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Personality Disorders

(patient information)

Paranoid Personality Disorder Schizoid Personality Disorder Schizotypal Personality Disorder Antisocial Personality Disorder (ASP) Borderline Personality Disorder Histrionic Personality Disorder Narcissistic Personality Disorder Avoidant Personality Disorder Dependent Personality Disorder Obsessive-Compulsive Personality Disorder Personality Disorders: Management

John G. Gunderson, M.D. Glen O. Gabbard, M.D. Personality Disorders Introduction Since the publication of Treatments of Psychiatric Disorders, Second Edition, advances in the diagnostic understanding and treatment of personality disorders have been substantial. As recent reviews (Gabbard 2000; Gunderson and Gabbard 2000; Perry et al. 1999) have emphasized, a growing empirical literature on psychotherapy for personality disorders has shown that at least some personality disorders are eminently treatable with psychotherapy. In a parallel way, the literature on pharmacotherapy and the biology of personality disorders also has been marked by several significant recent contributions (Cloninger 1999; Coccaro and Kavoussi 1997; Silk 1998). We have asked all the chapter authors in this section to incorporate recent empirical research as well as current knowledge stemming from contributions by expert clinicians into this new edition of the text. A variety of treatment modalities are addressed in the chapters that follow: pharmacotherapy, group and family therapy, psychoanalysis, individual psychodynamic psychotherapy, cognitive-behavioral therapies such as dialectical behavior therapy, hospital and partial hospital treatment, and other treatments to the extent they are relevant. The treatment literature is still sufficiently limited that almost no head-to-head comparisons are available that would allow clinicians to determine which treatment is better for any specific personality disorder. Similarly, we know little about the relative efficacy of combined pharmacotherapy and psychotherapy versus either treatment alone. Hence, we have relied on expert opinion to summarize both the empirical literature and the available clinical wisdom to guide the reader through the treatment options in a way that should be useful in planning a comprehensive treatment approach for patients with personality disorders. It is important to keep in mind, however, that many patients who meet criteria for one personality disorder also meet criteria for one or more additional personality disorders. Therefore, clinicians may wish to develop

their own creative combinations of treatments for a patient with aspects of more than one personality disorder. Historical Background When personality disorders surfaced as topics for psychiatric classification, the overriding descriptor of "psychopathy" was used to describe people with stable and severe, but not clearly symptomatic, forms of personal inadequacies or moral degeneracy. In that context, the term character disorder has often been used in a pejorative sense. More complicated usage for personality diagnoses evolved out of the psychoanalytic contributions of Freud and his successors. Although Freud's original model suggested that the accurate identification of unconscious conflict would lead to the resolution of neurotic symptoms, this result often failed to occur. Subsequent generations of psychoanalysts came to focus their attention on their patients' resistances to change, that is, their patients' defenses, now identified as important structures of personality. Wilhelm Reich paved the way for this shift in focus with his emphasis on "character armor" and "character analysis." Such personality structures were seen as arising out of "compromise formations" by early analysts, such as Abraham and Waelder, and as evolving out of the child's early experience with parents by later theorists, such as Sullivan, Erikson, and Fairbairn. Concurrent with the idea within psychoanalysis that the personality embodies the resistances to conflict resolution and symptom reduction were efforts within descriptive psychiatry, most notably by Kurt Schneider, to define the overriding construct of personality disorders as stable maladaptive traits that were resistant to change from life experience and likely resistant also to any therapeutic interventions. Against this background of therapeutic pessimism, a series of pioneering clinicians suggested that specific forms of intervention could be effective. Reich presented a theory of therapy advocating persistent and repetitious interpretations of characterological defenses directed at making them more dystonic and eventually weaker. Maxwell Jones developed a model of sociotherapy that involved peer confrontation about maladaptive behaviors in the context of a milieu from which the person with a personality disorder could not easily avoid self-examination. Nonetheless, until the late 1960s, the prevailing wisdom was that although "character neuroses" were treatable, more severe personality disorders were, at best, manageable. At that time, Kernberg (1967, 1968) popularized the concept of "borderline personality organization" (a construct encompassing most forms of major personality disorder) and suggested that patients with this personality organization were understandable and modifiable by long-term psychoanalytic psychotherapy. The resulting wave of ambitious psychodynamic, residential, family, and individual therapeutic efforts gave expression to a new and widespread interest in the therapeutic possibilities for such patients.

Read more: Personality Disorders http://www.health.am/psy/personality-disorderspro/#ixzz1HomeVxtH

About Dialectical Behavior Therapy (DBT) Dialectical Behavior Therapy in a Nutshell


Dialectical Behavior Therapy (DBT) is a comprehensive cognitive-behavioral treatment developed by Dr. Marsha Linehan over the last 25 years. DBT was originally developed to treat suicidal patients, evolved into a treatment for suicidal BPD patients, and has since been adapted for the treatment of BPD patients with presenting problems other than suicidal behaviors. DBT is designed to treat BPD patients at all levels of severity and complexity of disorder and is conceptualized as occurring in stages. In Stage I, the primary focus is on stabilizing the patient and achieving behavioral control. Stage I treatment targets are addressed in the following hierarchical order: 1) life-threatening behaviors (primarily suicidal and selfinjurious behavior), 2) therapy-interfering behaviors (e.g., poor attendance), and 3) severe quality of life-interfering behaviors (e.g., frequent use of crisis services, substance abuse). Stage I DBT consists of several modes of treatment, each designed to achieve specific functions: individual therapy focuses on increasing client motivation (i.e., identifying specific factors maintaining problem behavior and providing interventions); group skills training teaches basic capabilities (i.e., behavioral skills including distress tolerance, emotion regulation, interpersonal effectiveness, and mindfulness); phone coaching provides the basis for generalization of skills to the natural environment; and the therapist consultation team functions to increase therapist capabilities and motivation. Presently, DBT is by far the best studied treatment for BPD and DBT treatment outcome studies have focused primarily on Stage I targets.

Dialectical Behavior Therapy: Research Findings


To date, there have been nine published randomized controlled trials and five controlled trials of DBT (see Figure 1 below for a summary of these results). Two of these trials (carried out in our research clinic) specifically targeted highly suicidal women with BPD and we are in the midst of a third trial targeting the same population. In our first study, results favoring DBT were found in each DBT target area. Compared to treatment-as-usual (TAU), DBT subjects were significantly less likely to attempt suicide or self-injure, reported fewer intentional self-injury episodes at each assessment point, had less medically severe intentional self-injury episodes, lower treatment drop-out, tended to enter psychiatric units less often, had fewer inpatient psychiatric days, reported less anger, and improved more on scores of global as well as social adjustment. In our second study, we compared DBT to a much stronger control condition, treatment by non-behavioral community experts (TBE). In comparison to TBE, DBT reduced suicide attempts by half, had less medically severe self-injurious episodes, lower rates of treatment drop-out, and fewer admissions to both emergency departments and inpatient units due to suicidality. In studies of DBT for BPD patients that have been conducted outside of our research clinic, DBT has outperformed control treatments in reducing intentional self-injury, suicidal ideation, inpatient hospitalizations, hopelessness, depression, dissociation, anger, and impulsivity. In studies of substance dependent BPD patients conducted at our research clinic as well as other sites, DBT has been found to be superior to control treatments in reducing substance use. In sum, DBT is an extremely effective treatment for keeping suicidal BPD patients alive by helping them to gain control over life-threatening and other severe behaviors.

Dialectical behavior therapy


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Dialectical behavior therapy (DBT) is a system of therapy originally developed by Marsha M. Linehan, a psychology researcher at the University of Washington, to treat people with borderline personality disorder (BPD) .[1][2] DBT combines standard cognitive-behavioral techniques for emotion regulation and reality-testing with concepts of distress tolerance, acceptance, and mindful awareness largely derived from Buddhist meditative practice. DBT may be the first therapy that has been experimentally demonstrated to be generally effective in treating BPD.[3][4] A meta-analysis found that DBT reached moderate effects.[5] Research indicates that DBT is also effective in treating patients who present varied symptoms and behaviors associated with spectrum mood disorders, including self-injury.[6] Recent work suggests its effectiveness with sexual abuse survivors[7] and chemical dependency.[8]

Contents
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1 Overview 2 Four modules o 2.1 Mindfulness 2.1.1 "What" skills 2.1.2 "How" skills o 2.2 Distress tolerance o 2.3 Emotion regulation 3 Interpersonal effectiveness 4 Tools o 4.1 Diary cards o 4.2 Chain analysis o 4.3 Milieu 5 See also 6 References 7 Notes 8 Further reading 9 External links

[edit] Overview
Linehan observed "burn-out" in therapists after coping with non-motivated patients who repudiated cooperation in successful treatment. Her first core insight was to recognize that the chronically suicidal patients she studied had been raised in profoundly invalidating environments, and, therefore, required a climate of unconditional acceptance (not Rogers positive humanist approach, but Hanhs metaphysically neutral one), in which to develop a successful therapeutic alliance.[note 1] Her second insight involved the need for a commensurate commitment from patients, who needed to be willing to accept their dire level of emotional dysfunction.

DBT strives to have the patient view the therapist as an ally rather than an adversary in the treatment of psychological issues. Accordingly, the therapist aims to accept and validate the clients feelings at any given time, while, nonetheless, informing the client that some feelings and behaviors are maladaptive, and showing them better alternatives.[2] Linehan and others combined a commitment to the core conditions of acceptance and change through the Hegelian principle of dialectical progress (in which thesis + antithesis synthesis) and assembled an array of skills for emotional self-regulation drawn from Western psychological traditions, such as cognitive behavioral therapy and an interpersonal variant, "assertiveness training", and Eastern meditative traditions, such as Buddhist mindfulness meditation. Arguably her most significant contribution was to alter the adversarial nature of the therapist-client relationship in favor of an alliance based on intersubjective tough love. All DBT can be said to involve two components:

Individual - The therapist and patient discuss issues that come up during the week (recorded on diary cards) and follow a treatment target hierarchy. Self-injurious and suicidal behaviors take first priority. Second in priority are behaviors which, while not directly harmful to self or others, interfere with the course of treatment. These behaviors are known as therapyinterfering behaviors. Third in priority are quality of life issues and working towards improving one's life generally. During the individual therapy, the therapist and patient work towards improving skill use. Often, a skills group is discussed and obstacles to acting skillfully are addressed. Group - A group ordinarily meets once weekly for two to two-and-a-half hours and learns to use specific skills that are broken down into four skill modules: core mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance.

Neither component is used by itself; the individual component is considered necessary to keep suicidal urges or uncontrolled emotional issues from disrupting group sessions, while the group sessions teach the skills unique to DBT, and also provide practice with regulating emotions and behavior in a social context.

[edit] Four modules

[edit] Mindfulness
Further information: mindfulness (psychology)

Mindfulness is one of the core concepts behind all elements of DBT. It is considered a foundation for the other skills taught in DBT, because it helps individuals accept and tolerate the powerful emotions they may feel when challenging their habits or exposing themselves to upsetting situations. The concept of mindfulness and the meditative exercises used to teach it are derived from traditional Buddhist practice, though the version taught in DBT does not involve any religious or metaphysical concepts. Within DBT it is the capacity to pay attention, non-judgmentally, to the present moment; about living in the moment, experiencing one's emotions and senses fully, yet with perspective.
[edit] "What" skills Observe

This is used to non-judgmentally observe ones environment within or outside oneself. It is helpful in understanding what is going on in any given situation. Describe This is used to express what one has observed with the observe skill. It is to be used without judgmental statements. This helps with letting others know what you have observed. Participate This is used to become fully involved in the activity that one is doing. To be able to fully focus on what one is doing. [edit] "How" skills Non-judgmentally This is the action of describing the facts, and not thinking about whats good or bad, fair, or unfair. These are judgments because this is how you feel about the situation but isnt a factual description. Being non-judgmental helps to get your point across in an effective manner without adding a judgment that someone else might disagree with. One-mindfully This is used to focus on one thing. One-mindfully is helpful in keeping your mind from straying into emotion mind by a lack of focus. Effectively This is simply doing what works. It is a very broad-ranged skill and can be applied to any other skill to aid in being successful with said skill.[9]

[edit] Distress tolerance


Many current approaches to mental health treatment focus on changing distressing events and circumstances.[specify] They have paid little attention to accepting, finding meaning for, and tolerating distress. This task has generally been tackled by psychodynamic, psychoanalytic, gestalt, or narrative therapies, along with religious and spiritual communities and leaders. Dialectical behavior therapy emphasizes learning to bear pain skillfully. Distress tolerance skills constitute a natural development from DBT mindfulness skills. They have to do with the ability to accept, in a non-evaluative and nonjudgmental fashion, both oneself and the current situation. Since this is a nonjudgmental stance, this means that it is not one of approval or resignation. The goal is to become capable of calmly recognizing negative situations and their impact, rather than becoming overwhelmed or hiding from them. This allows individuals to make wise decisions about whether and how to take action, rather than falling into the intense, desperate, and often destructive emotional reactions that are part of borderline personality disorder.[9]
Distract with ACCEPTS

This is a skill used to distract oneself temporarily from unpleasant emotions.


Activities - Use positive activities that you enjoy. Contribute - Help out others or your community. Comparisons - Compare yourself either to people that are less fortunate or to how you used to be when you were in a worse state. Emotions (other) - cause yourself to feel something different by provoking your sense of humor or happiness with corresponding activities. Push away - Put your situation on the back-burner for a while. Put something else temporarily first in your mind. Thoughts (other) - Force your mind to think about something else. Sensations (other) Do something that has an intense feeling other than what you are feeling, like a cold shower or a spicy candy.[9]

Self-soothe This is a skill in which one behaves in a comforting, nurturing, kind, and gentle way to oneself. You use it by doing something that is soothing to you. It is used in moments of distress or agitation.[9] IMPROVE the moment This skill is used in moments of distress to help one relax.

Imagery - Imagine relaxing scenes, things going well, or other things that please you. Meaning - Find some purpose or meaning in what you are feeling. Prayer - Either pray to whomever you worship, or, if not religious, chant a personal mantra. Relaxation - Relax your muscles, breathe deeply; use with self-soothing. One thing in the moment - Focus your entire attention on what you are doing right now. Keep yourself in the present. Vacation (brief) - Take a break from it all for a short period of time. Encouragement - Cheerlead yourself. Tell yourself you can make it through this.[9]

Pros and cons Think about the positive and negative things about not tolerating distress.[9] Radical acceptance Let go of fighting reality. Accept your situation for what it is.[9] Turning the mind Turn your mind toward an acceptance stance. It should be used with radical acceptance.[9] Willingness vs. willfulness Be willing and open to do what is effective. Let go of a willful stance which goes against acceptance. Keep your eye on the goal in front of you.[9]

[edit] Emotion regulation

Further information: emotional self-regulation

Individuals with borderline personality disorder and suicidal individuals are frequently emotionally intense and labile. They can be angry, intensely frustrated, depressed, or anxious. This suggests that these clients might benefit from help in learning to regulate their emotions. Dialectical behavior therapy skills for emotion regulation include:[10][11]

Identify and label emotions Identify obstacles to changing emotions Reduce vulnerability to emotion mind Increase positive emotional events Increase mindfulness to current emotions Take opposite action Apply distress tolerance techniques[9]

Story of emotion This skill is used to understand what kind of emotion one is feeling. 1. 2. 3. 4. 5. 6. 7. Prompting event Interpretation of the event Body sensations Body language Action urge Action Emotion name, based on previous items on list[9]

PLEASE MASTER This skill concerns ineffective health habits can make one more vulnerable to emotion mind. This skill is used to maintain a healthy body, so one is more likely to have healthy emotions. PhysicaL illness (treat) - If you are sick or injured, get proper treatment for it. Eating (balanced) - Make sure you eat a proper healthy diet, and eat in moderation. Avoid mood-altering drugs - Do not take non-prescribed medication or illegal drugs. They are very harmful to your body, and can make your mood unpredictable. Sleep (balanced) - Do not sleep too much or too little. Eight hours of sleep is recommended per night for the average adult. Exercise - Make sure you get an effective amount of exercise, as this will both improve body image and release endorphins, making you happier.[9] MASTERy (build) Try to do one thing a day to help build competence and control.[9] Opposite action This skill is used when you have an unjustified emotion, one that doesnt belong in the situation at hand. You use it by doing the opposite of your urges in the moment. It is a tool

to bring you out of an unwanted or unjustified emotion by replacing it with the emotion that is opposite.[9] Problem solving This is used to solve a problem when your emotion is justified. It is used in combination with other skills.[9] Letting go of emotional suffering Observe and experience your emotion, accept it, then let it go.[9]

[edit] Interpersonal effectiveness


Interpersonal response patterns taught in DBT skills training are very similar to those taught in many assertiveness and interpersonal problem-solving classes. They include effective strategies for asking for what one needs, saying no, and coping with interpersonal conflict. Individuals with borderline personality disorder frequently possess good interpersonal skills in a general sense. The problems arise in the application of these skills to specific situations. An individual may be able to describe effective behavioral sequences when discussing another person encountering a problematic situation, but may be completely incapable of generating or carrying out a similar behavioral sequence when analyzing his or her own situation. The interpersonal effectiveness module focuses on situations where the objective is to change something (e.g., requesting that someone do something) or to resist changes someone else is trying to make (e.g., saying no). The skills taught are intended to maximize the chances that a persons goals in a specific situation will be met, while at the same time not damaging either the relationship or the persons self-respect.
DEARMAN - getting something This acronym is used to aid one in getting what he or she wants when asking.

Describe your situation. Express why this is an issue and how you feel about it. Assert yourself by asking clearly for what you want. Reinforce your position by offering a positive consequence if you were to get what you want. Mindful of the situation by focusing on what you want and ignore distractions. Appear Confident even if you dont feel confident. Negotiate with a hesitant person and come to a comfortable compromise on your request.

GIVE - giving something This skill set aids one with maintaining his or her relationships, whether they are with friends, coworkers, family, romantic partners, etc. It is to be used in conversations.

Gentle: Use appropriate language, no verbal or physical attacks, no put downs, avoid sarcasm unless you are sure the person is alright with it, and be courteous and nonjudgmental. Interested: When the person you are speaking to is talking about something, act interested in what they are saying. Maintain eye contact, ask questions, etc. Do not use your cell phone while having a conversation with another person! Validate: Show that you understand a persons situation and sympathize with them. Validation can be shown through words, body language and/or facial expressions. Easy Manner: Be calm and comfortable during conversation, use humor, smile.

FAST - keeping self-respect This is a skill to aid one in maintaining his or her self-respect. It is to be used in combination with the other interpersonal effectiveness skills.

Fair: Be fair to both yourself and the other person. Apologies (few): Dont apologize more than once for what you have done ineffectively, or apologize for something which was not ineffective. Stick to Your Values: Stay true to what you believe in and stand by it. Dont allow others to get you to do things against your values. Truthful: Dont lie. Lying can only pile up and damage relationships and your selfrespect.[9]

[edit] Tools

[edit] Diary cards


For more details on this topic, see therapy interfering behavior.

Specially formatted cards for tracking therapy interfering behaviors that distract or hinder a patient's progress.

[edit] Chain analysis


Chain analysis is a form of functional analysis of behavior but with increased focus on sequential events that form the behavior chain. It has strong roots in behavioral psychology in particular applied behavior analysis concept of chaining.[12] A growing body of research supports the use of behavior chain analysis with multiple populations.

[edit] Milieu
The milieu, or the culture of the group involved, plays a key role in the effectiveness of DBT.

[edit] See also


Acceptance and Commitment Therapy Rational emotive behavior therapy Nonviolent Communication Emotional dysregulation Mentalization-based treatment

Social skill Behavioral psychotherapy

Dialectical Behavior Therapy


What Is Dialetical Behavior Therapy?
By Nancy Schimelpfening, About.com Guide Updated September 19, 2011 About.com Health's Disease and Condition content is reviewed by the Medical Review Board
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What Is Dialectical Behavior Therapy?

Dialectical behavior therapy (DBT) is a type of cognitive behavioral therapy. Its main goal is to teach the patient skills to cope with stress, regulate emotions and improve relationships with others. DBT is derived from a philosophical process called dialectics. Dialectics is based upon the concept that everything is composed of opposites and that change occurs when one opposing force is stronger than the other, or in more academic terms: thesis, antithesis and synthesis.

History of Dialectical Behavior Therapy


DBT was developed in the late 1970s by Dr. Marsha Linehan and colleagues when they discovered that cognitive behavioral therapy alone did not work as well as expected in patients with borderline personality disorder. Dr. Linehan and her team added additional techniques and developed a treatment which would meet the unique needs of these patients.

The Three Fundamentals of Dialectical Behavior Therapy


1. Cognitive Behavioral Therapy Learning new behaviors -- which can be anything a person thinks, feels or does -- is a crucial part of DBT. There are four main strategies that are used to change behavior: skills training, exposure therapy, cognitive therapy, and contingency management.

Skills Training - Attending skills groups, doing homework assignments and role playing new ways of interacting with people. Exposure Therapy - Exposing oneself to feelings, thoughts or situations which were previously feared and avoided. Cognitive Therapy - Recognizing and reassessing patterns of negative thoughts and replacing them with positive thoughts that more closely reflect reality. Contingency Management - Identifying how maladaptive behavior is rewarded and how adaptive behavior is punished and using this knowledge to modify behavior in a positive way.

2. Validation For patients with borderline personality disorder, the process of cognitive behavioral therapy can cause a great deal of distress. The push for change feels to them as if it invalidates the emotional pain they are feeling. Linehan and her team found that by offering validation along with the push for change, patients were more likely to cooperate and less likely to suffer distress at the idea of change. The therapist validates that the person's actions "make sense" within the context of his personal experiences without necessarily agreeing that they are the best approach to solving the problem. 3. Dialectics Dialectics makes three basic assumptions: (1) all things are interconnected (2) change is constant and inevitable and (3) opposites can be integrated to form a closer approximation of the truth. In DBT, the patient and therapist are working to resolve the seeming contradiction between self-acceptance and change in order to bring about positive changes in the patient.

What Is Dialectical Behavior Therapy Used For?


DBT is designed for use by people who have urges to harm themselves, such as those who self-injure or who have suicidal thoughts and feelings. It was originally intended for people with borderline personality disorder, but has since been adapted for other conditions where the patient exhibits self-destructive behavior, such as eating disorders and substance abuse.
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