人格障碍与其治疗.ppt

第十一章人格障碍及其矫正(personalitydisorders),于丽琴,一、人格障碍概述(PersonalityDisorders:AnOverview),3,Whatisapersonalitydisorder?,maladaptivepersonalitytraitstraitsarerelativelyenduringfeaturesofapersonthatarepersistentovertimeandsituationspeoplewithpersonalitydisorderstendtobe:rigidandinflexible,showarestrictedrangeoftraits,haveadominantsingletraitpersonalitydisordersareegosyntonic,morethanegodystonic,DSMIV强调病人在认知、情感、人际关系和冲动控制方面的偏离，指出这种偏离类型在长时间内相当稳定，至少可以追溯到青少年或早期成年时。,5,PersonalityDisorders:FactsandStatistics,PrevalenceofPersonalityDisordersAbout0.5%to2.5%ofthegeneralpopulation6-9%（Kathleen，1986）0.13（我国，1986）Ratesarehigherininpatientandoutpatientsettings。prevalencehigheramongpeoplewithothermentaldisorders6-9%ofpopulationhaveoneormorepersonalitydisordermostpeoplewithpersonalitydisordersnevercometotheattentionofmentalhealthprofessionals,6,OriginsandCourseofPersonalityDisordersThoughttobegininchildhoodRunachroniccourseComorbidityratesarehighGenderDistributionandGenderBiasGenderbiasexistsindiagnosisCriterionvs.assessmentgenderbias,DSM-IV将10种人格障碍划分为3大类群:A类群：行为古怪、奇异ClusterAOddoreccentricExamplesincludeparanoid,schizoidB类群：戏剧化、情感强烈、不稳定ClusterBDramatic,emotional,erraticExamplesincludeantisocial,borderlineC类群：紧张、焦虑行为ClusterCFearfuloranxiousExamplesincludeavoidant,obsessive-compulsive,分类DSM-IVandDSM-IV-TRPersonalityDisorderClusters,人格障碍类型,clusterAclusterBclusterC偏执型表演型回避型分裂型自恋型依赖性分裂样反社会型强迫型边缘型,9,10,PERSONALITYDISORDERSHistoricalperspective,Rootsinpsychoanalysisnarcissism,masochism,etc.KarlAbrahamfirsttheoristtofocusonpersonalitydisorders,11,PERSONALITYDISORDERSDiagnosticissues,poorunderstandingofetiologyofmostpersonalitydisorderscomorbidityanddiagnosticoverlapgenderandculturalissuesreliabilityofdiagnosis,12,PERSONALITYDISORDERSEtiologyTheoreticalperspectives,PsychodynamictheoryAttachmenttheoryparticularlyfordramatic,emotional,erraticCognitive-behaviouralperspectivesBiologicalparticularlyforodd,eccentricanddramatic,emotional,erratic,13,（一）偏执型人格障碍（paranoidPD),1、临床特征2、形成原因3、治疗,临床特征,主要特征：猜疑、偏执表现为对他人持久的不信任，社会隔离，过分警惕临床发现男性居多,16,0.5-2.5%ofthepopulation.oMenWomen.oHigherincidenceinrelativesofschizophrenics.oHigheramongminorities,immigrants,andthedeaf.,17,18,19,Suspects,withoutsufficientbasis,thatothersareexploiting,harming,ordeceivinghimorher.Ispreoccupiedwithunjustifieddoubtsabouttheloyaltyortrustworthinessoffriendsorassociates.Isreluctanttoconfideinothersbecauseofunwarrantedfearthattheinformationwillbeusedmaliciouslyagainsthimorher.Readshiddendemeaningorthreateningmeaningsintobenignremarksorevents.,20,Persistentlybearsgrudges,i.e.,isunforgivingofinsults,injuries,orslights.Perceivesattacksonhisorhercharacterorreputationthatarenotapparenttoothersandisquicktoreactangrilyortocounterattack.Hasrecurrentsuspicions,withoutjustification,regardingfidelityofspouseorsexualpartner.DoesnotoccurexclusivelyduringthecourseofaPsychoticDisorderandisnotduetoageneralmedicalcondition.,形成原因,生物学原因在精神分裂症患者亲属中较多心理分析偏执来自无意识中强烈的仇恨和敌意的外向投射认知的观点与歪曲的认知或想法有关文化因素特殊人群，如犯人、难民、有听力障碍的人等易形成这种人格障碍,22,23,治疗,建立信任关系非常重要心理动力学治疗认知治疗Acknowledgemistakes.Beopenandhonest.Haveaprofessionalandnotoverlywarmstyle.DontconfrontSetlimits.Clearlyexplainprocedures,medicationsandresults.,25,summary:ParanoidPersonalityDisorder,OverviewandClinicalFeaturesPervasiveandunjustifiedmistrustandsuspicionTheCausesBiologicalandpsychologicalcontributionsareunclearEarlylearningthattheworldisadangerousplaceTreatmentOptionsFewseekprofessionalhelpontheirownTreatmentfocusesondevelopmentoftrustCognitivetherapytocounternegativisticthinkingLackgoodoutcomestudies,（二）分裂样人格障碍（SchizoidPD）,1、临床特征2、形成原因3、治疗,临床特征,特征：社会隔绝、情感疏远表现为孤单、冷淡的沉默，不介入日常事务，不交际，不关心他人。将精力投注于非人类的事物（如数学）患病率美、德等国采用PDQ（人格障碍诊断问卷）、SCID等得到的患病率为0.71.6男性多见7.5%ofthepopulation.oA2-to-1male-to-femaleratio.,29,30,Neitherdesiresnorenjoyscloserelationships,includingbeingpartofafamily.Almostalwayschoosessolitaryactivities.Haslittle,ifany,interestinhavingsexualexperienceswithanotherperson.Takespleasureinfew,ifany,activities.Lacksclosefriendsorconfidantsotherthanfirst-degreerelatives.,31,Appearsindifferenttothepraiseandcriticismofothers.Showsemotionalcoldness,detachment,orflattenedaffectivity.DoesnotoccurexclusivelyduringthecourseofaPsychoticDisorder,oraPervasiveDevelopmentalDisorderandisnotduetoageneralmedicalcondition.,生物学可能有与孤独症类似的生理机能缺陷心理动力学基本的接触需要没有获得满足认知治疗不能有效的关注周围的情况来获得准确的感知社会心理在早期学习、人际交往中形成问题,形成原因,33,治疗,心理治疗发展对社会关系的兴趣，认识社会关系的价值社交技能训练Understandtheirneedforisolation.MinimizenewcontactsandintrusionsMaintainaquiet,reassuring,andconsiderateinterestinthem.Dontinsistonreciprocalresponses,（三）分裂型人格障碍（schizotype）,1、临床特征2、形成原因3、治疗,临床特征,特征社会隔绝、情感疏远、古怪行为、多疑表现为认识或感知方面的歪曲以及古怪的行为患病率可能高于精神分裂症和其他人格障碍3%ofthepopulation.Sexratioisunknown.Greaterassociationamongbiologicalrelativesofschizophrenicpatients.Thepremorbidpersonalityoftheschizophrenicpatient.,37,38,Ideasofreference(excludingdelusionsofreference).Oddbeliefsormagicalthinkingthatinfluencesbehaviorandisinconsistentwithsubculturalnorms(e.g.,superstitiousness,beliefinclairvoyance,telepathy,orthesixthsense!Unusualperceptualexperiences,includingbodilyillusions.Oddthinkingandspeech(e.g.vague,circumstantial,metaphorical,overelaborate,orstereotyped).Suspiciousnessorparanoidideation.,39,Inappropriateorconstrictedaffect.Behaviororappearancethatisodd,eccentric.OrpeculiarLackofclosefriendsorconfidantsotherthanfirst-degreerelatives.Excessivesocialanxietythatdoesnotdiminishwithfamiliarityandtendstobeassociatedwithparanoidfearsratherthannegativejudgmentsaboutself.DoesnotoccurexclusivelyduringthecourseofaPsychoticDisorderoraPervasiveDevelopmentalDisorder.,形成原因,生物学的解释精神分裂症亲属中有较高的此型患病率,41,42,43,44,治疗,心理治疗：社交技能训练帮助其与人交往，减少对他人的不信任感药物治疗：治疗精神分裂症的药物可使其症状有中等程度的改善oSimilartoSchizoidPD.oMisperceptionsofphysicalsymptomsandtreatment.oDonotridiculeorjudge.oRespecttheirneedforprivacy.,（四）表演型人格障碍（HistrionicPD）,1、临床特征2、形成原因3、治疗,临床特征,又称癔症型、寻求注意型、或心理幼稚型特征人格不成熟、情绪不稳定表现：需要情爱和注意、依赖性、作弄他人的倾向患病率美、德等国采用PDQ、SCID等临床调查表、定式检核表等工具得到的为1.33.0女性2倍于男性2-3%.Diagnosedmorefrequentlyinwomenthaninmen.AssociatedwithSomatizationDisorderandAlcoholAbuse/Dependence.,48,49,Isuncomfortableinsituationsinwhichheorsheisnotthecenterofattention.Interactionwithothersisoftencharacterizedbyinappropriatesexuallyseductiveorprovocativebehavior.Displaysrapidlyshiftingandshallowexpressionofemotions.Consistentlyusesphysicalappearancetodrawattentiontoself.,50,Hasastyleofspeechthatisexcessivelyimpressionisticandlackingindetail.Showsself-dramatization,theatricality,andexaggeratedexpression.Issuggestible,i.e.,easilyinfluencedbyothersorcircumstances.Considersrelationshipstobemoreintimatethattheyactuallyare.,形成原因,对其原因或治疗的研究少心理分析理论作为对内心低自尊感的一种反抗，病人总是试图成为他人的注意中心。,52,53,治疗,对人际关系治疗奖励与惩罚结合SimilartoBorderlinePD.oMedicalillnessesthreatentheirsenseofattractivenessandself-image.,（五）自恋型人格障碍(NarcissisticPD),1、临床特征2、形成原因3、治疗,临床特征,特征妄自尊大观念表现：自我中心，夸大（幻想或行为），需要他人赞扬患病率美、德等国：00.42-16%intheclinicalpopulation.1%inthegeneralpopulation.Numberofcasesincreasingsteadily.,形成原因,心理分析家长对其子女不爱和不接受的行为方式行为和认知模型过分积极的赞赏或宠爱社会影响因素及时行乐、个人主义、竞争和成功等观念影响,59,60,Hasagrandiosesenseofself-importance(e.g.,exaggeratesachievementsandtalents,expectstoberecognizedassuperiorwithoutcommensurateachievements).Ispreoccupiedwithfantasiesofunlimitedsuccess,power,brilliance,beauty,orideallove.Believesthatheorsheis!special!anduniquecanonlybeunderstoodby,orshouldassociatewith,otherspecialorhigh-statuspeople(orinstitutions).Requiresexcessiveadmiration.,61,Hasasenseofentitlement,i.e.,unreasonableexpectationsofespeciallyfavorabletreatmentorautomaticcompliancewithhisorherexpectations.Isinterpersonallyexploitative,i.e.,takesadvantageofotherstoachievehisorherownends.Lacksempathy:isunwillingtorecognizeoridentifywiththefeelingsandneedsofothers.Isoftenenviousofothersorbelievesthatothersareenviousofhimorher.Showsarrogant,haughtybehaviororattitudes.,治疗,对治疗的研究非常有限心理治疗主要集中于其被扭曲的自我（自我夸大感），对评价的病态的敏感等方面Handlecriticismpoorly.Becomeeasilyenraged.Medicalillnessescanbeablowtotheirself-esteem.Reinforcethattheyarerespectedandappreciated.Setlimitsondemandingbehavior.,（六）反社会型人格障碍(AntisocialPD),1、临床特征2、形成原因3、治疗,临床特征,特征经常发生违反社会规范的行为表现：工作不良，婚姻不良，酒精与药物滥用，情感肤浅、无情、自我中心，不诚实、欺骗、作弄他人，冲动性、攻击性及法律问题等患病率Vaillantmoneyisviewedassomethingtobehoardedforfuturecatastrophes.S