Verso una concezione condivisa del trattamento dei disturbi di personalità

1. Verso una concezione condivisa del trattamentodeidisturbi di personalità Cesare Maffei, MD Università Vita-Salute San Raffaele, Milano Inetrnational Society for the Study of Personality Disorders (ISSPD)

2. Verso una concezione condivisa… La letteratura scientifica sul trattamento dei disturbi di personalità, sia ad orientamento qualitativo, clinico, che quantitativo, di ricerca empirica, è fortemente disomogenea rispetto alla rappresentatività dei disturbi stessi.

3. Verso una concezione condivisa… Il disturbo Borderline è di gran lunga il più studiato, a tal punto da avere consentito la pubblicazione di linee-guida per il trattamento (APA, 2001). Per gli altri disturbi le conoscenze sono inferiori o carenti, e ciò è anche connesso al grado di validità attribuito ad ogni singola categoria diagnostica. Peraltro, come è noto, il problema della validità diagnostica riguarda tutto l’ambito dei disturbi di personalità.

4. Verso una concezione condivisa… I termini della questione • Organizzazione Borderline di personalità • Disturbo Borderline di personalità

5. Verso una concezione condivisa… Problemi di intimità relazionale Moderata “aggressività” (impulsività/aggressività) “Aggressività”(impulsività/aggressività) Ciclotimia DP Istrionico DP Schizoide DP Narcisistico SadomasochisticoDP Borderline DP Paranoide Narcisismo Maligno DP Antisociale Organizzazione Borderline di personalità secondo Kernberg e Disturbi di personalità del DSM

6. Verso una concezione condivisa… I trattamenti • Transference-Focused Psychotherapy (TFP) (Kernberg) • Dialectic Behaviour Therapy (DBT) (Linehan) • Cognitive Analytic Therapy (CAT) (Ryle) • Mentalization Based Therapy (MBT) (Bateman e Fonagy) • Varie forme di psicoterapia analitica • Varie forme di psicoterapia cognitiva • Interventi di comunità • Farmaci psicoattivi

7. Verso una concezione condivisa… Tutti i tipi di trattamento elencati hanno aspetti comuni: • Alto livello di strutturazione • Scopi chiari • Sviluppo di una relazione di attaccamento sicura • Sforzo di mantenere un buon livello di adesione al trattamento • Ruolo attivo del terapeuta • Centralità del contratto terapeutico (variabile) • Integrazione con altre modalità di trattamento (variabile)

8. Verso una concezione condivisa… La differenziazione tra i vari tipi di trattamento, così come la specificità del loro effetto, sono aspetti di non facile valutazione in quanto ogni trattamento ha aspetti sovrapponibili agli altri e caratteristiche simili possono essere denominate in maniera differente a causa di diversità di concezioni e di linguaggio

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10. Verso una concezione condivisa… The clinical management of Borderline subjects involves four organizing levels: • Conceptual • Strategic • Tactical • Technical

11. Verso una concezione condivisa… Conceptual Issues

12. Verso una concezione condivisa… • BPD has been conceptualized according to various psycho(patho)logical perspectives, that focused on different clinical phenomena, etio-pathogenetic pathways and therapeutic principles • DSM-IV BPD is an eclectical diagnostic container • Current empirical research seems to suggest that many treatments have effective components and no single approach is more effective than the others

13. Verso una concezione condivisa… The Effectiveness of Psychodynamic Therapy and Cognitive Behavior Therapy in the Treatment of Personality Disorders: A Meta-Analysis Falk Leichsenring, D.Sc. and Eric Leibing, D.Sc. (Am J Psychiatry 2003; 160:1223–1232)

14. Verso una concezione condivisa… Conclusions: There is evidence that both psychodynamic therapy and Cognitive Behavior therapy are effective treatments of personality disorders. Since the number of studies that could be included in this meta-analysis was limited, the conclusions that can be drawn are only preliminary. Further studies are necessary that examine specific forms of psychotherapy for specific types of personality disorders and that use measures of core psychopathology. Both longer treatments and follow-up studies should be included.

15. Verso una concezione condivisa… Strategic Issues

16. Verso una concezione condivisa… Strategies are clusters of interventions sharing a common objective that translate concepts into therapeutic actions: • General Therapeutic Strategies: used with all patients at all stages of treatment to manage and treat the core features of BPD 2.Specific Therapeutic Strategies: used to treat specific problems in individual patients. They vary across patients, phases of therapy, and problems that are the focus of change

17. Verso una concezione condivisa… What are the core psychopathological dimensions of BPD ? Empirical research suggests that they are (Rosenberger and Miller, 1983; Clarkin et Al., 1993; Maffei et Al., 1999; Sanislow et Al., 2000;): • Identity / Interpersonal problems • Impulsivity • Affect instability

18. Verso una concezione condivisa… General Therapeutic Strategies The building and preservation of a therapeutic alliance is a major task concerning all the borderline subjects in all the phases of treatment. It is the first bulwark against the core dimensions of the disorder.

19. Verso una concezione condivisa… Gerald Adler (1979) said that the therapeutic alliance with borderline patients is a myth…

20. Verso una concezione condivisa… Forms of Therapeutic Alliance • Contractual (behavioral): initial agreement between the patient and the clinician on treatment goals and their roles in achieving them • Relational (affective/empathic): based on empathy, understanding, genuinity • Working (cognitive/motivational): patient joins the clinician as a reliable collaborator to help him/her understand his/her problems

21. Verso una concezione condivisa… Borderline subjects often involve people, and clinicians, in their deep unrealistic interpersonal needs (to be totally loved, to be omnipotently saved...) inducing them to emphasizeaffective answers, that is to favour relational aspects of therapeutic alliance. When this relational pattern fails, that is unavoidable, therapeutic alliance is severely menaced by the appearance of feelings of disappointment, abandonment, helplessness, hopelessness, rage and impulsive (self-injuring) behaviors.

22. Destructive, bad infant Controlled, enraged child Unwanted child Defective, worthless child Abused victim Sexually assaulted prey Deprived child Out-of-control,angry child Sexually excited child Dependent, gratified child Punitive sadistic parent Controlling parent Uncaring selfish parent Contemptuous parent Sadistic attacker Attacker, rapist Selfish parent Impotent parent Castrating parent Doting, admiring parent Otto Kernberg Object Relations Theory (1999): pairs in BPD

23. Verso una concezione condivisa… The contractual (behavioral) alliance has a primary role in order to minimize this danger: its objective is to try to share a common reality Why is it so important ? Because it limits the stable distorced patterns of interaction with others, characterized by intense affective involvement (idealization and devaluation), that often “trigger” the sudden and unpredictable appearance of impulsive (mostly self-injuring) behaviors

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25. Verso una concezione condivisa… Relational (affective/empathic) components of therapeutic alliance are useful to regulate negative emotions and affects. A well-balanced use of what is needed to empathically “support” the patient (identification of feelings, validation, insight into interpersonal needs) is useful to stabilize and reinforce the contractual alliance, that remains central.

26. Verso una concezione condivisa… Specific Therapeutic Strategies Borderline subjects can present specific clinical problems. They can vary across patients or phases of treatment: • Axis-I symptomatology • Crisis situations (suicidal, self-injuring, impulsive behavior) • Significant distress and/or impairment in relevant areas of functioning

27. Verso una concezione condivisa… Axis-I symptomatology Frequently borderline subjects suffer from Axis-I disorders that lead them to ask for clinical help: they should be carefully identified and treated. There are two main risks: • If only Axis-I disorders are identified, the problem of personality disorder is neglected and can negatively interfere with treatment • If borderline personality disorder is too emphasized, Axis-I disorders are not adequately treated

28. Verso una concezione condivisa… Crisis situations Possible crisis-related situations are: • Suicidal/self destructive behavior • Threatend aggression/intrusions • Threats of discontinuing treatment • Acute Axis-I symptomathology • Emergency room visits • Telephone calls • Therapists’ absence

29. Verso una concezione condivisa… Each of these problematic situations asks the clinician to decide what to do: solutions also depend on the resources that clinicians have. Examples are: • Brief hospitalization • Day Hospital intervention • Medications • Focused cognitive interventions • Contract change

30. Verso una concezione condivisa… An example: Suicidal threats

31. Verso una concezione condivisa… Guidelines for suicidal threats (Clarkin et Al., 1999): • Determine if the suicidal ideation is a manifestation of a major depressive episode • If yes, engage family, hospitalize the patient… • Determine the presence or absence of suicidal intent • If yes, engage family, send the patient to an emergency room, hospitalize him/her… • If no, explore the origin and the meaning of this ideation… • Determine if there is secondary relational gain • If yes, limit it… • If no, etc.

32. Verso una concezione condivisa… • The general strategy (therapeutic alliance) is always the framework of the specific strategies ! • Sometimes specific problems can be resolved only by changing the general strategy !

33. Verso una concezione condivisa… Significant distress and/or impairment in relevant areas

34. Verso una concezione condivisa… When borderline subjects refer to clinicians for chronic life problems (relationships, affective life, work…) or chronic distress (sense of inutility, of emptyness, boredom, chronic unsatisfaction…) “psychotherapy” can be considered as a first choice treatment.

35. Verso una concezione condivisa… Tactical Issues

36. Verso una concezione condivisa… Tactical aspects of management concern the maneuvers that the clinician uses to guide intervention at the level of the individual meeting.

37. Verso una concezione condivisa… They depend on the theoretical choice of the clinician (psychodynamic, cognitive…), however some of them seem to have an overall value: • Choosing a priority theme, starting from emergency priorities • Protecting the frame of treatment • Establishing/Increasing common elements of shared reality • Analyzing both positive and negative aspects of the therapeutic relationship

38. Verso una concezione condivisa… Technical Issues

39. Verso una concezione condivisa… They depend on the theoretical choice of the clinician (psychodynamic, cognitive…) For instance, they concern the role of interventions such as clarification, confrontation, interpretation, advice, support during the individual meetings

40. Verso una concezione condivisa… A Hierarchical organization of management priorities (from Livesley, 2003): Stage 1: Safety Stage 2: Containment Stage 3: Control and regulation Stage 4: Exploration and change Stage 5: Synthesis

41. Verso una concezione condivisa… • Stage 1: Safety: interventions to ensure safety of patients and others • Stage 2: Containment: interventions to contain and settle crisis states and episodes of acute instability and self-harm • Stage 3: Control and regulation: interventions to reduce self-harming behavior and promote control over emotions and impulses • Stage 4: Exploration and change: interventions to exploration and change the cognitive, affective, interpersonal, and situational processes contributing to maladaptive behaviour • Stage 5: Synthesis:the development of an integrated sense of identity (self) and integrated representations of others

42. Verso una concezione condivisa… • 1: Safety: • Provision of structure and support • 2: Containment: • Supportive and containing interventions • Medication • 3: Control and regulation: • Medication • Cognitive-behavioural interventions • 4: Exploration and change: • Cognitive, interpersonal, and psychodynamic interventions • 5: Synthesis: • Cognitive and psychodynamic interventions

43. Verso una concezione condivisa… The previous hierarchical organization of management priorities is organized in stages that can be also considered as a temporal sequence going from severe problems (survival) to quiet psychoterapeutic sessions (mental synthesis). During the treatment it can happen that patients in a stage show problems related to a previous stage: this is one of the aspects of treatment, that sometimes goes from the bottom to the top, and sometimes from the top to the bottom.