verso una concezione condivisa del trattamento dei disturbi di personalità cesare maffei, md...

Verso una concezione condivisa del Verso una concezione condivisa del trattamentotrattamento

deideidisturbi di personalitàdisturbi di personalità

Cesare Maffei, MDCesare Maffei, MD

Università Vita-Salute San Raffaele, MilanoUniversità Vita-Salute San Raffaele, Milano

Inetrnational Society for the Study of Personality Inetrnational Society for the Study of Personality DisordersDisorders

(ISSPD)(ISSPD)

Verso una concezione condivisa…Verso una concezione condivisa…

La letteratura scientifica sul trattamento dei La letteratura scientifica sul trattamento dei

disturbi di personalità, sia ad orientamento disturbi di personalità, sia ad orientamento

qualitativo, clinico, che quantitativo, di ricerca qualitativo, clinico, che quantitativo, di ricerca

empirica, è fortemente empirica, è fortemente disomogeneadisomogenea rispetto rispetto alla alla

rappresentatività dei disturbi stessi. rappresentatività dei disturbi stessi.


Il disturbo Il disturbo BorderlineBorderline è di gran lunga il più studiato, a tal è di gran lunga il più studiato, a tal

punto da avere consentito la pubblicazione di linee-guida punto da avere consentito la pubblicazione di linee-guida

per il trattamento (APA, 2001). per il trattamento (APA, 2001).

Per gli altri disturbi le conoscenze sono inferiori o carenti, e Per gli altri disturbi le conoscenze sono inferiori o carenti, e

ciò è anche connesso al grado di ciò è anche connesso al grado di validitàvalidità attribuito ad ogni attribuito ad ogni

singola categoria diagnostica. Peraltro, come è noto, il singola categoria diagnostica. Peraltro, come è noto, il

problema della validità diagnostica riguarda tutto l’ambito problema della validità diagnostica riguarda tutto l’ambito

dei disturbi di personalità.dei disturbi di personalità.


I termini della questioneI termini della questione

• OrganizzazioneOrganizzazione Borderline di personalità Borderline di personalità

• DisturboDisturbo Borderline di personalità Borderline di personalità


Problemi di intimità relazionaleModerata “aggressività” (impulsività/aggressività)

“Aggressività”(impulsività/aggressività)

Ciclotimia DP Istrionico

DP Narcisistico

Sadomasochistico DP Borderline

DP Paranoide Narcisismo Maligno DP Antisociale

DP Schizoide

Organizzazione Borderline di personalità secondo Kernberg e Disturbi di personalità del DSM


I trattamenti I trattamenti

• Transference-Focused Psychotherapy (TFP) (Kernberg)Transference-Focused Psychotherapy (TFP) (Kernberg)• Dialectic Behaviour Therapy (DBT) (Linehan)Dialectic Behaviour Therapy (DBT) (Linehan)• Cognitive Analytic Therapy (CAT) (Ryle)Cognitive Analytic Therapy (CAT) (Ryle)• Mentalization Based Therapy (MBT) (Bateman e Fonagy)Mentalization Based Therapy (MBT) (Bateman e Fonagy)• Varie forme di psicoterapia analiticaVarie forme di psicoterapia analitica• Varie forme di psicoterapia cognitivaVarie forme di psicoterapia cognitiva• Interventi di comunitàInterventi di comunità

• Farmaci psicoattiviFarmaci psicoattivi


Tutti i tipi di trattamento elencati hanno aspetti comuni:Tutti i tipi di trattamento elencati hanno aspetti comuni:

• Alto livello di strutturazioneAlto livello di strutturazione• Scopi chiariScopi chiari• Sviluppo di una relazione di attaccamento sicuraSviluppo di una relazione di attaccamento sicura• Sforzo di mantenere un buon livello di adesione al Sforzo di mantenere un buon livello di adesione al

trattamentotrattamento• Ruolo attivo del terapeutaRuolo attivo del terapeuta• Centralità del contratto terapeutico (variabile)Centralità del contratto terapeutico (variabile)• Integrazione con altre modalità di trattamento Integrazione con altre modalità di trattamento

(variabile)(variabile)


La differenziazione tra i vari tipi di trattamento, così La differenziazione tra i vari tipi di trattamento, così come come

la specificità del loro effetto, sono aspetti di non la specificità del loro effetto, sono aspetti di non facile facile

valutazione in quanto ogni trattamento ha valutazione in quanto ogni trattamento ha aspetti aspetti

sovrapponibilisovrapponibili agli altri e caratteristiche simili agli altri e caratteristiche simili possono possono

essere essere denominate in maniera differentedenominate in maniera differente a causa di a causa di

diversità di concezioni e di linguaggiodiversità di concezioni e di linguaggio


The The clinical managementclinical management of Borderline subjects of Borderline subjects involves involves

four organizing levels:four organizing levels:

1.1. ConceptualConceptual

2.2. StrategicStrategic

3.3. TacticalTactical

4.4. TechnicalTechnical


Conceptual IssuesConceptual Issues


• BPD has been conceptualized according to various BPD has been conceptualized according to various psycho(patho)logical perspectives, that focused on psycho(patho)logical perspectives, that focused on different clinical phenomena, etio-pathogenetic different clinical phenomena, etio-pathogenetic pathways and therapeutic principlespathways and therapeutic principles

• DSM-IV BPD is an eclectical diagnostic containerDSM-IV BPD is an eclectical diagnostic container

• Current empirical research seems to suggest that Current empirical research seems to suggest that many treatments have effective components and many treatments have effective components and no single approach is more effective than the no single approach is more effective than the others others


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)


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 treatmentsand follow-up studies should be included.


Strategic IssuesStrategic Issues


Strategies are clusters of interventions sharing a Strategies are clusters of interventions sharing a common common

objective that translate concepts into therapeutic objective that translate concepts into therapeutic actions:actions:

1.1. General Therapeutic StrategiesGeneral Therapeutic Strategies: : used with all used with all patients at all stages of treatment to manage and patients at all stages of treatment to manage and treat the core features of BPDtreat the core features of BPD

2.2. Specific Therapeutic StrategiesSpecific Therapeutic Strategies: : used to treat used to treat specific problems in individual patients. They vary specific problems in individual patients. They vary across patients, phases of therapy, and problems that across patients, phases of therapy, and problems that are the focus of changeare the focus of change


What are the What are the core psychopathological dimensions core psychopathological dimensions of of BPD ?BPD ?

Empirical research suggests that they are (Empirical research suggests that they are (Rosenberger and Rosenberger and Miller,Miller,

1983; Clarkin et Al., 1993; Maffei et Al., 1999; Sanislow et Al., 1983; Clarkin et Al., 1993; Maffei et Al., 1999; Sanislow et Al., 2000;):2000;):

1.1. Identity / Interpersonal problemsIdentity / Interpersonal problems2.2. ImpulsivityImpulsivity3.3. Affect instabilityAffect instability


General Therapeutic StrategiesGeneral Therapeutic Strategies

The building and preservation of a The building and preservation of a therapeutic alliancetherapeutic alliance is a is a

major task concerning all the borderline subjects in all major task concerning all the borderline subjects in all the the

phases of treatment. phases of treatment.

It is the first bulwark against the core dimensions of the It is the first bulwark against the core dimensions of the

disorder.disorder.


Gerald Adler (1979) said that the Gerald Adler (1979) said that the therapeutic therapeutic

alliancealliance with borderline patients is with borderline patients is a mytha myth……


Forms of Therapeutic AllianceForms of Therapeutic Alliance

1.1. Contractual (behavioral)Contractual (behavioral): initial agreement : initial agreement between the patient and the clinician on between the patient and the clinician on treatment goals and their roles in achieving themtreatment goals and their roles in achieving them

2.2. Relational (affective/empathic)Relational (affective/empathic): based on : based on empathy, understanding, genuinityempathy, understanding, genuinity

3.3. Working (cognitive/motivational)Working (cognitive/motivational): patient joins the : patient joins the clinician as a reliable collaborator to help him/her clinician as a reliable collaborator to help him/her understand his/her problemsunderstand his/her problems


Borderline subjects often Borderline subjects often involve involve people, andpeople, and clinicians, clinicians, in in their deep their deep unrealistic interpersonal needsunrealistic interpersonal needs (to be totally (to be totally loved, to be omnipotently saved...) inducing them to loved, to be omnipotently saved...) inducing them to emphasizeemphasize affective answersaffective answers, that is to favour relational , that is to favour relational aspects of therapeutic alliance. aspects of therapeutic alliance. When this When this relational pattern failsrelational pattern fails, that is unavoidable, , that is unavoidable, therapeutic alliance is therapeutic alliance is severely menacedseverely menaced by the appearance by the appearance of feelings of disappointment, abandonment, helplessness, of feelings of disappointment, abandonment, helplessness, hopelessness, rage and impulsive (self-injuring) behaviors.hopelessness, rage and impulsive (self-injuring) behaviors.

Otto KernbergOtto Kernberg

Object Relations Theory (1999): pairs in BPD Object Relations Theory (1999): pairs in BPD

• Destructive, bad infantDestructive, bad infant• Controlled, enraged childControlled, enraged child• Unwanted childUnwanted child• Defective, worthless childDefective, worthless child• Abused victimAbused victim• Sexually assaulted preySexually assaulted prey• Deprived childDeprived child• Out-of-control,angry childOut-of-control,angry child• Sexually excited childSexually excited child• Dependent, gratified childDependent, gratified child

• Punitive sadistic parentPunitive sadistic parent• Controlling parentControlling parent• Uncaring selfish parentUncaring selfish parent• Contemptuous parentContemptuous parent• Sadistic attackerSadistic attacker• Attacker, rapistAttacker, rapist• Selfish parentSelfish parent• Impotent parentImpotent parent• Castrating parentCastrating parent• Doting, admiring Doting, admiring

parentparent


The The contractual (behavioral) contractual (behavioral) alliance has a primary role in alliance has a primary role in order to minimize this danger: its objective is to try to order to minimize this danger: its objective is to try to share a common realityshare a common reality

Why is it so important ?Why is it so important ?

Because it limits the stable distorced patterns of interaction Because it limits the stable distorced patterns of interaction with others, characterized by intense affective involvementwith others, characterized by intense affective involvement(idealization and devaluation), that often “trigger” the (idealization and devaluation), that often “trigger” the sudden and unpredictable appearance of impulsive (mostly sudden and unpredictable appearance of impulsive (mostly self-injuring) behaviorsself-injuring) behaviors


Relational (affective/empathic)Relational (affective/empathic) components of therapeutic components of therapeutic

alliance are useful to regulate negative emotions and alliance are useful to regulate negative emotions and

affects. affects.

A A well-balancedwell-balanced use of what is needed to empathically use of what is needed to empathically

““support”support” the patient (identification of feelings, validation, the patient (identification of feelings, validation,

insight into interpersonal needs) is useful to stabilize and insight into interpersonal needs) is useful to stabilize and

reinforce the reinforce the contractual alliancecontractual alliance, that remains , that remains centralcentral..


Specific Therapeutic StrategiesSpecific Therapeutic Strategies

Borderline subjects can present specific clinical Borderline subjects can present specific clinical problems. problems.

They can vary across patients or phases of treatment:They can vary across patients or phases of treatment:

1.1. Axis-I symptomatologyAxis-I symptomatology2.2. Crisis situations (suicidal, self-injuring, impulsive Crisis situations (suicidal, self-injuring, impulsive

behavior)behavior)3.3. Significant distress and/or impairment in relevant Significant distress and/or impairment in relevant

areas of functioningareas of functioning


Axis-I symptomatologyAxis-I symptomatology

Frequently borderline subjects suffer from Axis-I disorders Frequently borderline subjects suffer from Axis-I disorders

that lead them to ask for clinical help: they should be carefully that lead them to ask for clinical help: they should be carefully

identifiedidentified and and treatedtreated..

There are two main There are two main risksrisks: :

• If only Axis-I disorders are identified, the problem of personality If only Axis-I disorders are identified, the problem of personality disorder is neglected and can negatively interfere with treatmentdisorder is neglected and can negatively interfere with treatment

• If borderline personality disorder is too emphasized, Axis-I disorders If borderline personality disorder is too emphasized, Axis-I disorders are not adequately treatedare not adequately treated


Crisis situationsCrisis situations

Possible crisis-related situations are:Possible crisis-related situations are:

• Suicidal/self destructive behaviorSuicidal/self destructive behavior

• Threatend aggression/intrusionsThreatend aggression/intrusions

• Threats of discontinuing treatmentThreats of discontinuing treatment

• Acute Axis-I symptomathologyAcute Axis-I symptomathology

• Emergency room visitsEmergency room visits

• Telephone calls Telephone calls

• Therapists’ absenceTherapists’ absence


Each of these problematic situations asks the clinician to Each of these problematic situations asks the clinician to decide what to do: solutions also depend on the decide what to do: solutions also depend on the

resources resources that clinicians have.that clinicians have.

Examples are: Examples are: • Brief hospitalizationBrief hospitalization• Day Hospital interventionDay Hospital intervention• MedicationsMedications• Focused cognitive interventions Focused cognitive interventions • Contract changeContract change


An example:An example:

Suicidal threatsSuicidal threats


Guidelines for suicidal threats (Clarkin et Al., 1999):Guidelines for suicidal threats (Clarkin et Al., 1999):

• Determine if the suicidal ideation is a manifestation of a Determine if the suicidal ideation is a manifestation of a major depressive episode major depressive episode – If yes, engage family, hospitalize the patient…If yes, engage family, hospitalize the patient…

• Determine the presence or absence of Determine the presence or absence of suicidal intentsuicidal intent– If yes, engage family, send the patient to an emergency room, If yes, engage family, send the patient to an emergency room,

hospitalize him/her…hospitalize him/her…– If no, explore the origin and the meaning of this ideation…If no, explore the origin and the meaning of this ideation…

• Determine if there is Determine if there is secondary relational gainsecondary relational gain– If yes, limit it…If yes, limit it…– If no, etc.If no, etc.


• The general strategy (therapeutic alliance) is The general strategy (therapeutic alliance) is always the framework of the specific strategies !always the framework of the specific strategies !

• Sometimes specific problems can be resolved Sometimes specific problems can be resolved only by only by

changing the general strategy !changing the general strategy !


Significant distress and/or impairment in relevant Significant distress and/or impairment in relevant areasareas

When borderline subjects refer to clinicians for chronic When borderline subjects refer to clinicians for chronic lifelife

problemsproblems (relationships, affective life, work…) or chronic (relationships, affective life, work…) or chronic

distressdistress (sense of inutility, of emptyness, boredom, (sense of inutility, of emptyness, boredom, chronic chronic

unsatisfaction…) “psychotherapy” can be considered as unsatisfaction…) “psychotherapy” can be considered as a a

first choice treatment. first choice treatment.



Tactical IssuesTactical Issues


Tactical aspects of management concern the Tactical aspects of management concern the

maneuvers that the clinician uses to maneuvers that the clinician uses to guide guide

intervention at the level of the individual intervention at the level of the individual meetingmeeting..


They depend on the theoretical choice of the clinician They depend on the theoretical choice of the clinician

(psychodynamic, cognitive…), however some of them seem (psychodynamic, cognitive…), however some of them seem

to have an overall value:to have an overall value:

• Choosing a priority theme, starting from emergency Choosing a priority theme, starting from emergency prioritiespriorities

• Protecting the frame of treatmentProtecting the frame of treatment

• Establishing/Increasing common elements of shared Establishing/Increasing common elements of shared realityreality

• Analyzing both positive and negative aspects of the Analyzing both positive and negative aspects of the therapeutic relationshiptherapeutic relationship


Technical IssuesTechnical Issues


They depend on the theoretical choice of the They depend on the theoretical choice of the clinician clinician

(psychodynamic, cognitive…)(psychodynamic, cognitive…)

For instance, they concern the role of interventions For instance, they concern the role of interventions such as such as

clarification, confrontation, interpretation, advice, clarification, confrontation, interpretation, advice, supportsupport

during the individual meetings during the individual meetings


A Hierarchical organization of management

priorities (from Livesley, 2003):

Stage 1: SafetyStage 2: ContainmentStage 3: Control and regulationStage 4: Exploration and changeStage 5: Synthesis


• 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


• 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


The previous hierarchical organization of management The previous hierarchical organization of management priorities is organized in priorities is organized in stages stages that can be also that can be also

considered considered as a temporal sequence going from severe problems as a temporal sequence going from severe problems (survival) to quiet psychoterapeutic sessions (mental (survival) to quiet psychoterapeutic sessions (mental synthesis).synthesis).During the treatment it can happen that patients in a During the treatment it can happen that patients in a

stage stage show problems related to a previous stage: this is one of show problems related to a previous stage: this is one of the aspects of treatment, that sometimes goes from the the aspects of treatment, that sometimes goes from the bottom to the top, and sometimes from the top to the bottom to the top, and sometimes from the top to the bottom.bottom.

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