2

Marsha Linechan

• dialectical behavior therapy

• most eminent innovative clinical psychologists of the past serval decades

• figures how to treat clients do whom there was no previous effective treatment

• adolsecent i

boderline personality disorder

• instability of interpersonal relationships, self-image, and effects and marked impulsivity

• >5 symptoms

• recurrent suicidal behavior, gestures, threats or self mutilating

• affective instability due to a marked reactivity of mood

• chronic feelings of emptiness

• inappropriate intense anger or difficulty controlling anger

• transient, stress related paranoid ideation or severe dissociative symptoms

>5 symptoms of borderline personality disorder

• frantic efforts to avoid real or imagined abandonment

• pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization. and devaluation

• identity disturbance: markedly and persistently unstable self image or sense of self 

• impulsivity in at least 2 areas that are potentially self damaging 

Lifespan trajectory

• earliest symptoms and indicators of BPD emerge during puberty

• peak in severity in late adolescence and emerging adulthood

• most tend to show a natural attenuation of symptoms without any intervention

• 25-40%: recovery from symptoms

• symptoms continue to decline

  • but unclear if other types of symptoms become stronger during this time

Is Borderline Personality Disorder comorbid?

• yes highly with mood, subtance use and eating disorders 

other facts of borderline personality disorder

• 1-12% of population but constitutes 20-25% impatient admissions

• difficulties with emotion regulation is one of the core features of BPD and a what to distinguish it form other other disorders

• tend to be more reactive, greater emotional fluctuations , and more intense emotions

• commonly experienced negative emotions: anger, sadness, shame

Why use borderline?

• identifying patient as “borderline” started post-Freud era

• diagnosis was not particularly descriptive relative to today and patients were classified according to how “analyzable” they were

• “borderline”- being between psychosis (not analyzable) and neurosis (analyzable)

  • when diagnosed, did not improve with psychoanalysis it was attributed to their unconscious guilt, envy, and need ti destroy the therapist

What is BPD associated with?

• low educational attainment

• employment trouble

• few friendships

• lack of romantic relationships

• limited social support

• low life satisfaction

What are examples of abrupt changes?

• rapid changes in self-image, emotions and relationships

• feeling happy and elated to having profound suicidal ideation within a few hours

• dichotomous thinking

dichotomous thinking

viewing situations in extreme either/or categories 

• switch from all good to all bad

Cognitions and Self image in BPD

• hypervigilant to threat and danger

• view themselves as powerless and in danger ad the world is malevolent

• tend to allocate attention to negative information more than neutral or positive

• tend to recall more negative information

• rate neutral or ambiguously interpersonal stimuli more negatively

rumination

• people with BPD very prone to rumination and in the same way with depression

  • distress and its causes and consequences

  • anger rumination

anger rumination

dwelling experiences that evoke anger

• predicts engagement in many rash, impulsive behaviors

• more severe and frequent anger rumination is correlated with

Is this a personality disorder or truama disorder?

• highly correlated to trauma

• 14x more likely to report childhood trauma

Why do we diagnose this as having personality disorders rather than trauma disorders?

• open ended

What causes this according to Linehan

• biological predisposition to emotion dysregulation

• invalidating childhood environment

biological predisposition

• genetics

• experiences during fetal development

how do they infleunce each other 

• as emotional experiences are dismissed, ignored or punished

• children don’t learn how to understand, tolerate or regulate their emotional responses

• switch between emotinal inhibition and emotional instability

Dialectical Behavior Therapy (DBT)

• tested for 2 decades, component for component

• treat recurrent suicidal and self injurious behavior 

• validated on people the most effective treatment for BPD 

• improves suicidal and self-injurious behavior, emotional regulation and interpersonal difficulties 

• since demonstrated to work for maby other disorders and situations

  • “treatment resistnet”

why dialectic?

• 2 conflicting ideas can both be true at the same time

• guiding dialectic is typically fully accepting yourself and your circumstances and recognizing the need for change 

Radical Acceptance

accepting reality as it is, without judgement or resistance, even if it is painful and difficult

Components of DBT

• skills training group: meets weekly 2 hrs each time, takes 6 months to work through all modules, can choose to come longer and repeat modules

  • modules target mindfulness, interpersonal effectiveness, emotion regulation, distress tolerance

• individual therapy: supplements skills group; focus on suicidal and self-injurious behaviors, behaviors that interfere with therapy and with quality of life, trauma history, building self respect

• telephone consultation: people with BPD often do not ask for help because of past invalidating experiences or ask for help in ways other people perceive negatively; telephone consultation is available at all times of day except in the 24 hrs after self-injurious behavior; people are told the expectation is they contact therapist prior to self-injurious behavior

• therapist Consultation Team: weekly meetings of individual and group therapists providing DBT to support therapists and scaffold the treatment

What is the goal of DBT?

• not help people with borderline cope with stressors but to change how people understand and respond to their emotions

Pharmacotherapy

• medication is not recommended or supported for BPD

• both antipsychotics and mood stabilizer are frequently used, with roughly 2/3 of people with BPD one more than one medication

• medication can improve comorbid conditions

Narcissistic Personality Disorder (Cluster B)

• pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy

• >5 or more

>5 or more of Narcissistic Personality  

• has a grandiose sense of self-importance

• preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love

• believes that he or she is “special” and unique and can only be understand by, or should associate with, other special or high-status people (or institutions)

• requires excessive admiration

• sense of entitlement

• is interpersonally exploitative

• lacks empathy

• often envious or believes people are envious of them

• shows arrogant, haughty behaviors or attitudes 

grandiose narcissists

confident, extraverted, often perceived as charming, arrogant feels superior to other, overt expressions of superiority

Vulnerable narcissists

introverted, believe they are special and simultaneously feel inadequate and insecure, often react with anger or shame when status is threatened

• extremely sensitive to criticism, often feel misunderstood

Grandiose and Vulnerable Narcissism

• embody one or the other, or oscillate

• associated with a tendency towards antagonism , entitlement and efforts to maintain a positive image of themselves

• high in narcissism perceive others as asserting themselves or threatening them, they often respond with conflict or aggression

Can narcissism change?

• no treatment nor empirical evidence

• hypersensitivity, feeling entitled naturally decline with age (>40)

Dependent Personality Disorder (Cluster C)

• persuasive and excessive need to be taken care of—> submissive and clinging behavior and fears of separation

• >5 symptoms 

Symptoms of dependent personality disorder

• difficulty making everyday decisions without excessive amount of advice and reassurance from others

• needs others to assume responsibility for most major areas of his/her life

• difficulty expressing disagreement with others because of fear of loss of support or approval

• difficulty initiating projects or doing things on his/her own

• goes to excessive lengths to obtain nurturance and support from others to the point of volunteering to do things that are unpleasant

• feels uncomfortable or helpless when aline because of exaggerated fears of being unable to care for him/her self

• urgently seeks another relationship as a source of care and support when a close relationship ends

• unrealistically preoccupied with fears of being left to take care of him/her self 

Yes humans do depend on each other, but what makes the difference?

• people with dependent PD have a strong belief that they are helpless and inept and others are strong and competent

What is dependent PD correlated it?

• positively with agreeableness and neuroticism

• negatively with openness, conscientiousness and extraversion

• less prevalent than other personality disorders at roughly .5%

Treatment for dependent PD

• people frequently seek treatment 

• no “first line”

• CBT 

  • reduces symptoms

  • hierarchy of situations client would find difficult to do independently as well as rethinking the need to rely on others