Comorbiditeit van ‘common mental disorders’
Bocking, Ruhe, Spijker & Spinhoven
Comorbiditeit van syndroomstoornissen en persoonlijkheidsstoornissen

Inleiding

Fenomenologie en begeleidende verschijnselen van persoonlijkheidsstoornissen

Persoonlijkheidsstoornissen zijn psychische problemen die zijn ontstaan in de jeugd, en zich in een veelheid van situaties voordoen, waarbij de persoon of diens omgeving leed wordt aangedaan. Dit is persistent, pervasief en pathologisch.

Het denken, voelen en doen van de persoon is egosyntoon.

Persoonlijkheid kan nog veranderen in volwassenheid. De verandering van persoonlijkheidstrekken vind gemiddeld genomen plaats in de richting van betere adaptatie.

Persoonlijkheidsstoornissen zijn geassocieerd met een verlaagde kwaliteit van leven, lager dan bij veel syndroomstoornissen.

Comorbiditeit is meer de regel dan uitzondering bij persoonlijkheidsproblematiek.

Behandelmodellen (sequentieel/parallel/geïntegreerd) voor deze comorbiditeit

Modellen bij de behandeling van comorbide syndroom- en persoonlijkheidsstoornissen zijn: 1) klassieke psychodynamisch, elke syndroomstoornis is het gevolg van onderliggende persoonlijkheidsproblematiek. De behandeling dient zich op de persoonlijkheid te richten 2) Klassieke CGT-denken, ontkende persoonlijkheidsstoornissen aanvankelijk. De behandeling diende zich louter op de syndroomstoornis te richten 3) Stepped care, er wordt begonnen bij de syndroomstoornis. Als deze behandeling niet goed aanslaat of er complicaties ontstaan wordt de patiënt doorverwezen naar een gespecialiseerd behandelprogramma. 4) Geïntegreerde en parallelle behandeling, komen minder voor.

Assessment

Detectie

Er zijn geen (vroeg)detectie instrumenten voor persoonlijkheidsstoornissen bekend met voldoende sensitiviteit en specificiteit om individueel toe te passen. De hulpverlener moet letten op langdurige dysfunctionele patronen van denken, voelen en doen, die zich ook buiten de syndroomstoornissen manifesteren.

Diagnostisch systeem

Persoonlijkheidsstoornissen zijn in de DSM-5 hetzelfde als in de DSM-IV. Dit is in drie clusters: A, het vreemde, bizarre cluster, gekenmerkt door merkwaardige ideeënvorming. B, het dramatische, impulsieve en emotionele cluster, gekenmerkt door excessieve uitingen van emoties en impulsen. C, het angstige cluster, gekenmerkt door overmatige vrees en vrees-gedreven coping als vermijding, aanklamping en perfectionisme. En er is nog een rest-categorie.

Gespecialiseerde assessment

Voor valide diagnostiek is het noodzakelijk om klinische interviews te gebruiken. Hiermee worden systematisch de criteria van de diagnoses nagegaan. Ze helpen clinici om niet te snel tot een oordeel te komen.

De diagnostiek van persoonlijkheidsstoornissen dient vooraf te gaan door diagnostiek van syndroomstoornissen.

Twee fouten moeten worden vermeden: een syndroom stoornis aan te zien voor een persoonlijkheidsstoornis en een persoonlijkheidsstoornis aanzien voor een syndroomstoornis.

Planning van de behandeling

Bij een comorbide syndroom- en persoonlijkheidsstoornis is het van belang een goed diagnostisch beeld te vormen.

De behandeling wordt meestal vooral gericht op de primaire diagnose. Uit klinische interviews blijkt echter niet altijd welke diagnose primair is.

Om te bepalen waarde behandeling primair op

 “The Neurobiology of Personality Disorders: Implications for Psychoanalysis”
Siever, Larry J, and Lissa N Weinstein (2009)
Journal of the American Psychoanalytic Association 57, no. 2 361–98. doi:10.1177/0003065109333502

Abstract

A low threshold for impulsive aggression, as observed in borderline and anti-social personality disorders, may be related to excessive amygdala reactivity, reduced prefrontal inhibition, and diminished serotonergic facilitation of prefrontal controls.

Affective instability may be mediated by excessive limbic reactivity in gabaminergic/glutamatergic/cholinergic circuits. This results in an increased sensitivity or reactivity to environmental emotional stimuli.

Disturbances in cognitive organization and information processing may contribute to detachment, desynchrony with the environment and cognitive/perceptual distortions.

A low threshold for anxiety may contribute to the avoidant, dependent and compulsive personality disorders.

Alterations in critical regulatory domains will influence how representations of self and others are internalized. Aspects of neurobiological functioning become cognized through the medium of figurative language into an ongoing narrative of the self.

Introduction

Temperamental abnormalities lie at the basis of the personality disorders emerging in the context of a specific experiential developmental trajectory.

Most personality characteristics are influenced by the underlying variability in biological endowments.

Individual differences in temperament along dimensions of affect regulation, impulse control, cognitive organisation, modulation of anxiety, and social information processing may contribute to the unique characterological constellation of each individual.

Temperament influences how an individual internalizes experiences.

Dimensional vs categorical approaches

This paper is based on a continuum model in which personality is seen as organized around basic psychological dimensions.

Four broad psychological dimensions based on disturbances are: Mood/affect, impulse/action, attention/cognition and anxiety.

These dimensions can be formulated as affective dysregulation or instability, impulsivity, cognitive disorganization and anxiety. Vulnerability to the development of personality disorders is patterned by genes expressing themselves in these dimensions, which are shaped by the environment. Difficulties in some of these domains cluster together and are associated with specific personality disorders.

Within the normal range, individual variations on the four domains will form the template for character traits.

Domains of temperament

Impulse aggression

Impulsivity/aggression is a lowered threshold for the activation of motoric responses to external stimuli without reflection or appropriate constraint.

Aggression expressed clinically must be understood form the perspective both of the more primitive limbic systems involved in its generation and of the

Handbook of personality disorders
Chapter 8
Cognitive structures and processes in personality disorders

Introduction

It is assumed that cognitive structures underlie personality disorders (PDs). These have a more pervasive and permanent character. They are assumed to emerge early in development from the interaction between temperament and environmental influences.

Schemas can be defined as generalized knowledge structures that is represented in memory and governs information processing. They consists of verbal and nonverbal knowledge.

Schemas and information processing constitute the basis for our subjective experience.

Three layers of the beliefs that are part of schemas central to PDs are: 1) unconditional beliefs, represent basic assumptions about the self, others, and the world. 2) conditional assumptions, beliefs about conditional relationships 3) instrumental beliefs, beliefs about how to act to avoid bad things and acquire good things

Patients with PD report elevated levels of specific maladaptive beliefs.

Early maladaptive schemas (EMSs) are thought to arise form experiences during early childhood when basic needs are not met. They are not considered to be related to specific DSM-5 PDs.

Coping styles reflect the way individuals deal with activation of a schemas. Early maladaptive schema-related copings styles are thought to be built on primitive responses that animals exhibit under high levels of threat. Coping responses are grouped into three clusters: 1) overcompensation, fight. The person behaves and thinks in a way that is the opposite of the triggered schema. 2) avoidance, flight. Prevent triggering of the schema, or avoiding the emotions and thoughts that are aroused. 3) surrender, freeze, submitting to what the schema dictates.

Schema mode is the emotional-cognitive-behavioural state of the person. Some schema modes show a specific relationship to certain PDs. A schema mode is a combination of an activated specific EMS and a specific coping style. Sudden switches in schema modes are ‘mode switches’.

In schema therapy, therapist and patient make an idiosyncratic case conceptualization that explains the problems with which the patient is struggling and link these, through these models, to the early experiences that lie at their root. Through the session, the therapist tries to detect what mode is activated, and next chooses among a specific set of techniques developed to deal with that mode.

Origins and content of schemas

Schemas that are central to PDs are assumed to develop during childhood from the interaction of biological and environmental influences. Children differ in their innate sensitivity to environmental influences and in how they response to stressors. These

Temperament, Character, and Personality Disorders in Adults with Autism Spectrum Disorder: a Systematic Literature Review and Meta-Analysis
Vuijk, Richard, Mathijs Deen, Bram Sizoo, and Arnoud Arntz. (2018)
doi:10.1007/s40489-018-0131-y.

Abstract

Autism spectrum disorder (ASD) is associated with an introvert, rigid, passive-dependent temperament with low novelty seeking, high harm avoidance, low reward dependence and high persistence. It Is associated with an immature and poorly developed character with low self-directedness, low cooperativeness, and high self-transcendence.

There is a positive correlation between ASD severity and neuroticism. There is a negative correlation between ASD severity and extraversion, openness to experience, agreeableness and conscientiousness.

There is a positive correlation between ASD and paranoid, schizoid, schizotypal, avoidant, and obsessive-compulsive PDs.

Autism spectrum disorder

ASD is an impairing neurodevelopmental disorder with social problems as a key symptom. People with ASD show persistent deficits in social communication and social interaction and restricted, repetitive patterns of behaviour, interests and activities.

ASD is associated with cognitive limitations and deficits in social cognition and social perception, executive functions, and bottom-up and top down information processing.

Personality

Personality is a complex pattern of deeply embedded psychological characteristics that are largely unconscious, cannot be eradicated easily, and express themselves automatically in almost every facet of functioning. These traits emerge from a complicated matrix of biological dispositions and experiential learnings.

Temperament is close to biological substrates. Character is influenced by social-cultural factors.

Temperament

Temperament is those aspects of an individual’s personality that are often regarded as the result of biological evolution, initially constitutionally based rather than learned. It is a combination of 1)  a certain level of activity 2) a tolerance for feelings 3) a certain degree of vitality 4) a certain degree of extraversion/introversion.

A baby shapes his environment with his temperament and this temperament is influenced by the environment.

The interaction between temperament and social environment influences the formation of character.

Character

Character is theorized as less heritable, later developing, influenced by processes of maturation, and representing individual differences in self-object relationships.

Character includes the following: self-directedness, cooperativeness and self-transcendence.

Personality disorder

Personality disorders are associated with ways of thinking and feelings about oneself and others,

Textbook of child and adolescent mental health
Chapter 4
Borderline personality disorder

Introduction

Borderline personality disorder is characterized by a pervasive and persistent pattern of instability and impulsivity.

Epidemiology

Prevalence

Prevalence of borderline personality disorder is estimated to be between 0.7 and 1.8%.

Gender and culture

Prevalence in the general population is considered to be similar for both gender. In clinical samples, females represent three quarters of all patients.

Thresholds for each criteria in the DSM may differ depending on their and their patient’s culture.

Burden of illness

The consequences of borderline personality disorder for the people around the sufferer depend on their vulnerability to the behaviour and demands of borderline personality disorder patients.

Patients with borderline personality disorder are exposed to risks due to impulsivity. Instability in emotional and inter-personal relationships leads to communication problems.

Age of onset and course

A diagnosis should not be made before the age of 18 years. Diagnosis is made earlier when symptoms are clear and persistent.

Remission is common. Remission is in most cases a reduction of the number of symptoms below the diagnostic threshold. There appear to be two clusters of symptoms: 1) stable and persistent, anger, feelings of abandonment 2) unstable or less persistent, self-harm and suicide attempts.

The risk of dead by suicide is between 4 and 10%.

Causes and risk factors

The cause of borderline personality disorder is unknown.

Repeated childhood trauma is a frequent element in borderline personality disorder.

Early maternal separation is associated with both borderline personality disorder and the persistence of borderline personality disorder symptoms over time.

Inheritance of borderline personality disorder is polygenic.

Diagnosis

Subtypes

Subtypes of borderline personality disorder may be defined by the comorbidities.

Some researchers propose two subtypes: 1) dependent, characterized by ambivalent, unstable relationships 2) impulsive, characterized by impulsive acts in multiple areas.

Presenting symptoms

Presentations are often prompted by another psychiatric problem, problematic behaviour, or relationship problems.

From a categorical to a dimensional concept of borderline personality disorder

For a dimensional diagnosis of borderline personality disorder, the following would be required: 1) significant

Oxford Textbook of Psychopathology
Chapter 30
Narcissistic personality disorder and pathological narcissism

DMS Narcissistic personality disorder: Pathological narcissism as extreme grandiosity

The DSM-5 NPD diagnosis exemplifies the conceptualization of pathological narcissism as excessive grandiosity.

Criteria for NPD in DSM-5

The DSM-5 criteria for NPD describe the following symptoms: 1) the person with NPD has an inflated sense of self-worth 2) is preoccupied with fantasies of unlimited influence, achievement, intelligence, attractiveness, or romance 3) believes that he or she is extraordinary or distinctive and can only be understood by, and should only associate with, other unusual or elite status people or institutions 4) requires excessive respect, appreciation and praise 5) has a sense of privilege and due 6) is willing to use and take advantage of others for personal gain 7) lacks compassion 8) is often jealous of others or believes that others are jealous of him or her 9) exhibits conceited, self-aggrandizing behaviours and attitudes.

The diagnosis reflects chronic expression of excessive or extreme grandiosity.

Prevalence

It is the least commonly diagnosed PD. Prevalence of NPD ranges from 0-5.7%.

Stability

The temporal stability of NPD is modest.

Discriminant validity of NPD criteria

The discriminant validity of NPD against other PD’s is poor.

Comorbidity

NPD exhibits the highest rates of comorbidity with antisocial and histrionic PDs. There are also comorbidities with symptom disorders. Diagnoses that most strongly predicted comorbid NPD are: bipolar I disorder, anxiety disorders, drug dependence, post-traumatic stress disorder, mood disorders and substance use disorders.

NPD research

Research on NPD is rare because of the low prevalence.

Patients with NPD exhibit deficits in emotional empathy but not cognitive empathy.

Patients with NPD have smaller gray volume in the left anterior insula and in frontoparalimic brain regions comprising the rostral and median cingulate cortex and the dorsolateral and medial parts of the prefrontal cortex.

Patients with NPD show a specific deficit for emotions representing fear and disgust. They do not have lower explicit self-esteem.

There are no empirically validated treatments for NPD.

Critiques for NPD

The lack of research on patients with NPD renders the validity and clinical utility of the diagnosis questionable.

The low prevalence of NPD reported in large-scale epidemiological studies are lower than the rates being treated in psychotherapy. It may be that there is a lack of sufficient NPD criteria.

The Oxford Handbook of Personality Disorders
Chapter 23
Dependent personality disorder

Introduction

Dependent personality disorder is associated with an array of negative outcomes. It is also associated with increased adaptation in a variety of areas 1) sensitivity to subtle interpersonal cues 2) decreased delay in seeking medical help following symptom onset 3) conscientious adherence to medical and psychological treatment regimes.

The evolution of dependent personality disorder

Descriptive psychiatry and psychoanalysis

In classical psychoanalytic theory, dependency is inextricably linked to events that occur during the first months of life (the oral state). Frustration or over gratification during the infantile, oral phase was thought to result in oral fixation and an inability to resolve the developmental issues that characterize this period (conflicts regarding dependency and autonomy). Research regarding this has produced weak results.

Current diagnostic frameworks

DSM-IV/DSM-IV-R

The essential feature of dependent personality disorder in the DSM-IV and DSM-IV-R is ‘a pervasive and excessive need to be taken care of that leads to submissive and clinging behaviour and fears of separation, beginning in early adulthood and present in a variety of contexts’.

The DSM-IV list eight specific symptoms. The patient must meet criteria for five of these symptoms to qualify for a dependent personality disorder diagnosis. 1) difficulty making everyday decisions without excessive advice and reassurance 2) needing other people to assume responsibility for most major areas in life 3) difficulty expressing disagreement because of fear of loss of support or approval 4) difficulty initiating projects or doing things on one’s own 5) going to excessive lengths to obtain nurturance and support from others 6) feeling uncomfortable and helpless when alone 7) urgently seeking another relationship as a source of care and support when a close relationship ends 8) being unrealistically preoccupied when fears of being unable to care for oneself

Empirical evidence regarding these criteria is mixed. And none of the symptoms include mention of the central cognitive feature of dependency, a perception of oneself as powerless and ineffectual.

The PDM

In the Psychodynamic diagnostic manual, dependent personality disorder is described in terms of dependent individuals’ tendency to ‘define themselves mainly in relation to others and seek security and satisfaction predominantly in interpersonal contexts’. Dependency must be evaluated with sensitivity to cultural and subcultural contexts.

The PDM is descriptive. It does

The Oxford Handbook of Personality Disorders
Chapter 26
Obsessive-compulsive personality disorder

History of a concept

Early psychoanalytical perspectives

Freud hypothesized that orderliness, parsimony and obstinacy were either sublimations of. Or reaction formations against, anal-erotic instincts of childhood. This is without empirical support.

Early psychoanalysts provided rich clinical descriptions of what would later become known as compulsive or obsessive-compulsive personality disorder. Several of the traits were incorporated into later diagnostic criteria.

The diagnostic and statistical manual of mental disorders and revisions

DSM-IV and DSM-IV-TR specified the essential feature of obsessive-compulsive personality disorder as ‘preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency. An individual must have at least four of the eight criteria in order to meet the diagnosis.

Obsessive-compulsive personality traits in moderation may be especially adaptive, particularly in situations that reward high performance.

International classification of diseases

The equivalent of obsessive-compulsive personality disorder in the ICD-10, is anankastic personality disorder. Criteria are: 1) preoccupation with details, rules, list, order, organisation or schedule 2) perfectionism that interferes with task completion 3) excessive conscientiousness and scrupulousness 4) undue preoccupation with productivity to the exclusion of pleasure an interpersonal relationships 5) rigidity and stubbornness 6) unreasonable insistence by the individual that others submit to exactly his or her way of doing things 7) feelings of excessive doubt and caution 8) excessive pedantry and adherence to social conventions.

Clinical aspects

Epidemiology

Estimates about the prevalence of obsessive-compulsive personality disorder range from 1.6-2.5%.

The prevalence in men and women is similar. The prevalence s greater in older age groups.

Comorbidity

Anxiety and mood disorders

Patients with OCPD had higher prevalences of anxiety disorder, social phobia, obsessive-complusive anxiety disorder and mood disorder.

Obsessive-compulsive disorder

Neuroticism and OCPD may be alternative expressions of the same underlying vulnerability in at least some families with OCD.

Eating disorders

OCPD has been found to be the most common personality disorder in patients with eating disorders.

Co-occurrence with other personality disorders

There is considerable diagnostic overlap between OCPD and other personality disorders. There are significant correlations with: avoidant PD, dependent PD, paranoid PD and borderline PD.

More than half the patients with OCPD had a co-occurring personality disorder.

Functional impairment

A substantial proportion of patients with OCPD show evidence of functional

Personality Disorders: Toward the DSM-V
Chapter 4
Schizoid personality disorder

Introduction

Schizoid personality disorder (SCPD) is distinguished from the other two personality disorders in the ‘odd/eccentric’ cluster by the prominence of social, interpersonal and affective deficits in the absence of psychotic-like cognitive/perceptual distortions.

The diagnosis of schizoid personality disorder

Prevalence

Schizoid personality disorder is among the least frequently observed of the personality disorders. This may be due to the uncommon appearance of schizoid individuals in clinical settings.

Schizoid personality disorder may be first apparent in late childhood. This is a period in which cooperative play is in ascendance, and the social isolation becomes more salient.

The disorder is more common in men.

DSM-IV-TR criteria for schizoid personality disorder

The DSM-criteria for schizoid personality disorder are: a pervasive pattern of detachment from social relationships and a restricted range of expression of emotions in interpersonal settings, beginning by early adulthood and present in a variety of contexts, as indicated by four of the following: 1) neither desires nor enjoys close relationships 2) almost always chooses solitary activities 3) has little, if any, interest in having sexual experiences with another persons 4) takes pleasure in few, if any, activities 5) lacks close friends or confidants other than first-degree relatives 6) appears indifferent to praise or criticism from others 7) behaviour or appearance that is odd, eccentric or peculiar.

Psychometric properties

The internal consistency of measures of schizoid personality disorder is poor.

Comorbidity

The highest co-occurrence of schizoid personality disorder is with schizotypal personality disorder. This might be due to the high overlap between the two criteria sets. Another high comorbid disorder is avoidant personality disorder. Lesser degrees of comorbidity are demonstrated with paranoid, antisocial, and borderline personality disorder.

Schizoid and avoidant personality disorder

Some studies suggest that schizoid personality disorder can be distinguished from avoidant personality disorder on the basis of intimacy needs and sensitivity to rejection. But, anxiety and clinical symptoms occur in both disorders.

Research literature has demonstrated poor discriminant validity between schizoid personality disorder and avoidant personality disorder.

Schizoid personality disorder and Asperger’s syndrome

There is significant overlap in the phenomenological criteria for schizoid personality disorder and asperger’s syndrome.

The clinical presentation of the two disorders is different. Autism becomes evident between two and three years of age when

Cognitive Therapy of Personality Disorders
Chapter 1
Overview of cognitive-behavioural therapy of personality disorders

Introduction

According to the Big Five model, human personality is composed of five factors: openness, conscientiousness, extraversion, agreeableness and neuroticism.

Each factor includes a variety of more specific personality traits.

The cognitive-behavioural approach to personality disorders

The cognitive-behavioural therapy (CBT) framework/paradigm has a set of interrelated theoretical principles.

Among CBT psychological treatments there are 1) acceptance and commitment therapy 2) dialectic behaviour therapy 3) schema therapy 4) cognitive therapy 5) rational-emotive behaviour therapy.

CBT theoretical foundations

CBT doesn’t treat personality disorder symptoms as an expression of an underlying illness, but as learned human responses to specific or general stimuli. The cognitive component is often prompted as a preliminary ‘cause’ of the disorder. This doesn’t mean that the causality is unidirectional. Al types of responses are strongly interrelated, forming a multidimensional interactive psychological structure.

The general ABC model of CBT is: 1) A, activating event, whether external and/or internal   2) B, beliefs 3) C, consequences: emotional, behavioural and psychophysiological.

Once generated, a consequence can become a new activating event, thus further priming metabeliefs/secondary beliefs that generate metaconsequences/secondary consequences.

Cold cognitions are descriptions of reality and the individual’s interpretations/inferences. Hot cognitions refer to how we evaluate/appraise these descriptions and inferences about reality. Both can be more surface beliefs or core beliefs.

The sequence of CT typically focuses first on automatic thoughts and later on core beliefs. At some point, CT focuses on activating events by problem-solving strategies and/or on the consequences of the beliefs by behavioural and/or coping techniques. The interactive nature of the core elements is different for each individual.

REBT focuses on altering dysfunctional consequences by changing irrational beliefs first and then, on changing cold cognitions. The process is first focuses on the surface beliefs in forms of specific irrational self-statements and later on general irrational core beliefs. After the cognitive restructuring process, REBT would focus on the other components.

Integrative multimodal CBT framework

According to the integrative and multimodal CBT framework, there are two types of core beliefs 1) Related to core cognitions, the general core beliefs coded in the human mind as general schemas 2) Hot cognitions, general irrational core beliefs coded in the mind as evaluative schemas.

These cold

Handbook of Personality Disorders
Chapter 29
Dialectical behaviour therapy

Introduction

Dialectial behaviour therapy (DBT) is developed to address the skills deficits of individuals with borderline personality disorder, as well as the issues that lead therapist frequently to get stuck.

DBT is rooted in the principles of behaviour therapy including 1) a strong emphasis on ongoing data collection during treatment 2) clearly defined target behaviours 3) a collaborative therapist-patient relationship 4) the use of standard cognitive and behavioural treatment strategies.

DBT has an emphasis on dialectics. The fundamental dialectic is the need for both acceptance and change. The therapist needs to fully accept the patient as (s)he is and at the same time persistently push for and help the patient to change. The therapist also tries to develop and strengthen an attitude of acceptance toward reality on the part of the patient, as well as the motivation and ability to change what can be changed.

The fundamental treatment dialectic of acceptance and change is expressed through validation and problem solving.

DBT involves a dialectic of communication style between reciprocal, warm interpersonal style and a more irreverent style.

There is a dialectic in case management between consultation to the patient to help manage his or her environment and direct environmental intervention by the therapist.

Scope and focus: Domains of psychopathology

DBT addresses problems associated with pervasive emotion dysregulation.

Treatment stages and targets

DBT consists of five stages: 1) Pretreatment 2) control 3) order 4) synthesis 5) transcendence.

Each session agenda is based on the patient’s behaviour since the last session. It is the therapist’s responsibility to remain mindful of treatment goals and to ensure that patient treatment activities are directed toward creating a life worth living.

Pretreatment

The objectives of this stage are 1) To orient patients to the philosophy and structure of treatment 2) for therapist and patient to reach agreement on the goals of treatment.

If patients are currently engaging in suicidal or other self-harming behaviours, they must agree that reducing or eliminating such behaviour is the first priority. Patients must agree not to kill themselves while they are on DBT. Explicit patient agreement is necessary prior to full participation in treatment.

With patients who express reluctance to commit to DBT goals, ongoing pretreament focuses on commitment-enhancing strategies.

Stage 1: from behavioural dyscontrol to stability and behavioural control

For patients who enter treatment with

Nieuwe ontwikkelingen in de Transference-focused psychotherapie
Draijer (2015)

Inleiding

Transference-focused psychotherapie (TFP) is ontwikkeld voor mensen met een borderline-persoonlijkheidsorganisatie (BPO). De borderline persoonlijkheidsorganisatie stamt uit objectrelationeel denken. Hier is in de borderline-persoonlijkheidsorganisatie de identiteit gespleten (de cliënt opereert in zwart-of-wit termen), de domenante afweer is onrijp en de realiteitstoetsing meestal intact.

Mensen met de borderline persoonlijkheidsorganisatie voelen zich verscheurd door hun verlangen naar nabijheid en hun verlangen naar autonomie. Het wordt beleeft als of-of. Ook ervaren zij zichzelf als wisselend alleen goed of alleen slecht.

Wat houdt TFP in?

Het doel van TFP is de integratie van de gespleten organisatie van de binnenwereld en identiteit, zodat men ambivalenties kan verdragen en kan leven met beperkingen van zichzelf en anderen (van of-of naar en-en).

De behandeling start met contractafspraken waarin het ageren begrensd wordt, dit houd het gevoel op een afstand. Een voorwaarde voor TFP is dat de cliënt toegezegd er alles aan te zullen doen om het ageergedrag niet te vertonen, als er neiging of sprake van het gedrag is moet dit als eerste worden besproken in de eerstvolgende zitting.

Het contract dient ook als het frame van de behandeling. Deze afspraken kan aan worden gerefereerd om moralisme binnen de behandelrelatie te voorkomen en het gevoel te kunne analyseren.

De belangrijkste interventies zijn: 1) Clarificatie, opheldering vragen 2) het benoemen van de dyade in de overdracht, de zelf, objectrepresnetatie en het verbindend affect 3) confrontatie, benoemen wisselingen tussen dyades 4) interpretatie, met elkaar in verband brengen van tegengestelde dyades.

Het centrale mechanisme van verandering in TFP is de integratie van gepolariseerde affectieve toestanden en afgesplitste representaties van zelf en anderen. Deze integratie begint op gang te komen als een therapeut de negatieve overdracht zo goed mogelijk containt (meekijkt) en empathisch begrijpt en zo teruggeeft aan de cliënt. De combinatie van de negatieve overdracht me de positieve ervaring van zich goed begrepen voelen werkt integrerend.

Interpretatie is een proces. Het begint met het signaleren en benoemen van de overdrachtsconstellatie, de dyade, waarin de cliënt de behandelaar een bepaalde rol toedicht binnen een voor hem relevant kader.

Werkzaamheid

TFP is alleen op werkzaamheid onderzocht bij borderlinepatiënten. In twee RCT’s was TFP beter dan de vergelijkingscondities in werkzaamheid.

TFP is een effectieve behandeling die in één jaar tot verbetering leidt.

TFP laat een structurele verandering zien in persoonlijkheidsstructuur.

Handboek Schematherapie
Hoofdstuk 3
Theoretisch model: schema’s, copingstrategiën en modi

Praktijk

Vroeg ontstane disfunctionele schema’s

Vanaf de eerste levensjaren worden ervaringen opgeslagen in ons autobiografisch geheugen in de vorm van schema’s. Zij omvatten de zintuigelijke waarnemingen, de ervaren emoties en handelingen en de betekenis die eraan is verleend. Vroegkinderlijke ervaringen worden op niet-verbale wijze opgeslagen.

Schema’s functioneren als filters waarmee mensen de wereld om zich heen ordenen, interpreteren en voorspellen.

De meeste mensen hebben schema’s ontwikkeld die hen helpen zichzelf en het gedrag van anderen en gebeurtenissen in de wereld beter te begrijpen. Dit stelt hen in staat een positief zelfbeeld en een genuanceerd beeld van anderen te ontwikkelen en om adequaat problemen op te lossen.

Mensen met persoonlijkheidsproblematiek hebben disfunctionele schema’s ontwikkeld.

Disfunctionele schema’s ontstaan op jonge leeftijd door de wisselwerking van het temperament van het kind, de opvoedingsstijl en de ouders en significante ervaringen. Disfunctionele schema’s weerspiegelen onvervuld emotionele behoeften van het kind. Het zijn aanpassingen aan negatieve ervaringen, gebrek aan liefde en warme, inadequate ouderlijke zorg en steun.

Disfunctionele schema’s zijn in de vroege kinderjaren, gezien de omstandigheden, adaptief. Ze interfereren wel met het goed doorlopen van ontwikkelingstaken. Dit kan leiden tot voortdurende negatieve ervaringen, die ervoor zorgen dat het schema steeds meer ingesleten en rigide raakt.

Hoe meer iemand op een bepaald gebied te kort is gekomen en hoe ernstiger de traumatische gebeurtenissen zijn, des te rigider en sterken bepaalde overtuigingen zich wortelen en des te meer last de persoon er van heeft.  

Schema’s zijn niet altijd even actief. Als omstandigheden meer gelijkenis vertonen met de situaties die hebben geleid tot het ontstaan van het schema, dan zal het schema ook meer op de voorgrond staan.

Iemand heeft copingstrategieën om zo min mogelijk last te hebben van het schema.

Beschrijving van de schema’s

Er zijn negentien schema’s, namelijk:

Emotionele verwaarlozing, de cliënt verwacht dat de eigen basale emotionele behoeften niet of onvoldoende door anderen zullen worden beantwoord. Hij volgt zich alleen een eenzaam.

Verlating/instabiliteit, de cliënt verwacht dat iedereen hem uiteindelijk in de steek zal laten. Anderen zijn onbetrouwbaar en onvoorspelbaar in hun steun en toewijding.

Wantrouwen en/of misbruik, de cliënt heeft de overtuiging dan anderen uiteindelijk misbruik van hem zullen maken of hem bedriegen of vernederen.

Sociaal isolement/vervreemding, de cliënt voelt zich geïsoleerd en anders dan anderen.

Minderwaardigheid/schaamte, de cliënt vind zichzelf innerlijk onvolkomen en slecht.

Sociale ongewenstheid, de