Appendix 4 Outcome psychic org and defen

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Published on December 15, 2008

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Long-Term Outcome, Psychic Organisation and Defenses in Personality Disorder. : Long-Term Outcome, Psychic Organisation and Defenses in Personality Disorder. MRCPsych Module. The Problems with Long-term Studies. : The Problems with Long-term Studies. SHORT TERM STUDIES OF PERSONALITY DISORDERS ARE OFTEN OF LITTLE VALUE. BUT, ARE LONG TERM STUDIES VALID? DIAGNOSTIC CRITERIA CHANGE FROM GENERATION TO GENERATION. LONG GAP BETWEEN TREATMENT AND OUTCOME RESPONSE MAY BE SPURIOUS BECAUSE OF INFERENCES ABOUT THE EFFICACY OF THE INITIAL TREATMENT. RETROSPECTIVE STUDY DESIGN IS OPEN TO MAJOR FLAWS BECAUSE OF MEMORY AND PATCHY OLD RECORDS. Cont., : Cont., PROSPECTIVE DESIGNS REDUCE THE MEMORY PROBLEM BUT LIMIT OUTCOME MEASURES TO MAINLY SHORT TERM GAIN. SYSTEMATIC LONG TERM STUDIES TARGETING OUTCOME MEASURES THAT LOOK AT BENEFITS IN THE FUTURE MAY HELP. PERSONALITY DISORDER PATIENTS OFTEN HIDE TRAITS FROM THE CLINICIAN The Importance of the Dimensional Approach : The Importance of the Dimensional Approach ‘ANTISOCIAL P D’; SELF SEEKING AND CONTENTIOUS OF OTHERS; THEREFORE COULD ALSO BE VIEWED AS ‘NARCISSISTIC’. BORDERLINE PATIENTS OFTEN HAVE ENOUGH OTHER TRAITS TO WARRANT A COMORBID PERSONALITY DIAGNOSIS. AS A RESULT, B P D IS BEST UNDERSTOOD IN DIMENSIONAL TERMS (STONE 1980). 500 MALADAPTIVE TRAITS (STONE 1990), ANALYSABLE INTO SOME 66 DIMENSIONS Emphasis of Diagnosis : Emphasis of Diagnosis CURRENT DEFINITIONS OF BORDERLINE, ANTI-SOCIAL AND SCHIZOTYPAL DEPEND HEAVILY UPON THE SYMPTOMATIC ACTS AND DESCRIPTIONS OF IDENTITY DISTURBANCE. IT IS POSSIBLE TO DIVIDE DSM AXIS II PD INTO A LARGER GROUP OF ‘TRUE’ PERSONALITY DISORDERS DEFINED BY TRAITS AND A SMALLER GROUP OF ‘MIXED’ DISORDERS WHOSE DEFINITION INCLUDE SYMPTOMS AS WELL AS TRAITS. True and Mixed Personality Disorders : True and Mixed Personality Disorders PARANOID IS A TRUE PERSONALITY DISORDER. INGREDIENTS INCLUDES – MISTRUSTFULNESS, SUSPICIOUSNESS, GRUDGEHOLDING, GUARDEDNESS, HYPERVIGILENCE, OVER-REACTIVENESS AND JEALOUSY – ALL TRAITS ANTI-SOCIAL, BORDERLINE AND SCHIZOTYPAL ARE MIXED. FROM ICD: AFFECTIVE AND EXPLOSIVE ARE MIXED. Follow up Studies - BPD : Follow up Studies - BPD 1970’S: BRIEF DURATION STUDIES (3 –5 YEARS) USING A VARIETY OF DIAGNOSTIC CRITERIA. THE LIFE COURSE APPEARED UNFAVOURABLE (SIMILAR TO THE COURSE OF SCHIZOPHRENICS). 1980’S: STUDIES INCLUDED LARGER NUMBERS AND LONGER INTERVALS. THE SAMPLE WAS MORE HOMOGENOUS (RELATED TO GUNDERSON CRITERIA). The PI - 500 Study - Stone (1987; 1990). : The PI - 500 Study - Stone (1987; 1990). THE PATIENTS WERE WELL KNOWN TO THE AUTHOR. PATIENTS WERE PREDOMINATELY MIDDLE TO UPPER MIDDLE CLASS. 52% JEWISH, 91% SINGLE AVERAGE AGE WHEN ADMITTED TO HOSPITAL, 23 YEARS. AVERAGE LENGTH OF STAY WAS 12½ MONTHS. ONE QUARTER OF THE PATIENTS HAD NEVER BEEN ADMITTED BEFORE. AVERAGE IQ 118, MOST HAVING GONE TO COLLEGE. PARENTS WERE MUCH LESS VIOLENCE PRONE THAN IN OTHER BPD SAMPLE. Results… : Results… OVERALL FOLLOW-UP AT INTERVALS OF 10-30 YEARS. TWO THIRDS OF PATIENTS WERE CLINICALLY WELL AT FOLLOW-UP. MANY HAD RISIDUAL MILD SYMPTOMS. 20% WERE ASYMPTOMATIC WORKING WELL WITH GRATIFYING LONG TERM SEXUAL PARTNERSHIP. WOMEN APPEARED MORE STABLE THAN MEN. ONLY ONE IN FOUR OF THE PATIENTS WHO ENTERED FOURTH AND FIFTTH DECADE IN LIFE COULD BE DIAGNOSED WITH BPD. More Results… : More Results… RE-ADMISSION DURING THE FOLLOW-UP YEARS WAS A THIRD AS LIKELY FOR A BPD AS FOR A SCHIZOPHRENIC PATIENT. BPD PATIENTS WERE MORE LIKELY TO HAVE WORKED DURING THE FOLLOW-UP PERIOD THAN SCHIZOPHRENICS. WORK WAS AT A HIGHER LEVEL. A FACTOR INDICATED IN DELAYED RECOVERY OR POOR OUTCOME IS SUBSTANCE ABUSE. Relationship to functional psychosis. : Relationship to functional psychosis. DSM-III-R criteria has no resemblance. No cases of shizophrenia among 33 in-patients with BPD. Pope et al (1983) 10-15 year follow-up of 200 BPD patients revealed only one patient who developed schizophrenia. Stone (1990) Long term follow-up work needed on the effect of the addition of “transient paranoid ideation” in DSM IV Association to Affective Disorder. : Association to Affective Disorder. 50% of BPD subjects had at least one type of affective disorder. Akiskal et al., (1983). 50% of in-patients with unipolar depression had BPD. Baxter et al., (1984). BPD-Depression is often treatment resistant - so prompting referral. Independent rather than a subtype of affective dis. High co-morbidity. Gunderson & Phillips (1991). BPD + MAD + ALCOHOL : BPD + MAD + ALCOHOL MOST FATAL SUB-GROUP SUICIDE RATE AFTER AN AVERAGE OF 16 HALF YEARS FOLLOW-UP WAS 8½%. DEPRESION PLUS BPD POSES A BIG RISK. A DEPRESSED PERSON NOT INTENDING TO DIE MAKES A SUICIDE GESTURE THAT TURNS OUT TO BE FATAL – MARILYN MONROE. Risk of Suicide in BPD Patients. : Risk of Suicide in BPD Patients. CONTINUING ALCOHOL ABUSE. CHAOTIC IMPULSIVITY. HISTORY OF PARENTAL BRUTALITY OR SEXUAL MOLESTATION. (STONE, 1990) Course and Outcome of ASPD : Course and Outcome of ASPD RESEARCH SHOWS THAT PATIENTS RECOVER TO SOME EXTENT AS THEY GROW OLDER. (BLACK ET AL., 1995); FOLLOW-UP PERIODS RANGING FROM 16 – 45 YEARS. HOWEVER, MANY REMAINED LIMITED BECAUSE OF SEVERE INTERPERSONAL PROBLEMS. PI-500 STUDY – HISTORY OF ANTI-SOCIAL ACTS BEFORE A PSYCHIATRIC ADMISSION WAS NOT ALWAYS AN INDICATOR OF A BAD PROGNOSIS NOR OF A PSYCHOPATHIC PERSONALITY. Equivocal Findings in ASPD. : Equivocal Findings in ASPD. BUT MANY OF THE ASP PATIENTS WITH A HISTORY OF VIOLENT ACTS OR SERIOUS NON VIOLENT ACTS (OFTEN ASSOCIATED WITH DEPRESSION) UNIFORMALLY HAD POOR OUTCOMES. THOSE WITH LESS SERIOUS ANTI-SOCIAL BEHAVIOUR (TRUANCY, SHOP-LIFTING) ATTAINED GOOD ADJUSTMENT. BUT, ROBINS, (1991) NOTED ASP SYMPTOMOLOGY SHOWED SPONTANEOUS REMISSION BY THE 30’S. THE EQUIVOCAL FINDINGS IN OUTCOMES STUDIES OF ASP IS DUE TO CONFLATION OF BOTH TRANSITORY DELINQUENTS AND CONTINUOUS ANTI-SOCIALS. Cont., : Cont., CONTINUOUS ANTI-SOCIALS PROBABLY HAVE A HIGHER LOADING OF GENETIC OR ENVIRONMENTAL OR BOTH INFLUENCES. SHOW CRIMINAL ACTIVITY AT A YOUNGER AGE AND PERSIST IN THIS PATTERN. Borderline Personality Organisation. : Borderline Personality Organisation. Why? BPD is heterogenous - 93 ways to meet 5,6,7 or 8 criteria. Most BPD patients meet criteria for co-morbid Axis I and other Axis II diagnostic conditions. Family history studies show weighting among relatives, of borderline, substance abuse and antisocial personality traits. Gunderson and Zanarini (1989) suggests core problem is impulse and action. Kernberg (1995). : Kernberg (1995). The Syndrome of Identity Diffusion Lack of integration of the concept of self and concept of significant others - Identity diffusion Underline the chronic interpersonal difficulties. Chronic difficulty in assessing in an integrated way ones own motivations, behaviours and, motivation and integrated aspects of significant others- “cannot put them together”. Subjective experience of chronic emptiness. Diagnostically: others appear as caricatures cf. real Dominance of Primitive Defence Mechanisms. : Dominance of Primitive Defence Mechanisms. Centred around splitting or primitive dissociation. Deal with unconscious intrapsychic conflicts by mutual dissociation of contradictory aspects or motivation involved in conflict. Corresponding oscillation between contradictory ego states: “all good” : “all bad” experience of self and others. The behavioural components of the unconscious defences cause chaos and unpredictability and confusion in interpersonal relations..(impulsivity, manipulativeness, blaming tendency, arrogance, helpless and lack of modulation of affect). Reality Testing is maintained. : Reality Testing is maintained. Capacity to differentiate when confronted with behaviours, an intrapsychic origin from an external origin of stimuli. Aware of difference between self and others. Capacity for maintaining empathy with ordinary social criteria of reality. Combines Dimensional and Categorical. : Combines Dimensional and Categorical. The inclusion of a dimensional approach in BPO allows for the consideration of the relative degree of infusion of aggression, introversion versus extroversion. Neurotic Personality Organisation. : Neurotic Personality Organisation. Solid ego identity. The predominance of defenses around repression. Excellent reality testing Consistently impaired reality testing - psychotic level of organisation. Three substructures in BPO : Three substructures in BPO ASPD Malignant narcissism. Narcissistic structure. Different transference patterns. Prognostic indicators - order of severity increasing with AS traits. What form of therapy, which patients and what prognosis. Common features of Psychodynamic approaches : Common features of Psychodynamic approaches Stability of frame. Increased level of therapist involvement cf., neurotic patients. Tolerance of hostility Discouraging self destructive (make it ego-dystonic - clarification and confrontation) Use of interpretations to bridge acts and feelings Limits to block acting out. Here and now cf., genetic matierial. Counter transference monitoring. Transference Focused Psychotherapy. : Transference Focused Psychotherapy. Above + Clarification Confrontation Interpretation of positive and negative transference. Early stage of Tx, drop out is common - take up actively, the unspoken channels of communication. Look at behaviour and countertransference - split off self states. Countertransference - Racker 1957. : Countertransference - Racker 1957. Concordant CT - Therapist identifies with the pt’s central subjective experience at that moment eg., identification with the sense of being a victim. Complimentary CT - Therapist identifies with the internal other - often dissociated and projected. Rapidly shifting states result in labile identificatory states. Enactments. : Enactments. The oscillation between patient and clinician (complimentary ct.) The identificatory process (concordant ct). The ‘blind spot’ or defensive countertransference within the clinician. Narcissistic and Borderline Organisations : Narcissistic and Borderline Organisations Thick-skinned narcissist - ‘object destroying’: survival of an idealised self is paramount. The analyst is someone who is felt to dismantle this self and effect a cure and engender dependence. Defensive and devaluation of the work. Sneering superiority. Triumph over the object. : Triumph over the object. His sole purpose in identification with a destructive self is to survive by triumphing over life and creativity. Excitement and triumph. Thin-skinned narcissist. : Thin-skinned narcissist. Vulnerable. Ashamed of himself. Persistently judges himself as inferior and sensitive to rejection. He gets some stability in achievements at home and work - increasing self regard rather than feeding triumph. He is ‘object denying’ - looking for agreement and denying difference.

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