人格障礙與其治療

人格障礙與其治療第1頁/共117頁一、人格障礙概述(PersonalityDisorders:AnOverview)

第2頁/共117頁3Whatisapersonalitydisorder?

maladaptivepersonalitytraitstraitsarerelativelyenduringfeaturesofapersonthatarepersistentovertimeandsituationspeoplewithpersonalitydisorderstendtobe:rigidandinflexible,showarestrictedrangeoftraits,haveadominantsingletraitpersonalitydisordersareegosyntonic,morethanegodystonic第3頁/共117頁DSM－IV強(qiáng)調(diào)病人在認(rèn)知、情感、人際關(guān)系和沖動控制方面的偏離，指出這種偏離類型在長時間內(nèi)相當(dāng)穩(wěn)定，至少可以追溯到青少年或早期成年時。第4頁/共117頁5PersonalityDisorders:FactsandStatisticsPrevalenceofPersonalityDisordersAbout0.5%to2.5%ofthegeneralpopulation6-9%（Kathleen，1986）0.13‰（我國，1986）Ratesarehigherininpatientandoutpatientsettings。prevalencehigheramongpeoplewithothermentaldisorders6-9%ofpopulationhaveoneormorepersonalitydisordermostpeoplewithpersonalitydisordersnevercometotheattentionofmentalhealthprofessionals第5頁/共117頁6OriginsandCourseofPersonalityDisordersThoughttobegininchildhoodRunachroniccourseComorbidityratesarehighGenderDistributionandGenderBiasGenderbiasexistsindiagnosisCriterionvs.assessmentgenderbias第6頁/共117頁

DSM-IV將10種人格障礙劃分為3大類群:A類群：行為古怪、奇異ClusterAOddoreccentricExamplesincludeparanoid,schizoidB類群：戲劇化、情感強(qiáng)烈、不穩(wěn)定ClusterBDramatic,emotional,erraticExamplesincludeantisocial,borderlineC類群：緊張、焦慮行為ClusterCFearfuloranxiousExamplesincludeavoidant,obsessive-compulsive

分類DSM-IVandDSM-IV-TRPersonalityDisorderClusters第7頁/共117頁人格障礙類型 clusterAclusterBclusterC偏執(zhí)型 表演型 回避型分裂型 自戀型 依賴性分裂樣 反社會型強(qiáng)迫型 邊緣型第8頁/共117頁9第9頁/共117頁10PERSONALITYDISORDERS

Historicalperspective

Rootsinpsychoanalysis–narcissism,masochism,etc.KarlAbraham–firsttheoristtofocusonpersonalitydisorders第10頁/共117頁11PERSONALITYDISORDERS

Diagnosticissues

poorunderstandingofetiologyofmostpersonalitydisorderscomorbidityanddiagnosticoverlapgenderandculturalissuesreliabilityofdiagnosis第11頁/共117頁12PERSONALITYDISORDERS

Etiology–Theoreticalperspectives

PsychodynamictheoryAttachmenttheory–particularlyfordramatic,emotional,erraticCognitive-behaviouralperspectivesBiological–particularlyforodd,eccentricanddramatic,emotional,erratic第12頁/共117頁13第13頁/共117頁（一）偏執(zhí)型人格障礙（paranoidPD)1、臨床特征2、形成原因3、治療第14頁/共117頁臨床特征主要特征：猜疑、偏執(zhí)表現(xiàn)為對他人持久的不信任，社會隔離，過分警惕臨床發(fā)現(xiàn)男性居多第15頁/共117頁160.5-2.5%ofthepopulation.oMen>Women.oHigherincidenceinrelativesofschizophrenics.oHigheramongminorities,immigrants,andthedeaf.第16頁/共117頁17第17頁/共117頁18第18頁/共117頁19Suspects,withoutsufficientbasis,thatothersareexploiting,harming,ordeceivinghimorher.Ispreoccupiedwithunjustifieddoubtsabouttheloyaltyortrustworthinessoffriendsorassociates.Isreluctanttoconfideinothersbecauseofunwarrantedfearthattheinformationwillbeusedmaliciouslyagainsthimorher.Readshiddendemeaningorthreateningmeaningsintobenignremarksorevents.第19頁/共117頁20Persistentlybearsgrudges,i.e.,isunforgivingofinsults,injuries,orslights.Perceivesattacksonhisorhercharacterorreputationthatarenotapparenttoothersandisquicktoreactangrilyortocounterattack.Hasrecurrentsuspicions,withoutjustification,regardingfidelityofspouseorsexualpartner.DoesnotoccurexclusivelyduringthecourseofaPsychoticDisorderandisnotduetoageneralmedicalcondition.第20頁/共117頁形成原因生物學(xué)原因在精神分裂癥患者親屬中較多心理分析偏執(zhí)來自無意識中強(qiáng)烈的仇恨和敵意的外向投射認(rèn)知的觀點(diǎn)與歪曲的認(rèn)知或想法有關(guān)文化因素特殊人群，如犯人、難民、有聽力障礙的人等易形成這種人格障礙第21頁/共117頁22第22頁/共117頁23第23頁/共117頁治療建立信任關(guān)系非常重要心理動力學(xué)治療認(rèn)知治療Acknowledgemistakes.Beopenandhonest.Haveaprofessionalandnotoverlywarmstyle.Don‘tconfrontSetlimits.Clearlyexplainprocedures,medicationsandresults.第24頁/共117頁25summary:ParanoidPersonalityDisorderOverviewandClinicalFeaturesPervasiveandunjustifiedmistrustandsuspicionTheCausesBiologicalandpsychologicalcontributionsareunclearEarlylearningthattheworldisadangerousplaceTreatmentOptionsFewseekprofessionalhelpontheirownTreatmentfocusesondevelopmentoftrustCognitivetherapytocounternegativisticthinkingLackgoodoutcomestudies第25頁/共117頁（二）分裂樣人格障礙（SchizoidPD）1、臨床特征2、形成原因3、治療

第26頁/共117頁臨床特征特征：社會隔絕、情感疏遠(yuǎn)表現(xiàn)為孤單、冷淡的沉默，不介入日常事務(wù)，不交際，不關(guān)心他人。將精力投注于非人類的事物（如數(shù)學(xué)）患病率美、德等國采用PDQ（人格障礙診斷問卷）、SCID等得到的患病率為0.7－1.6％男性多見7.5%ofthepopulation.oA2-to-1male-to-femaleratio.第27頁/共117頁第28頁/共117頁29第29頁/共117頁30Neitherdesiresnorenjoyscloserelationships,includingbeingpartofafamily.Almostalwayschoosessolitaryactivities.Haslittle,ifany,interestinhavingsexualexperienceswithanotherperson.Takespleasureinfew,ifany,activities.Lacksclosefriendsorconfidantsotherthanfirst-degreerelatives.第30頁/共117頁31Appearsindifferenttothepraiseandcriticismofothers.Showsemotionalcoldness,detachment,orflattenedaffectivity.DoesnotoccurexclusivelyduringthecourseofaPsychoticDisorder,oraPervasiveDevelopmentalDisorderandisnotduetoageneralmedicalcondition.第31頁/共117頁

生物學(xué)可能有與孤獨(dú)癥類似的生理機(jī)能缺陷心理動力學(xué)基本的接觸需要沒有獲得滿足認(rèn)知治療不能有效的關(guān)注周圍的情況來獲得準(zhǔn)確的感知社會心理在早期學(xué)習(xí)、人際交往中形成問題形成原因第32頁/共117頁33第33頁/共117頁治療

心理治療發(fā)展對社會關(guān)系的興趣，認(rèn)識社會關(guān)系的價值社交技能訓(xùn)練

Understandtheirneedforisolation.MinimizenewcontactsandintrusionsMaintainaquiet,reassuring,andconsiderateinterestinthem.Don’tinsistonreciprocalresponses第34頁/共117頁（三）分裂型人格障礙（schizotype）1、臨床特征2、形成原因3、治療第35頁/共117頁臨床特征特征社會隔絕、情感疏遠(yuǎn)、古怪行為、多疑表現(xiàn)為認(rèn)識或感知方面的歪曲以及古怪的行為患病率可能高于精神分裂癥和其他人格障礙

3%ofthepopulation.Sexratioisunknown.Greaterassociationamongbiologicalrelativesofschizophrenicpatients.Thepremorbidpersonalityoftheschizophrenicpatient.第36頁/共117頁37第37頁/共117頁38Ideasofreference(excludingdelusionsofreference).Oddbeliefsormagicalthinkingthatinfluencesbehaviorandisinconsistentwithsubculturalnorms(e.g.,superstitiousness,beliefinclairvoyance,telepathy,orthesixthsense!±Unusualperceptualexperiences,includingbodilyillusions.Oddthinkingandspeech(e.g.vague,circumstantial,metaphorical,overelaborate,orstereotyped).Suspiciousnessorparanoidideation.第38頁/共117頁39Inappropriateorconstrictedaffect.Behaviororappearancethatisodd,eccentric.OrpeculiarLackofclosefriendsorconfidantsotherthanfirst-degreerelatives.Excessivesocialanxietythatdoesnotdiminishwithfamiliarityandtendstobeassociatedwithparanoidfearsratherthannegativejudgmentsaboutself.DoesnotoccurexclusivelyduringthecourseofaPsychoticDisorderoraPervasiveDevelopmentalDisorder.第39頁/共117頁形成原因生物學(xué)的解釋精神分裂癥親屬中有較高的此型患病率第40頁/共117頁41第41頁/共117頁42第42頁/共117頁43第43頁/共117頁44第44頁/共117頁治療心理治療：社交技能訓(xùn)練幫助其與人交往，減少對他人的不信任感藥物治療：治療精神分裂癥的藥物可使其癥狀有中等程度的改善oSimilartoSchizoidPD.oMisperceptionsofphysicalsymptomsandtreatment.oDonotridiculeorjudge.oRespecttheirneedforprivacy.第45頁/共117頁（四）表演型人格障礙（HistrionicPD）1、臨床特征2、形成原因3、治療第46頁/共117頁臨床特征又稱癔癥型、尋求注意型、或心理幼稚型特征

人格不成熟、情緒不穩(wěn)定表現(xiàn)：需要情愛和注意、依賴性、作弄他人的傾向患病率美、德等國采用PDQ、SCID等臨床調(diào)查表、定式檢核表等工具得到的為1.3－3.0％女性2倍于男性2-3%.Diagnosedmorefrequentlyinwomenthaninmen.AssociatedwithSomatizationDisorderandAlcoholAbuse/Dependence.第47頁/共117頁48第48頁/共117頁49Isuncomfortableinsituationsinwhichheorsheisnotthecenterofattention.Interactionwithothersisoftencharacterizedbyinappropriatesexuallyseductiveorprovocativebehavior.Displaysrapidlyshiftingandshallowexpressionofemotions.Consistentlyusesphysicalappearancetodrawattentiontoself.第49頁/共117頁50Hasastyleofspeechthatisexcessivelyimpressionisticandlackingindetail.Showsself-dramatization,theatricality,andexaggeratedexpression.Issuggestible,i.e.,easilyinfluencedbyothersorcircumstances.Considersrelationshipstobemoreintimatethattheyactuallyare.第50頁/共117頁形成原因?qū)ζ湓蚧蛑委煹难芯可傩睦矸治隼碚撟鳛閷?nèi)心低自尊感的一種反抗，病人總是試圖成為他人的注意中心。第51頁/共117頁52第52頁/共117頁53第53頁/共117頁治療對人際關(guān)系治療獎勵與懲罰結(jié)合SimilartoBorderlinePD.oMedicalillnessesthreatentheirsenseofattractivenessandself-image.第54頁/共117頁（五）自戀型人格障礙(NarcissisticPD)1、臨床特征2、形成原因3、治療第55頁/共117頁臨床特征特征妄自尊大觀念表現(xiàn)：自我中心，夸大（幻想或行為），需要他人贊揚(yáng)患病率美、德等國：0－0.4％2-16%intheclinicalpopulation.1%inthegeneralpopulation.Numberofcasesincreasingsteadily.第56頁/共117頁第57頁/共117頁形成原因心理分析家長對其子女不愛和不接受的行為方式行為和認(rèn)知模型過分積極的贊賞或?qū)檺凵鐣绊懸蛩丶皶r行樂、個人主義、競爭和成功等觀念影響第58頁/共117頁59第59頁/共117頁60Hasagrandiosesenseofself-importance(e.g.,exaggeratesachievementsandtalents,expectstoberecognizedassuperiorwithoutcommensurateachievements).Ispreoccupiedwithfantasiesofunlimitedsuccess,power,brilliance,beauty,orideallove.Believesthatheorsheis!°special!±anduniquecanonlybeunderstoodby,orshouldassociatewith,otherspecialorhigh-statuspeople(orinstitutions).Requiresexcessiveadmiration.第60頁/共117頁61Hasasenseofentitlement,i.e.,unreasonableexpectationsofespeciallyfavorabletreatmentorautomaticcompliancewithhisorherexpectations.Isinterpersonallyexploitative,i.e.,takesadvantageofotherstoachievehisorherownends.Lacksempathy:isunwillingtorecognizeoridentifywiththefeelingsandneedsofothers.Isoftenenviousofothersorbelievesthatothersareenviousofhimorher.Showsarrogant,haughtybehaviororattitudes.第61頁/共117頁治療對治療的研究非常有限心理治療主要集中于其被扭曲的自我（自我夸大感），對評價的病態(tài)的敏感等方面Handlecriticismpoorly.Becomeeasilyenraged.Medicalillnessescanbeablowtotheirself-esteem.Reinforcethattheyarerespectedandappreciated.Setlimitsondemandingbehavior.第62頁/共117頁（六）反社會型人格障礙(AntisocialPD)1、臨床特征2、形成原因3、治療第63頁/共117頁臨床特征特征經(jīng)常發(fā)生違反社會規(guī)范的行為表現(xiàn)：工作不良，婚姻不良，酒精與藥物濫用，情感膚淺、無情、自我中心，不誠實(shí)、欺騙、作弄他人，沖動性、攻擊性及法律問題等患病率Vaillant&Perry(1985)在0.05-15%之間男性多于女性3%inmenand1%inwomen.Mostcommoninpoorurbanareas.75%inprisonpopulations.Familialpatternpresent.第64頁/共117頁65第65頁/共117頁66Failuretoconformtosocialnormswithrespecttolawfulbehaviorsasindicatedbyrepeatedlyperformingactsthataregroundsforarrest.Deceitfulness,asindicatedbyrepeatedlying,useofaliases,orconningothersforpersonalprofitorpleasure.Impulsivityorfailuretoplanahead.Irritabilityandaggressiveness,asindicatedbyrepeatedphysicalfightsorassaults.Recklessdisregardforsafetyofselforothers.第66頁/共117頁67Consistentirresponsibility,asindicatedbyrepeatedfailuretosustainconsistentworkbehaviororhonorfinancialobligations.Lackofremorse,asindicatedbybeingindifferenttoorrationalizinghavinghurt,mistreated,orstolenfromanother.Theindividualisatleastage18years,andthereisevidenceofConductDisorderwithonsetbeforeage15years.TheoccurrenceofantisocialbehaviorisnotexclusivelyduringthecourseofSchizophreniaoraManicEpisode.第67頁/共117頁第68頁/共117頁形成原因生物學(xué)因素

遺傳、神經(jīng)生物學(xué)的假說社會心理學(xué)家庭與社會環(huán)境的影響，缺乏情感和父母粗暴拒絕心理分析超我發(fā)展不完善認(rèn)知心理學(xué)在道德原則和推理能力上的發(fā)展滯后第69頁/共117頁70第70頁/共117頁治療傳統(tǒng)的心理治療和醫(yī)學(xué)治療均無顯著的效果行為治療學(xué)習(xí)對問題情境作新的反應(yīng)認(rèn)知治療提高其認(rèn)知能力，改善社會和道德行為Setfirmlimits.Trynottobemanipulated.Havehighlevelofskepticism.Becarefulnottoprescribeexcessiveand/orunnecessarymedications.第71頁/共117頁邊緣型人格障礙(BorderlinePD)1、臨床特征2、形成原因3、治療第72頁/共117頁臨床特征特征人際關(guān)系、自我形象和情感的不穩(wěn)定表現(xiàn)：人際關(guān)系不良，不能耐受孤獨(dú)，常感孤單和空虛，易抑郁，情緒不穩(wěn)定，行為具沖動性，易發(fā)生自傷、自殺行為，存在自我認(rèn)同障礙患病率美、德等國：0.2-4.6％女性多于男性第73頁/共117頁741-2%ofthepopulation.oTwiceascommoninwomenasinmen.oIncreasedprevalenceofMajorDepressiveDisorder,AlcoholAbuse/Dependence,andSubstanceAbusefoundinfirst-degreerelatives.第74頁/共117頁75第75頁/共117頁76Franticeffortstoavoidrealorimaginedabandonment.Apatternofunstableandintenseinterpersonalrelationshipscharacterizedbyalternatingbetweenextremesofidealizationanddevaluation.Identitydisturbance:markedlyandpersistentlyunstableself-imageorsenseofself.Impulsivityinatleasttwoareasthatarepotentiallyself-damaging(e.g.,spending,sex,substanceabuse,recklessdriving,bingeeating).Chronicfeelingsofemptiness.第76頁/共117頁77Recurrentsuicidalbehavior,gestures,orthreats,orself-mutilatingbehavior.Affectiveinstabilityduetoamarkedreactivityofmood(e.g.,intenseepisodicdysphoria,irritability,oranxietyusuallylastingafewhoursandonlyrarelymorethanafewdays).Inappropriate,intenseangerordifficultycontrollinganger(e.g.,frequentdisplaysoftemper,constantanger,recurrentphysicalfights).Transient,stress-relatedparanoidideationorseveredissociativesymptoms.第77頁/共117頁形成原因生物學(xué)的解釋

神經(jīng)系統(tǒng)或腦內(nèi)生物化學(xué)方面的異常心理動力學(xué)的解釋父母對子女的不接納社會心理學(xué)對被遺棄的恐懼早期創(chuàng)傷，包括身體、性虐待第78頁/共117頁79第79頁/共117頁治療治療非常困難認(rèn)知行為治療心理動力學(xué)治療

集體治療與若干個人形成較親密的依戀關(guān)系藥物治療可減緩其沖動性，減輕抑郁等第80頁/共117頁81oBeawareofandanticipatedefenses.oOftenregress.oOpenandcontinuouscommunicationwithstaff.oStableandcalmreaction.oGentlyconfront.oSetfairandconsistentlimitsonactingout.第81頁/共117頁(七）回避型人格障礙（AvoidantPD）1、臨床特征2、形成原因3、治療第82頁/共117頁臨床特征特征長期和全面地脫離社會關(guān)系表現(xiàn)：對人回避、退縮，過分敏感，焦慮，對自我價值缺乏信心

患病率美、德等國：0.4-1.6％女性多于男性第83頁/共117頁84InfantswithatimidtemperamentmaybemorelikelytodevelopAvoidantPD.第84頁/共117頁85第85頁/共117頁86Avoidsoccupationalactivitiesthatinvolvesignificantinterpersonalcontact,becauseoffearsofcriticism,disapproval,orrejection.Isunwillingtogetinvolvedwithpeopleunlesscertainofbeingliked.Showsrestraintwithinintimaterelationshipsbecauseofthefearofbeingshamedorridiculed.第86頁/共117頁87Ispreoccupiedwithbeingcriticizedorrejectedinsocialsituations.Isinhibitedinnewinterpersonalsituationsbecauseoffeelingsofinadequacy.Viewsselfassociallyinept,personallyunappealing,orinferiortoothers.Isunusuallyreluctanttotakepersonalrisksortoengageinanynewactivitiesbecausetheymayproveembarrassing.第87頁/共117頁第88頁/共117頁形成原因生物學(xué)的解釋生物化學(xué)方面的異常、易患病的基因認(rèn)知行為模型的解釋習(xí)得性恐懼、不安的思維方式社會心理學(xué)的解釋羞恥感，與童年時期經(jīng)歷有關(guān)第89頁/共117頁90第90頁/共117頁治療支持和共情非常重要心理動力學(xué)揭示其癥狀的根源，使自我強(qiáng)壯起來認(rèn)知行為治療認(rèn)知重建、社交技能訓(xùn)練和暴露療法集體治療結(jié)合使用暴露療法、角色扮演法等藥物治療降低焦慮第91頁/共117頁92Havepatienceandunderstanding.oMedicalillnessesmaybeembarrassing.oMinimizenewandunfamiliarstaffcontacts.oRespondwithacalmandreassuringdemeanor.oDonotcriticizethem.第92頁/共117頁（八）依賴性人格障礙(DependentPD)1、臨床特征2、形成原因3、治療第93頁/共117頁臨床特征又稱不適當(dāng)型(inadequate)特征缺乏自信、依附他人表現(xiàn)：輕微應(yīng)激即退卻，尋求幫助，需要保護(hù)，性關(guān)系不成熟，往往存在婚姻問題，缺乏親密朋友患病率美、德等國：0.3-6.7％第94頁/共117頁95oMorecommoninwomenthanmen.oChildrenwithchronicphysicalillnessesmaybemoreprone.第95頁/共117頁96第96頁/共117頁97Hasdifficultymakingeverydaydecisionswithoutanexcessiveamountofadviceandreassurancefromothers.Needsotherstoassumeresponsibilityformostmajorareasofhisorherlife.Hasdifficultyexpressingdisagreementwithothersbecauseoffearoflossofsupportorapproval.Hasdifficultyinitiatingprojectsordoingthingsonhisorherown(becauseofalackofself-confidenceinjudgmentorabilitiesratherthanalackofmotivationorenergy).第97頁/共117頁98Goestoexcessivelengthstoobtainnurturanceandsupportfromothers,tothepointofvolunteeringtodothingsthatareunpleasant.Feelsuncomfortableorhelplesswhenalonebecauseofexaggeratedfearsofbeingunabletocareforhimselforherself.Urgentlyseeksanotherrelationshipasasourceofcareandsupportwhenacloserelationshipends.Isunrealisticallypreoccupiedwithfearsofbeinglefttotakecareofhimselforherself.第98頁/共117頁形成原因社會心理學(xué)父母出于愛或獨(dú)裁的目的過分保護(hù)孩子認(rèn)知理論適應(yīng)不良信念第99頁/共117頁100第100頁/共117頁治療行為和認(rèn)知療法認(rèn)知重建、自信訓(xùn)練人本主義治療集體治療第101頁/共117頁102Respecttheirfeelingsofattachment.oBecarefulwhenencouragingapatienttochangethedynamicsofanabusiverelationship.oWhenmedicallyilltheymaybecomefrustratedthattheyarenotbeinghelped.oBeactiveinthetreatmentplanning.第102頁/共117頁（九）強(qiáng)迫型人格障礙（Obsessive-CompulsivePD）1、臨床特征2、形成原因3、治療第103頁/共117頁臨床特征特征情緒限制，秩序性、堅(jiān)持執(zhí)拗、完美表現(xiàn)：秩序性、固執(zhí)、僵硬、異常節(jié)儉、謹(jǐn)小慎微、愛整潔、猶豫不決、嚴(yán)肅沉悶等美、德等國：1.7-6.4％男性多于女性第104頁/共117頁105Morecommoninmenthaninwomen.Diagnosedmoreinoldestchildren.Oftenahistoryofharshdisciplineasachild.第105頁/共117頁106第106頁/共117頁107Ispreoccupiedwithdetails,rules,lists,order,organization,orschedulestotheextentthatthemajorpointoftheactivityislost.Showsperfectio