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Using Diagnoses to Improve Treatment Robert M. Gordon, Ph.D. ABPP J&K Seminar 2013

Using Diagnoses to Improve Treatment Robert M. Gordon, Ph.D. ABPP J&K Seminar 2013. 1. How does diagnoses (DSM, ICD, PDM) affect treatment ? 2. How to tailor treatment to the diagnoses of personality organization and personality patterns . . My Eclectic Background.

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Using Diagnoses to Improve Treatment Robert M. Gordon, Ph.D. ABPP J&K Seminar 2013

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  1. Using Diagnoses to Improve TreatmentRobert M. Gordon, Ph.D. ABPPJ&K Seminar 2013 1. How does diagnoses (DSM, ICD, PDM) affect treatment? 2. How to tailor treatment to the diagnoses of personality organization and personality patterns.

  2. My Eclectic Background • Undergrad focus on science and epistemology • Temple’s psychology department heavily influenced by Wolpe and Lazarus. It was anti-psychoanalytic. • I studied with Rosnow and Lana the artifacts and assumptions in research (applied epistemology). • After my Ph.D., I studied with Albert Ellis (Rational Emotive Therapy), Salvador Manuchin, Jim Framo, and Peggy Papp (family therapy). • For a while my primary identification was, “family therapist.” (AFTA, AAMFT Supervisor) • Eventually, I became convinced that projections and transferences were the main issues in couples work and went on to study object relations (institute training and my psychoanalysis).

  3. Paradigm Shift to Evidence Based Practice

  4. An Integrative Theoretical Formulation Precedes an Integrative Treatment • Need for the best theoretical formulation that integrates research about the mind, brain, affects, cognitions, behaviors, temperament, and their interactions in an interpersonal context. • Need for technical eclecticism based on the needs of the patient and EBP.

  5. The New Three Core Competencies in Psychiatry • Supportive Therapy (Rogerian) • Cognitive- Behavioral Therapy (CBT) • Long-Term Psychodynamic Psychotherapy

  6. Our Brains Guided Us for Millions of Years without Consciousness or Rationality

  7. Hypothalamic Sites that Generate Instinctual Behavioral and Affective States in MammalsPanksepp (1982)

  8. The Affective Parts of the Mammalian Brain are largely Non-Cognitive and Instinctual

  9. Superego, Ego and Id was a First Step in Understanding a Brain in Conflict • The Amygdalae (A) are involved in the processing of emotions. • The Ventromedial prefrontal cortex (VMPC) moderates emotional reactions and sends signals to the Striatum (S) with input from past experiences. • If the associations are negative, the VMPC signals are inhibitory. The Striatum translates signals from the Amygdala and VMPC into body action. S VMPC A

  10. Ventromedial Prefrontal Cortex and Neurosis Studies with PTSD support the idea that the ventromedial prefrontal cortex is an important component for reactivating past emotional associations and events, mediating pathogenesis of PTSD.

  11. Brains of Borderlines Have Less Grey Matter in Anterior Cingulate Cortex Patients with borderline personality disorder had significantly lower density of grey matter (the brain's working tissue) in the anterior cingulate cortex, an area (yellow right) that regulates the brain's fear hub (amygdala-yellow left). MRI scan data shows the difference between patients and controls.

  12. Brains of Borderlines Have More Grey Matter in Amygdala Patients with borderline personality disorder had significantly higher density of grey matter in the brain's fear hub, the amygdala (red areas). MRI scan data shows where patients and controls differed.

  13. Emotions and attachment drives in mammals are similar and evolved for functional reasons. They may be affected by thoughts, but they are not created by them. Damasio, et al., 2002 Panksepp, J. (2003). Science, Oct 10th. Herman & Panksepp, 1979

  14. Attachment Security in Infancy and Early Adulthood: A Twenty-Year Longitudinal Study.Walters, E. Merrick., S.; Treboux, D.; Crowell, J. and Albersheim, L. (2000), Child Development. • Researchers looked at relationship patterns in 50 young adults who were studied 20 years earlier as infants. • Overall, 72% of the adults received the same secure verses insecure attachment classification they had in infancy.

  15. Experimental Test of Unconscious Transference • Study: subjects are subliminally shown aggressive (A) or positive (B) stimuli • and then rate a neutral stimulus (C) • Subjects shown panel A subsequently rated the boy in panel C more negatively(Eagle, 1959)

  16. Treat the Whole Person • Blatt, (2006), Norcross (2002), Wampold (2001) have concluded that the nature of the psychotherapeutic relationship, reflecting interconnected aspects of mind and brain operating together in an interpersonal context, predicts outcome more robustly than any specific treatment approach per se. • Westen, Novotny, and Thompson-Brenner (2004) have presented evidence that treatments that focus on isolated symptoms or behaviors (rather than personality, emotional, and interpersonal patterns ) are not effective in sustaining even narrowly defined changes.

  17. Value of Insight into the Self • 800 Psychologists ranked a list of 38 of the most beneficial things they got from their own psychotherapy. • They listed first, “Self-understanding.” • “Symptom relief” was halfway down the list • Included in the survey were psychologists from all theoretical orientations (Behaviorists, Cognitive-Behaviorists, Psychoanalytic, etc.). • Pope, K. T., B.G. (1994). Therapists as patients: A national survey of psychologists' experiences, problems, and beliefs. Professional Psychology: Research & Practice, 25(3), 247-258.

  18. Effectiveness of Long-term Psychodynamic Psychotherapy A Meta-analysisLeichsenring and Rabung (2008) JAMA, 3000,13,1551-1565. • 23 LTPP studies (11 RCT efficacy and 12 effectiveness) total of 1053 patients with personality disorders, and multiple and complex problems. • LTPP at least 1 year (an average of 151 sessions). • Results LTPP better than 96% of those in short term therapies (CBT, DBT, SFT, CAT, FT, STPP, etc.) with changes in not only symptoms relief but with increases in mental capacities.

  19. Importance of Transference and Attachment with BPD • Clarkin, et al. (2007): 90 BPD randomly assigned to transference-focused psychotherapy (TFT), dialectical behavior therapy (DBT), or supportive therapy (ST). • Patients in all 3 treatments showed significant positive change in depression, anxiety, global functioning, and social adjustment. • Both transference-focused psychotherapy and dialectical behavior therapy were significantly associated with improvement in suicidality. • Only transference-focused psychotherapy and supportive treatment were associated with improvement in anger. • Transference- focused psychotherapy and supportive treatment were each associated with improvement in impulsivity. • Only transference-focused psychotherapy was significantly predictive of change in irritability and verbal and direct assault.

  20. Over-all Research • Evidence Based short-term symptom focused treatments are allequally effective. • Long-term psychodynamic therapies that focus on temperament, conflicts, affects, cognitions, behaviors, interpersonal context, child development, conscious and unconscious levels are better than symptom focused treatments in treating personality disorders.

  21. Integrative Psychotherapeutic InterventionsGoing From Supportive, CBT and Psychodynamic • Personal Qualities of the Therapist • Maintaining the Therapeutic Frame • Reassurance • Listening • Behavioral Mastery: Self-Soothing • Cognitive Learning • Clarifications • Interpretations of mental life that affects subjective well-being and relationships

  22. Treatment of the Borderline Level Personality Disorder • Behavioral Mastery: desensitization and self-soothing • Cognitive Learning: how to better understand thoughts, feelings, and behaviors • Clarifications and Confrontations: of the patient’s confusions, distortions and consequences of judgment and impulses • Interpretations: focus on here and now defenses, transferences, enactments, and mentalization

  23. Treatment of the Neurotic Level Personality Disorder • Reconstructions: patients may benefit from a coherent, insightful narrative of their psychological history. Despite problems with recall and subjectivity, traumatic events can be recalled, masteredand integrated into a more cohesive identity. • Interpretations:insight into unconscious resistances, defenses, transferences and enactments.

  24. Kernberg’s Differentiation of Personality Organization That Preceded the PDM NeuroticBorderline Psychotic Identity +integrated - diffused - Integration Defensive +higher -primitive - Operations Reality + + - Testing

  25. Borderline Personality OrganizationBasic Characteristics- Kernberg Identity Diffusion No integrated concept of self No integrated concept of significant others Primitive Defenses – Splitting – Idealization/devaluation – Projective identification – Omnipotent control – Denial Variable Reality Testing

  26. Healthy Defense Mechanisms AnticipationAffiliation AltruismHumorSelf-AssertionSelf-ObservationSublimationSuppression

  27. Neurotic Level Defenses Displacement Dissociation Intellectualization Rationalization Isolation of Affect Reaction Formation Repression Undoing

  28. Borderline level Defenses Idealization / Devaluation Omnipotence and Omnipotent control Denial Projective identification Splitting of self-image or image of others Acting out Projection

  29. Psychotic Level Delusional projection Psychotic denial Psychotic distortion

  30. Anaclitic vs Introjective(accordingtoS.Blatt) • Anaclitic: Borderline, Histrionic, Dependent, Avoidant, Depressive anaclitic. • Introjective: Schizoid, Paranoid, Antisocial, Narcissistic, Obsessive, Depressive introjective. • Reference tools: Object Relations Inventory (ORI; Blatt et al., 2006)

  31. Personality Disorders P Axis Temperamental, Thematic, Affective, Cognitive, and Defense patterns

  32. P101. Schizoid Personality Disorders • Contributing constitutional-maturational patterns: Highly sensitive,shy, easily overstimulated • Central tension/preoccupation: Fear of closeness/longing for closeness • Central affects: General emotional pain when overstimulated, affects so powerful they feel they must suppress them • Characteristic pathogenic belief about self: Dependency and love are dangerous • Characteristic pathogenic belief about others: The social world is impinging, dangerously engulfing • Central ways of defending: Withdrawal, both physically and into fantasy and idiosyncratic preoccupations

  33. P102. Paranoid Personality Disorders • Contributing constitutional-maturational patterns: Possibly irritable/aggressive • Central tension/preoccupation: Attacking/being attacked by humiliating others • Central affects: Fear, rage, shame, contempt • Characteristic pathogenic belief about self: Hatred, aggression and dependency are dangerous • Characteristic pathogenic belief about others: The world is full of potential attackers and users • Central ways of defending: Projection, projective identification, denial, reaction formation

  34. P103. Psychopathic (Antisocial) Personality Disorder P103.1  Passive/Parasitic: “con artist” P103.2  Aggressive: explosive, predatory, often violent • Contributing constitutional-maturational patterns: aggressiveness, high threshold for emotional stimulation • Central tension/preoccupation: Manipulating/being manipulated • Central affects: Rage, envy • Characteristic pathogenic belief about self: I can make anything happen • Characteristic pathogenic belief about others: Everyone is selfish, manipulative, dishonest • Central ways of defending: Reaching for omnipotent control

  35. P104. Narcissistic Personality Disorders   P104.1  Arrogant/Entitled: devalues, vain, commanding   P104.2  Depressed/Depleted: idealizing, envious, easily hurt • Contributing constitutional-maturational patterns: No clear data • Central tension/preoccupation: Inflation/deflation of self-esteem • Central affects: Shame, contempt, envy • Characteristic pathogenic belief about self: I need to feel okay • Characteristic pathogenic belief about others: Others enjoy riches, beauty, power, and fame; the more I have of those, the better I will feel • Central ways of defending: Idealization/devaluation

  36. Narcissistic PD: Narcissistic Injury The Doberman threw himself out the second-story window after he realized the family had indeed named him “Binky.”

  37. P105. Sadistic and Sadomasochistic Personality Disorders P105.1  Intermediate Manifestation: Sadomasochistic Personality Disorders:alternate between attacking and feeling insulted • Contributing constitutional-maturational patterns: Unknown • Central tension/preoccupation: Suffering indignity/inflicting such suffering • Central affects: Hatred, contempt, pleasure (sadistic glee) • Characteristic pathogenic belief about self: I am entitled to hurt and humiliate others • Characteristic pathogenic belief about others: Others exist as objects for my domination • Central ways of defending: Detachment, omnipotent control, reversal, enactment

  38. Sadistic PD: I am entitled to hurt others

  39. P106. Masochistic (Self-Defeating) Personality Disorders   P106.1  Moral Masochistic: self-esteem depends on suffering   P106.2  Relational Masochistic: suffer for sake of relationship • Contributing constitutional-maturational patterns: None known • Central tension/preoccupation: Suffering/losing relationship or self-esteem • Central affects: Sadness, anger, guilt • Characteristic pathogenic belief about self: By manifestly suffering, I can demonstrate my moral superiority and/or maintain my attachments • Characteristic pathogenic belief about others: People pay attention only when one is in trouble • Central ways of defending: Introjection, introjective identification, turning against the self, moralizing

  40. Masochistic Personality Disorder “Penny for your thoughts, Arnold!”

  41. P107. Depressive Personality Disorders   P107.1  Introjective: self-critical, self-worth   P107.2  Anaclitic: concern with attachment issues • Contributing constitutional-maturational patterns: Possible genetic predisposition • Central tension/preoccupation: Goodness/badness or aloneness/relatedness of self • Central affects: Sadness, guilt, shame • Characteristic pathogenic belief about self: There is something essentially bad or incomplete about me • Characteristic pathogenic belief about others: People who really get to know me will reject me • Central ways of defending: Introjection, reversal, idealization of others, devaluation of self

  42. Depressive Personality Disorder Lodge owner Harold Shuffle saw only the negative side of things.

  43. P107.3  Converse Manifestation: Hypomanic Personality Disorder • Contributing constitutional-maturational patterns: Possibly high energy • Central tension/preoccupation: Overriding grief/succumbing to grief • Central affects: Elation, rage, unconscious sadness and grief • Characteristic pathogenic belief about self: If I stop running and get close to someone, I’ll be traumatically abandoned, so I’ll leave first • Characteristic pathogenic belief about others: Others can be charmed into not seeing the qualities that make people inevitably reject me • Central ways of defending: Denial, idealization of self, devaluation of others

  44. P108. Somatizing Personality Disorders • Contributing constitutional-maturational patterns: Possible physical fragility, early sickliness, early abuse • Central tension/preoccupation: Integrity/fragmentation of bodily self • Central affects: alexithymia, inferred rage, distress • Characteristic pathogenic belief about self: I am fragile, vulnerable, in danger of dying • Characteristic pathogenic belief about others: Others are powerful, healthy, and indifferent • Central ways of defending: Somatization, regression

  45. Somatizing Personality Disorder “My brother, Tilford, had trouble with hemorrhoids and he never did anything like this!”

  46. P109. Dependent Personality Disorders • Contributing constitutional-maturational patterns: Possible placidity, sociophila • Central tension/preoccupation: Keeping/lossing relationships • Central affects: Pleasure when securely attached; sadness and fear when alone • Characteristic pathogenic belief about self: I am inadequate, needy, impotent • Characteristic pathogenic belief about others: Others are powerful and I need their care • Central ways of defending: Regression, reversal, avoidance • Subtypes:Passive-Aggressive,   Counterdependent

  47. Dependent PD: Others are powerful and I need their care “You’re gonna spoil that dog, Annie!”

  48. P109. Dependent Personality DisordersP109.1  Passive-Aggressive Versions of Dependent Personality Disorders • Contributing constitutional-maturational patterns: Possibly irritable, aggressive • Central tension/preoccupation: Tolerating mistreatment/getting revenge • Central affects: Anger, resentment, pleasure in hostile enactments • Characteristic pathogenic belief about self: I am inadequate, needy, impotent • Characteristic pathogenic belief about others: Others are powerful and I need their care • Central ways of defending: Regression, reversal, avoidance

  49. Passive-Aggressive Personality Disorder “It’s almost like they do it on purpose, isn’t it, Fred?!”

  50. P109. Dependent Personality DisordersP109.2  Converse Manifestation: Counterdependent Personality Disorder • Contributing constitutional-maturational patterns: Possibly more aggressive than the overtly dependent type • Central tension/preoccupation: Demonstrating lack of or shameful dependence • Central affects: Contempt, denial of “weaker” emotions • Characteristic pathogenic belief about self: I don’t need anyone • Characteristic pathogenic belief about others: Others depend on me and require me to be “strong” • Central ways of defending: Denial, reversal, enactment

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