人格障碍的诊疗和治疗策略解读培训课件

1、课程提纲DSM-IV和DSM-V系统人格障碍诊断的变化精神动力学取向的诊断SWAP-200简介用SWAP-200做诊断不同的人格障碍和治疗策略案例研究（边缘、自恋和表演）课程提纲DSM-IV和DSM-V系统人格障碍诊断的变化DSM-IV和DSM-V人格障碍诊断及变化人格障碍的诊断及治疗策略DSM-IV和DSM-V人格障碍诊断及变化人格障碍的诊断及治人格？人格？看电影迟到了，拿着票却被看门老头拦在门口，说必须等到下一场才让进。迈克 泰森韦小宝许三多林黛玉看电影迟到了，拿着票却被看门老头拦在门口，说必须等到下一场才人格障碍的诊疗和治疗策略解读培训课件Hippocrates Classificati

2、onElementHumorTypeStyleAirBloodSanguineHopefulEnthusiasticOptimisticEarthBlack BileMelancholicSadFireYellow BileCholericIrascibleIrritableWaterPhlegmPhlegmaticApatheticSlowHippocrates ClassificationElem人格障碍的诊疗和治疗策略解读培训课件人格障碍的诊疗和治疗策略解读培训课件维度类别维度人格的维度系统Interpersonal Circumplex - Leary, Wiggins, Kiesle

3、rThree factors - Eysenck & EysenckFour factors - Livesley et al., Clark et al.Five factors - Costa & McCraeSeven factors - Cloninger et al.人格的维度系统Interpersonal Circumple人格维度子因素开放性（Openness）思想、幻想、审美、行动、情感、价值观尽责性（Conscientiousness）能力、秩序、责任感、上进心、自律、深思熟虑外向性（Extraversion）乐群、自信、活跃、兴奋寻求、积极情绪、热心随和性（Agreeabl

4、eness）信任、坦率、利他、顺从、谦逊、温和神经质（Neuroticism）焦虑、敌意、抑郁、自我意识、冲动、脆弱人格维度子因素开放性（Openness）思想、幻想、审美、行Three Major Brain Systems Influencing Stimulus Response CharacteristicsBrain System (Related Personality Dimension)Principal Monoamine NeuromodulatorRelevant StimuliBehavioral ResponseBehavioral activation(novelt

5、y seeking)DopamineNoveltyExploratory pursuitPotential rewardAppetitive approachPotential relief of monotony or punishmentActive avoidance, escapeBehavioral inhibition (harm avoidance)SerotoninConditioned signals for punishment, novelty, or frustrative nonrewardPassive avoidance, extinctionBehavioral

6、 maintenance(reward dependence)NorepinephrineConditioned signals for reward or relief of punishmentResistance to extinctionThree Major Brain Systems InflCloningers Seven-Factor ModelTemperament Domains (Moderately heritable, not greatly influenced by family environment)Novelty SeekingHarm AvoidanceR

7、eward DependencePersistence2.Character Domains (Moderately influenced by family environment, only weakly heritable)Self-transcendence （超越）CooperativenessSelf-directednessCloningers Seven-Factor Model人格障碍的诊疗和治疗策略解读培训课件DSM 类别系统DSM 类别系统人格障碍的诊疗和治疗策略解读培训课件DSM-IV Personality DisordersA. Cluster A (odd/ecc

8、entric)ParanoidSchizoidSchizotypalB. Cluster B (dramatic/emotional/impulsive)1.Antisocial2.Borderline3.Histrionic4.NarcissisticC. Cluster C (anxious/fearful)1.Avoidant2.Dependent3.Obsessive-CompulsiveD. Personality Disorder Not Otherwise SpecifiedDSM-IV Personality DisordersA人格和人格障碍连续谱人格和人格障碍连续谱DSM-

9、IV 人格障碍的定义A.明显偏离了患者所在文化所应有的持久的内心体验和行为类型，表现为下列二方面以上： （l）认知（即对自我、他人、和事件的感知和解释方式）； （2）情感（即：情绪反应的范围、强度、脆弱性、和适合性）； （3）人际关系； （4）冲动控制。 DSM-IV 人格障碍的定义A.明显偏离了患者所在文化所应有DSM-IV 人格障碍的定义 B.这种持久的类型是不可变的，并且涉及个人和社交场合的很多方面。 C.这种持久的类型导致临床上明显的痛苦烦恼，或在社交、职业、或其他重要方面的功能缺损。 D.这种类型在长时间内是相当稳定不变的，至少可以追溯到青少年或早期成年时。 E.这种行为类型不可能归

10、于其他精神障碍的表现或后果。 F.这种行为类型并非由于某种物质（例如某种滥用药物，治疗药品），或一般躯体情况（例如颅脑外伤）所致之直接生理性效应。 DSM-IV 人格障碍的定义 B.这种持久的类型是不可Prevalence of PDs in a Community Sample(N=2053)Overall 13.4%Torgersen, Kringlen, Cramer, 2001Prevalence of PDs in a CommuniPrevalence of PDs in a Community Sample(N=2053) Personality Disorder Present

11、 PrevalenceParanoid2.4Schizoid1.7Schizotypal0.6Antisocial0.7Borderline0.7Histrionic2.0Narcissistic0.8Avoidant5.0Dependent1.5Obsessive-Compulsive2.0Passive-Aggressive1.7Self-Defeating0.8 Torgersen, Kringlen, Cramer; 2001 Prevalence of PDs in a Communi轴I和轴II轴I和轴II轴I和轴II障碍的共同点DimensionAxis I DisorderAx

12、is II DisorderBiological IndexesCharacteristic TraitsDefenses and Coping StrategiesCognitive/ Perceptual OrganizationSchizophreniaOdd cluster(schizotypal PD)Eye movement dysfunction*, continuous performance task, backward masking test*, plasma HVA*, CSF HVA*, evoked potential response, VBRDisorganiz

13、ation, psychotic-like symptomsSocial isolation, detachment, guardednessImpulsivity/AggressionImpulse disordersDramatic cluster(borderline & antisocial PDs)CSF 5-HIAA*, responses to serotonergic challenge, galvanic skin response*, continuous performance taskReadiness to action, irritability/aggressio

14、nExternalization, dissociation, enactment, repressionAffectiveInstabilityMajor affective disordersDramatic cluster(borderline & possibly histrionic PDs)REM latency, responses to cholinergic challenges*, responses to catecholamingeric challenges*Environmentally responsive, transient affective shiftsE

15、xaggerated affectivity, “manipulativeness”, “splitting”Anxiety/ InhibitionAnxiety disordersAnxious cluster(avoidant PD)Heart rate variability*, orienting responses, responses to lactate and yohimbineAutonomic arousal, fearfulness, inhibitionAvoidant, compulsive, and dependent behaviors轴I和轴II障碍的共同点Di

16、mensionAxis I Di人格障碍的治疗心理动力治疗认知治疗For psychodynamic therapy, the effect sizes indicate long-term rather than short-term change in personality disorders (mean follow-up period = 1.5 years 78 weeks vs CBT mean follow-up = 13 weeks)Leichsenring F, Leibing E, Am J Psychiatry 2003; 160:1223-1232人格障碍的治疗心理动

17、力治疗Leichsenring F, L人格障碍的生物学基础心理治疗可至脑功能的改变，此种改变可通过脑成像技术检验。人格障碍的生物学基础心理治疗可至脑功能的改变，此种改变可通过Psychopathology Over Time: Hypothetical Data for One Subjectfrom Pfohl B, 1999Psychopathology Over Time: Hyp精神动力学取向的诊断人格障碍的诊断及治疗策略精神动力学取向的诊断人格障碍的诊断及治疗策略精神动力学概述人类行为下心理驱力的系统研究和系统理论，强调有意识动机和无意识动机的交互作用，以及情绪的功能性价值。历史研

18、究及认知神经基础精神动力学概述人类行为下心理驱力的系统研究和系统理论，强调有Locke KantPavlov DarwinSkinner FreudBehaviorism SystemsPsychoanalyticGordon, R.M. (2008a) An Expert Look at Love, Intimacy and Personal Growth. Second edition. (Chapter 9 Integrating Theories)Not historical, Not developmental, Learned Historical , Structural, Ge

19、stalt, Developmental历史Locke KantPavlov心智的动力学理解31心智的动力学理解31Morokoff (1985)Women highest on indexes of sex guilt showed more physiological arousal to erotic pictures, however, they denied being aroused.反向形成的研究-无意识防御32Morokoff (1985)Women highest 无意识移情研究(Eagle, 1959)33无意识移情研究(Eagle, 1959)33Eric Kandel神

20、经-精神分析学 我们的大多数行为是无意识的。Rudnstsky, P.L. (2008) “Nitty-Gritty Issues: An Interview with Eric R. Kandel” The American Psychoanalyst, 42,2, pp.6-7,15 and 16.34Eric Kandel神经-精神分析学 34超我、自我和本我的冲突Bechara, A., 2007. Decision-making, impulse control and loss of willpower to resist drugs: A neurocognitive persp

21、ective. Nature Neuroscience 8(11):1458-1463.VMPC AS超我、自我和本我的冲突Bechara, A., 2007. 精神动力取向诊断系统精神动力性诊断手册（PDM）操作性动力性诊断手册（OPD-II）精神动力取向诊断系统精神动力性诊断手册（PDM）PDM的结构多轴诊断P轴（人格轴）M轴（心理功能轴）S轴（症状轴）人格人格是相对稳定的思考、感受、行动以及与他人联结的方式。PDM的结构多轴诊断Healthy NeuroticPsychoticBorderlineLevel of personality organization LevelHealthy

22、 NeuroticPsychoticBordePersonality Stylehystericalobsessionalparanoidpsychopathicetc.Personality StylehystericalobsHealthy NeuroticPsychoticBorderlinehystericalobsessionalparanoidpsychopathicEtc.Personality StyleHealthy NeuroticPsychoticBordeBorderline Personality OrganizationAffect DysregulationDef

23、enses based on SplittingSplittingPrimitive ProjectionProjective IdentificationIdentity DiffusionBorderline Personality OrganizPDM中的心智功能调节、注意和学习关系能力（深度、广度和一致性）内部体验的质量（确定性和自我关注的水平）情感体验、表达和交流防御方式和能力形成内部表征的能力自我观察的能力（ mindedness）内部标准和理想：道德感PDM中的心智功能调节、注意和学习PDM中的心智功能M201 超过年龄阶段的卓越心智功能M202 适合年龄阶段的优秀心智功能M20

24、3 适合年龄阶段的心智功能M204 轻微的限制和不灵活M205 中度的限制和心智功能的改变M206 严重的限制和心智功能的改变M207 自我和他人表征的整合和组织，和（或）分化的缺陷M208 基本心智功能的严重缺陷PDM中的心智功能M201 超过年龄阶段的卓越心智功能OPD-II的结构轴I 疾病的体验和治疗条件轴II 人际关系轴III 冲突轴IV 结构轴V 心理和躯体障碍轴间交互OPD-II的结构轴I 疾病的体验和治疗条件人格障碍的诊疗和治疗策略解读培训课件几个问题如何理解症状？同样的心理疾病症状，其内在的原因可能并不相同。换句话说，“人格结构”和人格结构的“动力过程”中存在的问题才是心理疾病症状的根本原因。诊断的目的?形成治疗计划，提高治疗效益更为广泛的经验基础（不来自个案治疗，还来自偱证研究的结果）诊断的条件？几个问题如何理解症状？治疗师做诊断的条件是否建立了足够好的治疗关系，进入了工作状态？是否能准确觉察当事人的特点；是否收集到足够资料；治疗师是否“