Lecture 7: Treatment of adolescents with personality disorder Flashcards
(40 cards)
Can we diagnose adolescents with personality disorder? -> Their personality is still “under construction”
yes, we must diagnose and treat!
- prevention and early intervention
- PD features are markers for severe psychopathology
- PD features are markers for future problems
- adolescence and young adulthood are sensitive periods for the development of chronic psychosocial disability
- regular PD treatment is often inaccessible or less effective for young individuals
- inappropriate or ineffective treatment may cause iatrogenic harm
- eearly detection and intervention might have anti-stigmatizing side effects
3 layers of McAdams
- actor:
- dispositional traits (e.g. the big five)
- general tendencies to behave, think and feel in consistent situations in time
- global, internal, shaped by genes and environment - agent:
- characteristic adaptations of self
- the person is a motivated agent with clear goals, values, mental representations, coping strategies, contextualized in time, place and social roles
- personal, contextualized, developing in middle childhood - author:
- narrative identity
- internalized and evolving life story that integrates the past, present and future, into a coherent whole and creates personal identity
- personal, comprehensive, developing in adolescence
wat zegt het model van McAdams over PDs
individual differences in these layers of personality may play roles in the development, manifestation and course of PDs.
actor/dispositional traits: PDs often show
- high neuroticism
- low levels of agreeableness and conscientiousness
agent/characteristic adaptations: PDs often
- hypermentalize (excessive and unrealistic thinking about the thoughts of others)
- negative attributional style
- persistently use maladaptive coping strategies such as rumination, avoidance and aggression
author/narrative identity: PDs often show
- narrative identity disturbance: less coherent, agentic, and communal stories, more negative self-event connections
DSM 5 criteria for PD
DSM-5 Section II: the following symptoms must be present for ≥ 1 year:
* Cognition: problems in perceiving and interpreting the self, other people, and events
* Affect: abnormal range, intensity, lability, and appropriateness of emotional responses
* Interpersonal functioning: unstable relationships
* Impulse control: impulsivity
DSM-5 Section III: all personality disorders are characterized by:
* One or more pathological personality traits
* Moderate to extreme impairment in self-functioning and interpersonal functioning
emerging focus on adolescent PD
Through its developmentally sensitive conceptualizing of personality disorder, the AMPD in Section III has resulted in:
* More research on adolescent PD
* The development of interventions for adolescent PD (early intervention)
* An increase in treatment studies on adolescent PD
With a particular focus on Borderline PD (BPD):
* Among the most severe mental health problems
* Associated with suicidal behavior, poor psychosocial functioning
* Societal costs: increased use of health care services
DSM for BPD
- efforts to avoid real or imagined abandonment
- pattern of unstable or intense relationships, characterized by alternating between extremes of idealization and devaluation
- identity disturbance, unstable sense of self
- impulsivity in two areas that are potentially self-damaging (spending, sex, substances, driving, binge eating)
- recurrent suicidal behavior, gestures, or threats of self-injurious behavior
- emotional irritability due to a marked reactivity of mood (e.g., intense, episodic sadness, irritability, or anxiety usually lasting a few hours)
- chronic feeling of emptiness
- inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)
- transient, stress related paranoid ideation or severe dissociation
Adolescents with PD show increased:
- Suicidality
- Problems at school: difficulties, dropout
- Social problems: fewer friends
- Behavioral problems
- Risk behaviors: substance abuse
underlying mechanisms of personality disorders
- emotion regulation
- mentalizing
-> hier zijn ook de interventies op gebaseerd
emotion regulation according to the biosocial theory
PDs are developed due to emotion dysregulation, caused by transations between vulnerability (biological) and environment
risk factors:
1. biology:
- temperament: emotional reactivity, low distress tolerance
- personality: impulsivity, obsessive-compulsive, perfectionism
- environment:
- system: insecure attachment, low support and connection, high control and criticism
- trauma: emotional, physical, sexual, neglect, abuse
what happens in a stressful situation when there is emotion dysregulation
negative affect and negative cognition feed into one another.
emotion dysregulation: fear (of abandonment) and anger (underlying sadness) <-> rumination, devaluation (splitting)
to break this distressing cycle of emotion dysregulation: NSSI, suidical behaviour (regain a sense of control, alleviate negative thoughts, tone down mind)
these stressful situations lead to instable relationships and identity disturbance, feelings of emptiness
emotion dysregulation cycle
stressful situation (e.g. cancelling dinner plans) -> activation of ealry maladaptive schemas: i feel rejected, abandoned, worthless -> negative emotions -> low distress tolerance -> emotion dysregulation (anger) -> self-harm, interpersonal conflict, impulsivity <-> identity disturbance, feelings of inner emptiness
mentalizing problems: object-relations theory
PDs develop due to a disturbed mental/internal representation of self and others, caused by an invalidation environment (insecure attachment relationships)
all newborns split between two realities or mental representations:
- all good (mum loves me, i am safe with mum, mum feeds me
- all bad (i am alone, mum doesnt feed me)
when children mature, a healthy ambivalence can develop: mum is one source of pleasure and frustration
in case of an invalidated environment, it is hard to reconcile these two realities: how can mum both love and abuse me?
-> splitting is a defense mechanism, a person is either all good or all bad
treatment options for PDs
- psychosocial treatment: dialectical behavior therapy adolescents (DBT-A), mentalization based therapy adolescents (MBT-A), transferance-focused psychotherapy (TFP-A)
- pharmacotherapy is not recommended, only antipsychotics for a short period
- other services: drug and alcohol
DBT-A background
Skill-based treatment for adolescents who experience trouble managing their emotions, thoughts, and behaviors
Theoretical underpinnings and goals of DBT-A:
* Biosocial theory: key feature of BPD is emotion dysregulation, which, under stress, evokes impulsive decision-making and problematic behaviors
* Dialectical philosophy and mindfulness: balance acceptance and change, be fully present in the moment, focus without judgement
* Cognitive behavioral science: learn effective problem-solving skills to respond flexibly to stressful life experiences
-> improve the quality of life
DBT-A stages
Stage 0 (pretreatment): diagnostics and commitment (rationale and alliance!)
Stage 1: control behavior
* Suicidal and other life-threatening behavior (e.g., impulsive behavior)
* Therapy interfering behavior (e.g., chaotic relationships)
* Behavior that conflicts with a life worth living (e.g., emotional lability, rage)
* Stabilization of coping skills and learning skills
Stage 2: experience, label, and cope with emotions (exposure)
Stage 3: set individual goals, learn to be (un)happy
Relate – Regulate - Reason
DBT-A components
- Weekly individual psychotherapy
- Weekly multifamily skills training (4 to 6 adolescents and their families)
- Telephone crisis coaching for clients and their family members
- Individual family meetings
- (Weekly supervision and intervision for therapists)
- Dosage: one year, two to three sessions per week
DBT van de site
emoties leren reguleren en gevoelens leren verdragen. verminderen zelfdestructieve gedragingen, inzien disfunctionele gedragingen, omgaan met hevige emoties en gedachten.
biosocial theory: aangeboren emotionele kwetsbaarheid * invaliderende omgeving
je bent niet de schuld van je emotionele ontregelingen, maar wel de enige die daar vat op kan houden.
- familie en naasten betrokken
- vaardigheidstrainingen:
- mindfullness
- intermenselijk
- emotieregulatie vaardigheden: TIPP (temperature (koud water), intense ontspanning, paced breathing, progressive relaxation), opposite action (als je verdrietig bent en wilt terugtrekken -> juist contact zoeken), mindfullness
- frustratietolerantie vaardigheden: accepteren van verdriet en tegenslagen
- telefonische consultatie
DBT-A skills training
- attention skills/aandachtsvaardigheden: wees je bewust van situaties en interacties zonder oordeel, breng balans tussen de emotionele geest (limbisch systeem) en de rationele geest (prefrontale cortex)
- emotieregulatievaardigheden: emoties ervaren en benoemen, de aandacht afleiden van dingen die sterke emoties kunnen oproepen, lichamelijke spanning reguleren, inadequaat gedrag verminderen, positieve emoties vergroten
- crisis management/vaardigheden: emoties accepteren en verdragen, omgaan met gevoelens van ongemak en pijn (frustratietolerantie) zonder de situatie erger te maken, inadequaat gedrag verminderen
- relatievaardigheden: individuen met BPD hebben sociale skills, maar kunnen geen positieve relaties vormen door verstoring van emoties en cognities
skill training DBT: hoe worden die vaardigheden aangeleerd?
- attention skills: mindfulness (openen van de geest, focus, balanceren van emotionele geest en logische geest)
- emotieregulatie vaardigheden: ABC schemas, probleem oplossen (definiëren van probleem, identificeren van alternatieven, pros/cons afwegen, evalueren van resultaten), STOP (stop, take a step back, observe, proceed mindfully), afleiden (tot 10 tellen, kleuren tellen in een afbeelding/schilderij, lied zingen), focussen op sensaties (rubberen bal, ijsklontje, in de regen staan, koude douche, sporten).
- crisis management/frustratietolerantie: focus je aandacht op activiteiten die je moet doen (opruimen, buiten lopen, bellen van een vriend, podcast, boek lezen), self soothing
- intepersoonlijke skills: vertellen waar je op reageert, gevoelens en gedachten uitten over de situatie, begrijpen, leren en communiceren van grenzen
waarom wordt de familie er bij betrokken
- generalisatie en reinforcement van vaardigheden
- geven van een gedeelde vocabulaire
- validatie en support
DBT-A telephone crisis coaching
- Clients and their family members can call the therapist before crisis behavior occurs (e.g., self-injurious behavior)
- They learn to ask for help effectively
- This supports the application of newly developed skills ‘on the spot’
DBT-A family meetings
- To maintain a healthy contact between the patient and parents
- To help parents offer a stable and safe living environment
- To help parents validate the patient and support the patient in problem solving
- To help parents handling family conflicts
- To help parents regain a balance in upbringing
DBT-A supervision and intervision for therapists
- To discuss difficulties that therapists encounter (preventing burn-out)
- To discuss difficulties that therapists encounter when implementing DBT
- To share information on the skills training progress (growth of patients)
- To discuss policy and approach of the institute
- To get more training in DBT
mentalization-based therapy (MBT) background
Long-term treatment for adolescents who experience trouble reflecting on their own thoughts, feelings, and behavior, as well as those of others.
Theoretical underpinnings and goals of MBT-A:
* Psychoanalytic/psychodynamic theory: key feature of BPD is mentalizing problems or difficulty understanding the own mental states and those of others
* Attachment theory: mentalizing problems are the result of growing up in a context of unsafe and insecure attachment relationships
* In stressful situations and hyperactivated attachment, mentalization is prone to go offline, which can evoke intense interpersonal interactions and inaccurate assumptions about other people’s motives and behavior.
