Mixed Personality Disorder Research Articles

Commentary: Short-term group schema therapy for mixed personality disorders: an introduction to the treatment protocol.

The evidence base for schema therapy (ST) has grown rapidly in recent years, as applied to a wide range of clinical groups (Masley et al., 2011); for ST with groups see Farrell et al. (2009), Simpson et al. (2010), Farrell and Shaw (2012), van Vreeswijk et al. (2012), Renner et al. (2013), Videler et al. (2014). Variations exist between group schema therapy protocols utilized across clinical settings and client groups. It is therefore imperative that researchers describe treatment protocols in detail. A recent pilot study was published on the outpatient treatment of mixed personality disorders (Skewes et al., 2015), which demonstrated low attrition and clinical improvement over 20 weekly 60-min sessions. In addition, up to 5 × 30-min individual sessions are provided through the duration of the group for those who require additional support, especially during crises. This also includes a session provided at mid-therapy in order to provide feedback on progress to date and to focus goals for the second half of therapy. The purpose of this paper is to describe the treatment protocol utilized in this trial. The group is led by two therapists who alternate the role of taking the lead in session exercises, with the other focused on maintaining connection between participants, mainly through the use of eye-contact and non-verbal gestures. Therapist couples are able to model connection and confrontation through the way in which they communicate with each other and with group members. Therapists must balance the need to be “genuine” and consistent with their own individual therapeutic “style,” with the need to collaborate as a cohesive “parent couple,” guiding the group according to schema therapy “limited reparenting” principles. The schema model is applied in a flexible manner that requires group leaders to respond to modes as they appear on a moment-to-moment basis. Whereas participants with BPD often experience frequent mode “flipping,” those with cluster C personality disorders, tend to be overly fused to an avoidant or overcompensatory coping mode (e.g., “Detached Protector”; “Perfectionistic Overcontroller”). Therapists are required to respond to the needs of clients flexibly, and to be guided by sophisticated case conceptualizations that facilitate recognition of the range of modes present in a mixed personality disordered group. In order to ensure treatment fidelity and to check that all four aspects of the schema model (cognitive, behavioral, experiential, and limited reparenting) are covered adequately, sessions are monitored regularly by an accredited group trainer using the Group Schema Therapy Competency Rating Scale (Zarbock et al., 2014). A condition of participation in the group is that contact with external mental health professionals is limited to medical or psychiatric monitoring only. Mode “check-in points” are used at regular intervals during sessions, which involves a 5 minute mindfulness exercise to facilitate moment-to-moment awareness of modes and associated feeling-states (van Vreeswijk et al., 2014). A summary of the material incorporated within sessions is summarized in Table ​Table1.1. Some exercises can be found in Farrell et al. (2014). Table 1 Summary of schema therapy group protocol for mixed personality disorders. This protocol forms the basis for ongoing research into short-term treatment of mixed personality disorder population.

‘X’ – realism, fantasy and heroism in the National Youth Theatre's The Block

In 2010, as part of the National Youth Theatre's social inclusion educational outreach programme ‘Playing Up 2’, young people identified as ‘NEETS’ (Not in Education, Employment or Training) performed a new-writing play called The Block, by first time playwright Tarkan Cetinkaya. This play is set on an unnamed London council estate, and follows the intersecting lives of 10 estate denizens, brought together by the central character, Barry/Baz, and his struggle with an unspecified personality disorder. I argue that social inclusion practices work within a ‘heroic paradigm’. Many of the young people involved in the project lived or had lived on estates, and many faced ongoing social and economic problems that had interfered with their ability to find employment. In the final scene of the play, which up until this point follows the conventions of social realism, a mysterious character named ‘X’ is revealed to be a superhero. He turns back time and changes the course of events in the play, saving a young woman's life and preventing her brother from embarking on a lifetime of punishment, guilt and regret. This paper problematises the character of ‘X’, exploring how the relationship between realism and fantasy, in this performance, worked to suggest that social change hinges upon intervention from an outside ‘hero’. I ask what the implications of this message might be for participants and audience members and explore how the narrative of The Block intersects with the National Youth Theatre's wider social inclusion policy.

Listening to Patients With an Open Mind

Back to table of contents Previous article ViewpointsFull AccessListening to Patients With an Open MindJeffrey Geller, M.D., M.P.H.Jeffrey GellerSearch for more papers by this author, M.D., M.P.H.Published Online:6 Mar 2015https://doi.org/10.1176/appi.pn.2014.2a2AbstractRoger Redstone is a 55-year-old single man who has lived his entire life within easy commuting distance of the state hospital in which he has been an inpatient for 10 months on his third state hospital admission (one before age 18, one for eight years’ duration).During his admission, no one has observed Mr. Redstone reading a newspaper, magazine, or book; no one has seen him attending to the news on radio or television.Mr. Redstone’s diagnoses using DSM-5 criteria are schizoaffective disorder, mixed personality disorder, and unknown substance use disorder, moderate. Neuropsychological testing showed borderline IQ and a high score for psychopathy (30 on PCL-R).Mr. Redstone, after eight months of severely problematic behavior in the hospital—thought to be a combination of willful behaviors reflecting his psychopathy and impulse-driven behaviors out of his control—changed dramatically after an increase in his dose of fluphenazine decanoate. Prior to Wednesday, November 5, 2014, he had had many weeks without any of his prior intrusive, crude, dangerous behaviors. Mr. Redstone was scheduled to be discharged within a few weeks.On November 5, Mr. Redstone lost control, regressing to his earlier presentation. I met with him the next day, and the following conversation ensued:JG:“What happened? You were doing so well.”RR: “I’m going to lose my SSI/SSDI. I’ll be homeless. I’ll have nothing to eat. What will I do? This is awful.”Mr. Redstone was frantic.JG:“What are you talking about? Did something happen?”RR: “I’m in trouble. I won’t make it.”JG:“Let’s slow down. Why do you think all this is going to happen to you?”RR: “The election yesterday!”JG:“What about the election?”RR: “The governor.”Mr. Redstone told me that the person who was elected governor would cut out all funds for people like him.I informed him that anything the governor-elect might do would not occur for some time and that the impact on him would be very little, as he was mostly in federal, not state, programs.With this information, Mr. Redstone settled, used the self-soothing skills he had learned during this hospitalization, and the blip in progression toward discharge was over.I bring this vignette to your attention because it is another example of our frequent misperceptions of what individuals with serious, chronic mental illness are capable of or what they are attending to. Mr. Redstone could not tell me how he knew who was elected governor, and even more puzzling, how he knew the political views and expected social policies of the governor-elect.Perhaps I should not have been surprised. In 1992, I did a survey about what inpatients at the same hospital knew about Operation Desert Storm.The patients were well informed, to the surprise of many. We learned at that time not to jump to conclusions about patients’ answers without asking them what they meant when they gave what on first hearing sounded like a delusion. One question on the survey was, “Do you know what Jordan is?” Many indicated it was a country in the Middle East. One patient said, “It’s where I buy my underwear.” Sounds like psychosis. But the interviewer asked, “What do you mean?” The patient responded, “You know, Jordan Marsh.” Jordan Marsh was a department store in Massachusetts, often referred to as “Jordans.” ■Jeffrey Geller, M.D., M.P.H., is a professor of psychiatry and director of public sector psychiatry at the University of Massachusetts Medical School. He is also APA’s Area 1 Trustee. ISSUES NewArchived

Short-term group schema therapy for mixed personality disorders: a pilot study.

Schema Therapy has shown promising results for personality disorders but there is a limited evidence base for group schema therapy (ST-g) with mixed personality disorders. The aim of this study was to explore the feasibility, acceptability, and preliminary effectiveness of ST-g in a sample of eight participants with mixed personality disorders (with a predominant diagnosis of avoidant personality disorder) and high levels of comorbidity. Treatment was comprised of 20 sessions which included cognitive, behavioral, and experiential techniques. Specific schema-based strategies were chosen for a diagnostically mixed group of personality disorder clients. Six participants attended until end of treatment and two dropped-out before mid-treatment. All outcome measures showed changes with large effect sizes in avoidant personality disorder symptom severity, depression and anxiety levels between pre-therapy and follow-up. Four participants achieved a loss of personality disorder diagnosis at the end of therapy. By follow-up, five participants had achieved a loss of diagnosis, suggesting that participants derived ongoing benefits from the group even after treatment ended. Six participants no longer met criteria for depression at the end of treatment and this was maintained for all participants at 6-month follow-up. At follow-up, the majority of participants showed clinically significant change on the Global Symptom Index (GSI). For the Schema Mode Inventory (SMI) maladaptive modes, the majority of participants showed improvement at follow-up. At follow-up, 40% of participants showed clinically significant change on the SMI adaptive modes. Qualitative feedback indicates that the group helps to normalize participants' psychological experiences and difficulties and promotes self-expression and self-disclosure, while reducing inhibition. Preliminary results suggest that short-term ST-g may benefit those with mixed personality disorders, but generalizability is limited by the small sample size and lack of control group.

The use of mentalization-based treatment for adolescents (MBT-A) with a young woman with mixed personality disorder and tendencies to self-harm.

This article explores the psychological profile and treatment of young people who present clinically with features of borderline and avoidant personality disorder, along with vulnerable narcissistic traits. Self-harm in these youngsters is often used to regulate internal storms. It is argued that the adolescent phase of development is a trigger point for collapse in these vulnerable young people. In therapy, these patients are difficult to connect with emotionally and treatment can be fraught with strong countertransference reactions. A case study is used to illustrate the use of mentalization-based treatment for adolescents for such individuals.

Transactional analysis psychotherapy of mixed personality disorder

The paper presented here demonstrates what transactional analysis can achieve in the treatment of mixed personality disorder and points out to the challenges. The approach in question is integrative transactional analysis which also incorporates, in its diagnostics and choice of interventions, the theories and techniques from other modalities, dynamic and systemic. The concepts from transactional analysis that have proven resistant to postmodernist critique, unlike other concepts, such as games, transactions, or ego states, are the concepts of life script and personal adaptations. Script analysis and working on changing one's personal adaptations classify contemporary transactional analysis in the group of narrative therapies.

Homicidio y enfermedad mental. Un análisis retrospectivo de una serie de casos

IntroductionHomicide is the act, which causes the death of another person, being one of the parameters that best reflects the citizen security. Material and methodsWe performed a retrospective study of expert court-reports of thirty-seven murder suspects evaluated in Forensic Medical Clinic Courts in Plaza Castilla (Madrid) from July 2006 until May 2013. We completed a descriptive analysis of the different variables of the sample. ResultsThe mean age was 38.22 years (standard deviation of 16.49) with 81% of men and 19% women. The majority were single (51%) and had primary education (46%). The 58% had no criminal trial investigations and only 16% had been in prison. The minority (25%) had neither psychiatric history nor toxic consumption (38%). Also, 86% were charged with the murder of a known person (of which, 24% were intimate partners). The 78% used sharp instruments to commit the crime and the most frequent diagnosis (18%) was an adjustment disorder with disturbance of conduct and that of mixed personality disorder. DiscussionThe case series reported is one of the most numerous published in Spain, although there are many reviews on the subject. We found, as previously described in the literature, that one of the most frequent profiles of those who commit homicide is to be a male, under thirty, with low education, toxic consumer and to have a personality disorder.

Personality disorders and aging

Personality disorder can be defined as an enduring pattern of inner experience and behavior that markedly deviates from the expectations of the individual's culture. With aging, personality disorders may improve or worsen. Their prevalence in the elderly is slightly lower than the prevalence in young adult. Furthermore, their comorbidity and co-occurrence are the rule with an increased risk of late decompensation. Categorical approach used in the current international classifications (ICD-10 and DSM-5) is not adapted to the specificities of the elderly with consequent overrepresentation of "unspecified personality disorder". However, a pathological personality tends to complicate all interventions for somatic or psychological care in the elderly. Thus, this review describes changes in personality disorders related to aging in order to help the clinician to better identify these disorders. Indeed, recognizing a pathological personality in the elderly improves its management both in the field of mental health and in somatic disorders in which the role of personality must be evaluated. Personality and its disorders should therefore be taken into account in all geriatric practices, in particular in the context of cognitive disorders.

A comparative treatment efficacy study of conventional therapy and mode deactivation therapy (MDT) for adolescents with conduct disorders, mixed personality disorders, and experiences of childhood trauma.

Mode Deactivation Therapy (MDT) is a Cognitive-Behavioral Therapy (CBT) derivative that was developed to overcome specific problems in treatment of adolescents with dysfunctional behavior. This population typically has a history of abuse that developed into DSM Axis-I disorders such as Conduct and Oppositional Defiant Disorder, mood disorders, PTSD, and comorbid substance abuse, and Axis-Ii disorders that are commonly a constellation of personality disorder criteria. The MDT theoretical framework leans heavily on shoulders of work done by Prof. Aaron Beck in areas of negative automatic thoughts and cognitive schemas. Elements of Dialectical Behavior Therapy (DBT), Acceptance and Commitment Therapy (ACT), and mindfulness were combined with a novel change effect component to provide effective treatment for adolescents with behavioral problems. The Validation-Clarification-Redirection step is crux of MDT and based on concepts of awareness, validation, and acceptance of problems and their roots, rather than disputing them. In 15 years or so that MDT has been practiced, about 20 developer-conducted and independent research studies, including current study, consistently provided evidence of effectiveness of MDT in treating this adolescent population. * Literature review In work done by Aaron Beck, he focused on negative automatic thoughts as initiating mechanism of dysfunctional behavior (Beck, 2005). The automatic thoughts are activated by a trigger that can be associated with underlying experience-based core beliefs. Although he initially concentrated on study of depression, a broad variety of adolescent behavior problems are also widely associated with cognitive schemas that ACT as coping mechanisms in response to chronic distress. Such beliefs commonly result in poor regulation of affect and impulses, somatization, low self-esteem, dysfunctional attachments, guilt, shame, and dysfunctional worldviews. According to Luxenberg, Spinazzola, and Van der Kolk (2001), these are results of extreme deprivation during childhood and represent a complex adaptation to trauma. Based on extensive field work, they devised DESNOS symptomatology, and arranged a list of 27 symptoms associated with disorders of extreme stress not otherwise specified (DESNOS) into seven categories (see Table 1 on page 24): Dysregulation of (a) affect and impulses, (b) attention or consciousness, (c) self-perception, (d) perception of perpetrator, (e) relations with others; (f) somatization, and (g) systems of meaning. This constellation of symptoms was found to be very consistent and statistically correlated with PTSD. Among groups with different types of trauma, and early and late onset of symptoms, it was found that children below 14-years who experienced high-magnitude interpersonal violence endorsed most DESNOS items. In fact, the younger age of onset of trauma, more likely one is to suffer from cluster of DESNOS symptoms, in addition to PTSD (Van der Kolk, Roth, Pelcovitz, Sunday, & Spinazzola, 2005, p. 395). Therefore, such interpersonal trauma that is prolonged and first occurs at an early age, can have significant effects on psychological functioning beyond ptsd symptomatology. Childhood abuse also has an impact on personality development with constellations of personality traits common among adolescent abuse victims. Different personality constellations have been identified in this context. The first is a four-array classification with Internalizing Dysregulated, High Functioning Internalizing, Externalizing Dysregulated, and Dependent as distinct personality constellations with statistically different diagnostic and adaptive functioning (Bradley, Heim, & Westen, 2005). These groups represent different in- or outwards expressions as a response to childhood trauma, which is meaningful in determining underlying belief schemas. A second personality cluster classification, devised by Blagov, Bradley, and Westen (2007), also has four diagnostic groupings that resemble clinical concept of neurotic styles instead of internalizing and externalizing dimensions of behavior, namely depressive, hostile-competitive, obsessive, and hysterical. …

A case of intentional asenapine overdose.

To the Editor: Asenapine, marketed as Saphris, is a relatively new psychopharmaceutical agent approved in 2009 for the treatment of acute mania or mixed episodes in the context of bipolar I disorder as well as schizophrenia.1 Asenapine has a unique receptor profile and has been shown to be effective and well tolerated by patients experiencing an acute manic episode.2,3 Adverse effects of long-term use are not yet known, but the incidence of cardiovascular disease and diabetes is expected to be substantially lower than with older neuroleptic agents.4 Here we present the first published case of asenapine overdose of known quantity and route. Case report. Mr A, a 49-year-old man, presented to the emergency department (ED) after having ingested 74 tablets of asenapine in the ED parking lot several minutes previously. He was currently undergoing a course of electroconvulsive therapy (ECT), having been diagnosed with bipolar disorder with mixed episodes and borderline personality disorder (both according to DSM-IV-TR criteria) and was 1 day postdischarge from the inpatient psychiatry unit. The quantity of ingested tablets was confirmed by the patient’s mental health outreach worker after examination of packages in the patient’s car. Mr A had made previous suicide attempts using ibuprofen and clonazepam in overdose. Because the ED physician was unfamiliar with asenapine toxicity, the patient was admitted to the intensive care unit (ICU) for observation. Examination in the ED and ICU revealed a drowsy, yet easily rousable man who was unwilling to answer questions. Blood pressure was maintained at 149/88 mm Hg, pulse was 99 bpm, respiratory rate was 19/min, oxygen saturation was 98% on room air. Findings of cardiac, respiratory, and abdominal examinations were unremarkable. Urine drug screen was positive for amphetamines, marijuana, opiates, and benzodiazepines. There was no nausea or vomiting, and activated charcoal was not administered. Electrolytes, troponin I, international normalized ratio, complete blood cell count, and creatinine were all within normal laboratory values. Electrocardiogram showed only normal sinus rhythm. Mr A was determined to be medically stable by the ICU physician, and care was transferred to the psychiatric unit approximately 24 hours later. This patient’s bilateral ECT course was continued for a total of 10 treatments with good therapeutic effect and minimal side effects. He was subsequently discharged and has been followed by the outpatient psychiatry service, has received cognitive-behavioral therapy to address coping skills, and is doing well as of last contact. Here we present the first documented case of asenapine overdose with a known quantity and route of administration. Six previous cases of asenapine overdose have been noted at doses up to 400 mg, but the exact dose and route were not known.4 Similar to those cases, no specific adverse drug effects were observed. Notably, the bioavailability of asenapine is less than 2% when administered orally, compared to approximately 35% when given sublingually; this patient did not administer his overdose sublingually.4 Thus, despite ingesting 740 mg of asenapine, he was exposed to only the equivalent of 4 sublingual doses. Despite the large number of tablets and considerable concern from the ED, asenapine appears to be safe in overdose situations, likely due to its pharmacokinetic profile.

Complex case: A biofeedback intervention to control impulsiveness in a severely personality disordered forensic patient by Rick Howard, Klaus Schellhorn and John Lumsden

With this case report of successful biofeedback treatment for a severely disordered and treatmentrefractory forensic patient, the authors contribute to arguments for consideration of the inclusion of biofeedback for a group of extremely challenging patients. The term ‘complex patient’ barely captures the patient MN, whose psychopathology cuts across diagnostic borders and includes a mixed personality disorder with borderline, antisocial and histrionic features, paedophilia, attentional difficulties that may meet criteria for Attention Deficit Disorder/ Attention Deficit Hyperactivity Disorder, borderline intellectual functioning and an unspecified mood disorder. Prior to his transfer from a prison to a forensic hospital, the unremitting severity of his sexual deviance led to placement on a testosteronelowering agent, and his level of mood instability resulted in treatment with carbamazepine. Strengths of this case report include the extensive initial psychometric and psychological evaluation of the patient and the documentation of significant post-treatment improvement in biobehavioral (Flanker test) and electrophysiological (Go/No Go contingent negative variation) measures, as well as patient self-report of decreased impulsivity and improvement in attention/cognition at the study endpoint and at 3months of follow-up. This paper is a welcome addition to the literature on therapeutic interventions in severely personality disordered patients from several perspectives. Much of this patient’s history and behavioural presentation are characteristics of antisocial personality disorder (ASPD) and accompanying paedophilia, areas of psychopathology much neglected in psychiatric literature, with diagnoses for which therapeutic pessimism bordering on nihilism has led in the US to relegation of these patients to the criminal justice system. Patients with ASPD have significant deficits in mentalization, attachment and impulse control (Leichsenring et al., 2003), ego weaknesses that make them poor candidates for many psychotherapies and that render these patients destructive to a hospital-based therapeutic milieu. Indeed, MN had shown poor motivation and compliance with routine psychotherapies in the past. An advantage for forensic-type patients of neurofeedback treatments is that they work at basic neurophysiologic levels and focus on brain functioning rather than psychopathology; consequently these procedures largely bypass the need

Alternative DSM-5 Model for Personality Disorders

Alternative DSM-5 Model for Personality Disorders

Affective disorders among patients with borderline personality disorder.

BackgroundThe high co-occurrence between borderline personality disorder and affective disorders has led many to believe that borderline personality disorder should be considered as part of an affective spectrum. The aim of the present study was to examine whether the prevalence of affective disorders are higher for patients with borderline personality disorder than for patients with other personality disorders.MethodsIn a national cross-sectional study of patients receiving mental health treatment in Norway (N = 36 773), we determined whether psychiatric outpatients with borderline personality disorder (N = 1 043) had a higher prevalence of affective disorder in general, and whether they had an increased prevalence of depression, bipolar disorder or dysthymia specifically. They were compared to patients with paranoid, schizoid, dissocial, histrionic, obsessive-compulsive, avoidant, dependent, or unspecified personality disorder, as well as an aggregated group of patients with personality disorders other than the borderline type (N = 2 636). Odds ratios were computed for the borderline personality disorder group comparing it to the mixed sample of other personality disorders. Diagnostic assessments were conducted in routine clinical practice.ResultsMore subjects with borderline personality disorder suffered from unipolar than bipolar disorders. Nevertheless, borderline personality disorder had a lower rate of depression and dysthymia than several other personality disorder groups, whereas the rate of bipolar disorder tended to be higher. Odds ratios showed 34% lower risk for unipolar depression, 70% lower risk for dysthymia and 66% higher risk for bipolar disorder in patients with borderline personality disorder compared to the aggregated group of other personality disorders.ConclusionsThe results suggest that borderline personality disorder has a stronger association with affective disorders in the bipolar spectrum than disorders in the unipolar spectrum. This association may reflect an etiological relationship or diagnostic overlapping criteria.

P-924 - Interactive approach for establishing personality disorders diagnoses

Construction of tools for establishing personality disorders (PD) diagnoses continues to be a challenging issue. Practical and theoretical implications are obvious, and conceptual diversity of existing methods confirms the difficulty of the problem. We present A) an original method (working title POS-2000) based on interactive approach in evaluating people's behavior as well as B) first empirical data gained using POS-2000 in assessment of known PD's groups. We have analysed POS-2000 results of 37 inpatients with PD diagnosis determined by Structured interview for personality disorders (Pfohl, B., et al, 1989). Pearson's correlations gave us encouraging results, and it seems that specific configurations of interpersonal behavior may create a direct diagnostic guideline or may serve as additional data for differential diagnosis in mixed personality disorders. Our preliminary data gained using POS-2000 confirm that interactional paradigm of evaluating interpersonal behavior may be fruitful in diagnosing maladaptive behavior.

The outcome of behavioral intervention with a person living with schizophrenia who exhibited medication noncompliance: A case study.

Introduction A variety of multicultural issues in clinical settings have been studied and discussed and multicultural competence has become an important research area in the field of counseling psychology (Pope-Davis et al., 2002). One of the beliefs from the research is that if a client and a counselor do not match culturally, the sessions conducted between them can possibly have limitations (Sue, 1977). Besides, as concerned Flaskerud (1991), if a client suffers from a persistent mental illness, the limitations of multicultural counseling can be much greater. Tim (assumed name) was a middle-aged single male immigrant from a South American country. He first became the client of a mental health agency in the United States during the 1990's for about half a year; his diagnosis was adjustment disorder with depressed mood. He was referred to the same agency again in the beginning of the 21st Century due to social withdrawal; his diagnosis was avoidant personality disorder. Within a year, he dropped out of treatment. Several years later, he became a psychiatric hospital patient with diagnoses of atypical depression and mixed (schizotypal and avoidant) personality disorders. Because of his tendencies to avoid going out in public and not to comply with taking his medications, the treatment did not last long. Tim's symptoms degenerated until his parents appealed to the above hospital for help. The parents claimed that Tim was withdrawn and had become uncontrollable. They could not get enough sleep since Tim was making loud noises every night. When they asked Tim to be quiet, he showed anger and pushed the parents occasionally. Tim refused to come to the hospital with them. The case was accepted and the author, a Japanese counselor, was assigned the case. The author soon made a home-visit and met with Tim. Although he declined the author's proposal that the author would visit him once a week, he agreed to an alternative proposal that the author would visit him once a month. His diagnoses were: (a) Axis I: schizophrenia, paranoid type, and (b) Axis II: deferred. Client Tim resided with his parents who were both in their seventies. Tim had sisters who were married and living outside of his home. He was born and raised in a South American country. As a child he was quiet; he tended to prefer reading books or doing homework rather than playing outside. His grades were very good. When he was a teenager, he became a little more outgoing; he played sports and made friends. He and his family left their country and immigrated into the United States. After immigration, he enrolled in college. Due to the onset of the mental illnesses, he dropped out a couple of years later. He periodically did temporary work before and during his college days. He had been unemployed for a long time and was receiving social welfare. He had no friends; the only social interaction he had was with his immediate family. However, as the deterioration of his mental stability progressed, he avoided communication even with them. Since he was depressed, unable to concentrate, and developing some memory problems, he read psychology books and did certain psychotherapeutic exercises without supervision. Then, he had a panic attack and was sent to a psychiatric hospital. The precise year that his mental illness had entered the active phase was unknown. He was able to speak English to some degree, but the English abilities of his parents were limited. Tim was 6 feet tall and weighed approximately 200 pounds. He had not have a history of major physical diseases. He had not received a medical checkup in the last 20 years, so his health conditions at the time was unknown. He looked healthy. He had an appetite. In his college days, he used alcohol and cigarettes. However, he has never been a substance abuser. Tim was disheveled. His affect was flat. He did not leave his home at all and usually stayed in his room. He slept in the daytime and was awake at night. …

Die Behandlung von Persönlichkeitsstörungen in psychotherapeutischen Gruppen

This paper reviews the literature on the efficacy of group treatments for personality disorders. The formal change theory literature on group treatments of personality disorders is sparse, with the exception of dialectical behavior therapy for borderline personality disorder, which has been the subject of several randomized trials showing positive outcomes. In addition, group programs based around CBT or 12-step principles appear to be efficacious for patients with antisocial personality disorder who are seeking substance use treatment. Finally, group exposure alone brings about symptom reduction for patients with avoidant personality disorder, with some additional benefit offered by providing specific, skills-based help developing intimate relationships. Group-based day treatment programs for patients with mixed personality disorders are commonly used, but very few trials have evaluated the role of formal change theory in these programs; more could be done. Research on the roles of structural factors, patient factors, and group factors in group treatment of personality disorder are also briefly reviewed.

P02-137 Forensic psychiatric examination of the mixed personality disorders

The mixed personality disorder unlike other types is often enough diagnosed recently in forensic psychiatric clinic. Inspection of 50 patients with this diagnosis (men at the age from 18 till 47 years) which were convicted in violent and crimes against property has been spent.Concerning 39 persons the decision that in a crime they could realise actual character, the social danger of the actions and to supervise over them was made (full responsibility). Decisions about necessity of application of item 22 of the Criminal code of the Russian Federation («the reduced responsibility») have been accepted concerning the others exanimated persons with the recommendation about necessity of awarding punishment and treatment by the psychiatrist in the places of confinement. These persons to the present offence and inspection were earlier repeatedly involved in the criminal liability for violent crimes. They had mental immaturity, condition of unstable indemnification, infringement of inclinations (dependence on psychoactive substances, a pathological inclination to gambling, plural frustration of sexual preference). The basis for the decision about application in their relation of the item 22 of the Criminal code of the Russian Federation was the subjectively significant psycho injuring situation in a combination to the expressed emotional pressure, self-inflation reactions, and also peculiar to these persons immaturity and rigidity of emotional reactions, easing of the strong-willed control, and these factors limited their possibility to realise actual character and the social danger of the actions and to supervise over them during the tort.

Case-based learning on the web

The National Research Council emphasizes several factors as important in how people learn. The first is to assess the learner's basic assumptions and knowledge base on a particular topic before conveying information. Without this there can be miscommunication. The second is to present one topic in depth rather than cover a range of topics more superficially. This is critical because individuals who learn one area in depth are able to transfer their learning to related areas. The third factor is that for individuals to improve their analytic thinking it is important for them to hear experts discuss their analysis of an issue. Learning consultation psychiatry has relied on discussion of current cases by attending psychiatrists. Interviewing real patients is compelling to trainees. It is also efficient, because it combines clinical care with learning. However, it relies on the flow of patients, and it does not ensure that students will systematically be exposed to the core topics in the field. Moreover, attendings are not expert in all areas so that an in depth discussion and analysis may not always be possible. Case-based learning using the Web is an effective way for students to learn consultation psychiatry. It allows individuals to have their knowledge base assessed as they proceed through the learning exercise. It also allows them to learn a particular topic in depth and to hear experts analyze a case. Moreover, it assures that students are exposed to core topics in the field. The use of the Web allows easy access to this information and presents it in an interactive and engaging manner. This is an efficient way of reaching a large audience. There is an initial labor-intensive investment that pays its return through efficient and easy access of the material. A collaborative effort amongst universities to develop a library of case-based learning materials would be a very cost effective way of transmitting information and enhancing student's learning. A Web-based case developed by Tong, Poncelet and Berger involving headache complaints in a patient with mixed personality disorder and drug-seeking behavior will be presented.

A one year study of adolescent males with aggression and problems of conduct and personality: A comparison of MDT and DBT.

Abstract This study examines the effectiveness of Mode Deactivation Therapy, (MDT) and Dialectical Behavior Therapy, (DBT) in a Residential Treatment Center for adolescent males. All clients were admitted to the same Residential Treatment Center. Clients presented with physical aggression, suicidal ideation, with mixed personality disorders/traits. One group of clients was treated with MDT, while the other group received DBT treatment. Keywords: Mode Deactivation Therapy (MDT), Dialectical Behavior Therapy (DBT), Treatment Adolescents, Conduct Disorder, Personality Disorders, Aggression, Suicidal Ideation. Introduction Mode Deactivation Therapy, (MDT) was developed by Apsche (2004,2006) to treat issues among adolescent clients that were not successfully addressed in previous treatment events. These adolescents had complex topologies and were heterogeneous in their complex problems. In numerous studies, Linehan (1993) has shown that DBT can be effective in treating Borderline Personality Disorder in adult females. In a one year randomized study, Linehan, et. al., (1991), (who recently reported that DBT is effective in treating suicidal adolescents) found that DBT significantly reduced psychiatric inpatient stays and lessened parasuicidal behavior. Its use also encouraged treatment compliance. Miller, et. al., (2006) found DBT effective in reducing suicidal ideations in adolescents being treated in an inpatient setting. Apsche, Siv & Matteson, (2005) presented a case study comparing the effects of MDT and DBT. It appeared that MDT reduced physical aggression and self injurious behavior; whereas DBT, in this case, had been less than effective. Apsche & Bass, (2006) presented a study comparing 40 adolescent males presenting with aggression and suicidal ideations. MDT was significantly more effective than DBT treatment in this study. For a complete review of MDT, see Apsche, (2006). For a complete review of DBT, see Linehan, (1993). The sample size for each group type, MDT and DBT, was calculated based on the potential residential length of stay. Each group participant was randomly assigned to groups based on a census of 30. Since this was a clinical study, there were no study drop-outs. Also, due to the nature of the residential treatment center, the clients in the study were not homogenous and presented with more severe behavioral problems than target populations in typical research therapy. Kazdin & Weisz (2003). Written informed consent was obtained from all of the clients' parents or guardians. The sample was composed of twenty adolescent males, ten for each group, within ages ranging from 15-18, (mean=16.1 MDT 15.9 DBT.) Method Participants The sample was comprised of 20 male adolescents at a residential treatment center. All subjects were referred to the residential treatment center for anger, aggressions, and externalizing problem behaviors. The clients were referred to their treatment group randomly. The first client assignment was to the DBT group and was determined by a coin toss. The second assignment was to the MDT group, followed by DBT client assignment on an alternating basis, until each group was filled. The DBT group therapists were all trained in DBT at the official DBT training center. The MDT group therapists were trained by the creator and developer of MDT (the first author of the paper). Dialectical Behavior Therapy A total of ten male adolescents were assigned to the DBT group. The group consisted of African Americans, 3 European Americans and 1 Hispanic American, the principal Axis I diagnosis was conduct disorder (5), Oppositional Defiant Disorder (4) and Post Traumatic Stress Disorder (6). Axis II diagnoses for the group included Mixed Personality Disorder (3), Borderline Personality traits (3), and Narcissistic Personality Traits (2), and Dependent Personality Disorder (2). …

Simple Treatments for Complex Problems: A Flexible Cognitive Behavior Analysis System Approach to Psychotherapy

Back to table of contents Previous article Next article Book ReviewsFull AccessSimple Treatments for Complex Problems: A Flexible Cognitive Behavior Analysis System Approach to PsychotherapyRobert M. Goisman, M.D.Robert M. GoismanSearch for more papers by this author, M.D.Published Online:1 Sep 2005https://doi.org/10.1176/appi.ps.56.9.1166-aAboutSectionsView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail This volume demonstrates the application of cognitive behavior analysis system (CBAS) psychotherapy to a number of clinical problems, including personality disorders, anxiety disorders, couples and family distress, anger management, and correctional psychiatry. It uses multiple vignettes and a relatively standardized format in each chapter. This anthology has some systemic problems, none fatal, that impede it from reaching maximal usefulness.CBAS is probably best known through the work of Keller and associates (1), who conducted a widely cited study comparing nefazodone, CBAS, and their combination in the treatment of depression. One effect of this study was to illustrate the augmentation of antidepressant medication with psychotherapy, in this case CBAS. However, the specific nature of CBAS requires some explication. The authors write as though the principles, theory, and efficacy of CBAS are well known to the reader and can be taken for granted. Regrettably, this book devotes only one brief chapter to CBAS basics, so that any reader who is not familiar with the system must catch up very quickly. The method is spelled out in each clinical chapter, but it would have been better if the authors had initially taken their time, detailing their theoretical rationale, citing whatever outcome studies have been done with CBAS, and comparing CBAS with more standard forms of cognitive-behavioral therapy. If the reader is not adequately persuaded of the face validity of CBAS by the end of chapter 1, there is almost no subsequent discussion of these issues.Another problem relates to the book's treatment of patient noncompliance. The vignettes include examples of patients who do not follow through with homework assignments. But the process notes here give the reader the impression that one or two logical discussions with a well-informed and enthusiastic therapist is all it takes to enable patients to resume their compliance with homework. Particularly in the discussions of patients with personality disorders, this just does not seem credible.Yet much clinical wisdom and practical help can be found in this volume. The chapter on correctional settings is detailed and likely to help clinicians working in these settings. There are specific chapters on schizotypal, passive-aggressive, avoidant, and mixed (not otherwise specified) personality disorders, complicated nosologic entities often ignored in the literature. And the section on families, couples, and children includes useful strategies for the treatment of attention-deficit and oppositional problems.Overall, this book is a good sampler of applications of CBAS. To use it well, clinicians need a good grounding in basic cognitive-behavioral therapy, and attention to outcome studies would improve the rigor and generalizability of these vignettes considerably. If the CBAS method is to catch on, it will need to address these issues of theoretical superstructure and empirical validation. Once these are attended to, clinicians may find the method, and this anthology of its uses, quite compelling.Dr. Goisman is associate professor of psychiatry at Harvard Medical School and director of residency training and medical student education at the Massachusetts Mental Health Center in Boston.by Kimberly A. Driscoll; Mahwah, New Jersey, Lawrence Erlbaum Associates, 2003, 244 pages, $59.95Reference1. Keller MB, McCullough J, Klein DN, et al: A comparison of nefazodone, the cognitive behavioral-analysis system of psychotherapy, and their combination for the treatment of chronic depression. New England Journal of Medicine 342:1462–1470,2000Crossref, Medline, Google Scholar FiguresReferencesCited byDetailsCited byNone Volume 56Issue 9 September 2005Pages 1166-a-1167 Metrics History Published online 1 September 2005 Published in print 1 September 2005