人格障礙的診療和治療策略解讀培訓(xùn)課件

1、課程提綱DSM-IV和DSM-V系統(tǒng)人格障礙診斷的變化精神動(dòng)力學(xué)取向的診斷SWAP-200簡(jiǎn)介用SWAP-200做診斷不同的人格障礙和治療策略案例研究（邊緣、自戀和表演）課程提綱DSM-IV和DSM-V系統(tǒng)人格障礙診斷的變化DSM-IV和DSM-V人格障礙診斷及變化人格障礙的診斷及治療策略DSM-IV和DSM-V人格障礙診斷及變化人格障礙的診斷及治人格？人格？看電影遲到了，拿著票卻被看門老頭攔在門口，說(shuō)必須等到下一場(chǎng)才讓進(jìn)。邁克 泰森韋小寶許三多林黛玉看電影遲到了，拿著票卻被看門老頭攔在門口，說(shuō)必須等到下一場(chǎng)才人格障礙的診療和治療策略解讀培訓(xùn)課件Hippocrates Classificati

2、onElementHumorTypeStyleAirBloodSanguineHopefulEnthusiasticOptimisticEarthBlack BileMelancholicSadFireYellow BileCholericIrascibleIrritableWaterPhlegmPhlegmaticApatheticSlowHippocrates ClassificationElem人格障礙的診療和治療策略解讀培訓(xùn)課件人格障礙的診療和治療策略解讀培訓(xùn)課件維度類別維度人格的維度系統(tǒng)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.人格的維度系統(tǒng)Interpersonal Circumple人格維度子因素開放性（Openness）思想、幻想、審美、行動(dòng)、情感、價(jià)值觀盡責(zé)性（Conscientiousness）能力、秩序、責(zé)任感、上進(jìn)心、自律、深思熟慮外向性（Extraversion）樂(lè)群、自信、活躍、興奮尋求、積極情緒、熱心隨和性（Agreeabl

4、eness）信任、坦率、利他、順從、謙遜、溫和神經(jīng)質(zhì)（Neuroticism）焦慮、敵意、抑郁、自我意識(shí)、沖動(dòng)、脆弱人格維度子因素開放性（Openness）思想、幻想、審美、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人格障礙的診療和治療策略解讀培訓(xùn)課件DSM 類別系統(tǒng)DSM 類別系統(tǒng)人格障礙的診療和治療策略解讀培訓(xùn)課件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人格和人格障礙連續(xù)譜人格和人格障礙連續(xù)譜DSM-

9、IV 人格障礙的定義A.明顯偏離了患者所在文化所應(yīng)有的持久的內(nèi)心體驗(yàn)和行為類型，表現(xiàn)為下列二方面以上： （l）認(rèn)知（即對(duì)自我、他人、和事件的感知和解釋方式）； （2）情感（即：情緒反應(yīng)的范圍、強(qiáng)度、脆弱性、和適合性）； （3）人際關(guān)系； （4）沖動(dòng)控制。 DSM-IV 人格障礙的定義A.明顯偏離了患者所在文化所應(yīng)有DSM-IV 人格障礙的定義 B.這種持久的類型是不可變的，并且涉及個(gè)人和社交場(chǎng)合的很多方面。 C.這種持久的類型導(dǎo)致臨床上明顯的痛苦煩惱，或在社交、職業(yè)、或其他重要方面的功能缺損。 D.這種類型在長(zhǎng)時(shí)間內(nèi)是相當(dāng)穩(wěn)定不變的，至少可以追溯到青少年或早期成年時(shí)。 E.這種行為類型不可能歸

10、于其他精神障礙的表現(xiàn)或后果。 F.這種行為類型并非由于某種物質(zhì)（例如某種濫用藥物，治療藥品），或一般軀體情況（例如顱腦外傷）所致之直接生理性效應(yīng)。 DSM-IV 人格障礙的定義 B.這種持久的類型是不可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軸I和軸II軸I和軸II軸I和軸II障礙的共同點(diǎn)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軸I和軸II障礙的共同點(diǎn)Di

16、mensionAxis I Di人格障礙的治療心理動(dòng)力治療認(rèn)知治療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人格障礙的治療心理動(dòng)

17、力治療Leichsenring F, L人格障礙的生物學(xué)基礎(chǔ)心理治療可至腦功能的改變，此種改變可通過(guò)腦成像技術(shù)檢驗(yàn)。人格障礙的生物學(xué)基礎(chǔ)心理治療可至腦功能的改變，此種改變可通過(guò)Psychopathology Over Time: Hypothetical Data for One Subjectfrom Pfohl B, 1999Psychopathology Over Time: Hyp精神動(dòng)力學(xué)取向的診斷人格障礙的診斷及治療策略精神動(dòng)力學(xué)取向的診斷人格障礙的診斷及治療策略精神動(dòng)力學(xué)概述人類行為下心理驅(qū)力的系統(tǒng)研究和系統(tǒng)理論，強(qiáng)調(diào)有意識(shí)動(dòng)機(jī)和無(wú)意識(shí)動(dòng)機(jī)的交互作用，以及情緒的功能性價(jià)值。歷史研

18、究及認(rèn)知神經(jīng)基礎(chǔ)精神動(dòng)力學(xué)概述人類行為下心理驅(qū)力的系統(tǒng)研究和系統(tǒng)理論，強(qiáng)調(diào)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歷史Locke KantPavlov心智的動(dòng)力學(xué)理解31心智的動(dòng)力學(xué)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-無(wú)意識(shí)防御32Morokoff (1985)Women highest 無(wú)意識(shí)移情研究(Eagle, 1959)33無(wú)意識(shí)移情研究(Eagle, 1959)33Eric Kandel神

20、經(jīng)-精神分析學(xué) 我們的大多數(shù)行為是無(wú)意識(shí)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神經(jīng)-精神分析學(xué) 34超我、自我和本我的沖突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、自我和本我的沖突Bechara, A., 2007. 精神動(dòng)力取向診斷系統(tǒng)精神動(dòng)力性診斷手冊(cè)（PDM）操作性動(dòng)力性診斷手冊(cè)（OPD-II）精神動(dòng)力取向診斷系統(tǒng)精神動(dòng)力性診斷手冊(cè)（PDM）PDM的結(jié)構(gòu)多軸診斷P軸（人格軸）M軸（心理功能軸）S軸（癥狀軸）人格人格是相對(duì)穩(wěn)定的思考、感受、行動(dòng)以及與他人聯(lián)結(jié)的方式。PDM的結(jié)構(gòu)多軸診斷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中的心智功能調(diào)節(jié)、注意和學(xué)習(xí)關(guān)系能力（深度、廣度和一致性）內(nèi)部體驗(yàn)的質(zhì)量（確定性和自我關(guān)注的水平）情感體驗(yàn)、表達(dá)和交流防御方式和能力形成內(nèi)部表征的能力自我觀察的能力（ mindedness）內(nèi)部標(biāo)準(zhǔn)和理想：道德感PDM中的心智功能調(diào)節(jié)、注意和學(xué)習(xí)PDM中的心智功能M201 超過(guò)年齡階段的卓越心智功能M202 適合年齡階段的優(yōu)秀心智功能M20

24、3 適合年齡階段的心智功能M204 輕微的限制和不靈活M205 中度的限制和心智功能的改變M206 嚴(yán)重的限制和心智功能的改變M207 自我和他人表征的整合和組織，和（或）分化的缺陷M208 基本心智功能的嚴(yán)重缺陷PDM中的心智功能M201 超過(guò)年齡階段的卓越心智功能OPD-II的結(jié)構(gòu)軸I 疾病的體驗(yàn)和治療條件軸II 人際關(guān)系軸III 沖突軸IV 結(jié)構(gòu)軸V 心理和軀體障礙軸間交互OPD-II的結(jié)構(gòu)軸I 疾病的體驗(yàn)和治療條件人格障礙的診療和治療策略解讀培訓(xùn)課件幾個(gè)問(wèn)題如何理解癥狀？同樣的心理疾病癥狀，其內(nèi)在的原因可能并不相同。換句話說(shuō)，“人格結(jié)構(gòu)”和人格結(jié)構(gòu)的“動(dòng)力過(guò)程”中存在的問(wèn)題才是心理疾病癥狀的根本原因。診斷的目的?形成治療計(jì)劃，提高治療效益更為廣泛的經(jīng)驗(yàn)基礎(chǔ)（不來(lái)自個(gè)案治療，還來(lái)自偱證研究的結(jié)果）診斷的條件？幾個(gè)問(wèn)題如何理解癥狀？治療師做診斷的條件是否建立了足夠好的治療關(guān)系，進(jìn)入了工作狀態(tài)？是否能準(zhǔn)確覺察當(dāng)事人的特點(diǎn)；是否收集到足夠資料；治療師是否“