PDs: Treatment

Question 1

Which personality disorder has the most evidence for treatment?

Answer 1

Borderline Personality Disorder.

Question 2

What is one reason why personality disorders have received the most stigma from health professionals?

Answer 2

Because (historically) they were considered untreatable. Many professionals felt helpless and became burnt out from treating them. They would inadvertently reinforce the behaviours and perpetuate a cycle.

Question 3

What was the original treatment used for personality disorders (in particular BPD)? And did it work?

Answer 3

For many years (up until the 80s) CBT was used with little benefits or improvements.

Question 4

Today, in what way do clinicians understand the function of maladaptive behaviours within personality disorders?

Answer 4

Maladaptive behaviours are considered to be ADAPTIVE behaviours at one point. They originally were essential for the individual to get their emotional needs met, but are no longer useful.

Question 5

What are three common (stigmatising) labels that have been used to describe personality disorders?

Answer 5

• ‘acting out’.
• ‘manipulative’.
• ‘self-destructive’.

Question 6

Instead of using stigmatising language to describe someone’s behaviour, what is used now?

Answer 6

Behaviour that is trying to ‘get their needs met’.

Question 7

What is ‘small t’? What does it involve?

Answer 7

Complex trauma. It involves repeated, cumulative experiences in childhood that stem from a difficult environment. It often carries out with the dominant attachment relationship.

Question 8

As complex trauma is often a ‘subjective’ experience, the ways in which it plays out can be subtle. Give some examples of complex trauma.

Answer 8

A caregiver who is constantly dismissive, neglectful, or abusive. They might not be sensitively attuned to the child, or have the capacity to meet the child’s emotional needs.

Question 9

How does psychoanalytic theory understand personality disorders and complex trauma? From an object relations viewpoint.

Answer 9

An infant is instinctually always oriented toward attachment with their caregiver. If the caregiver is not attuned to the needs of the child, these two pieces of information (I need them + they don’t love me) can disrupt the child’s sense of self.

Question 10

Respond to this quote: ‘…repeated trauma in childhood forms and deforms the personality. The child trapped in an abusive environment is faced with formidable tasks of adaption. S/he must find a way to preserve a sense of trust in people who are untrustworthy, safety in a situation that is unsafe, control in a situation that is terrifyingly unpredictable, power in a situation of helplessness… unable to care for or protect herself, she must compensate for the failures of adult care and protection with the only means at her/his disposal, an immature system of psychological defences…’.

Answer 10

Behaviour that is now problematic and maladaptive was once used to help the child self-sooth and cope with the neglect.

Question 11

How does the ‘transactional model of Borderline PD’ describe the development of maladaptive behaviours?

Answer 11

Patterns of problematic behaviours form from the patterns of family dynamics. The original behaviour may have been normative but when the environment repeatedly responds in a certain way it shapes the behaviour to have bad response styles and emotional dysregulation.

Question 12

What is the actual model within the ‘transactional model of Borderline PD’?

Answer 12

Pervasive History of Invalidating Responses –>
Emotional vulnerability (sensitivity, reactivity, slow return to baseline) –>
Heightened Emotional Arousal (increased likelihood of emotion dysregulation) –>
Inaccurate Expression –>
Invalidating Responses –> (which leads back to the first one).

Question 13

Why are the emotions of some with BPD heightened?

Answer 13

Because they are often sensitive to noticing emotional things and have a predisposition to having a heightened emotional arousal that doesn’t reflect a normal response.

Question 14

Why are the heightened emotions of someone with BPD often dismissed?

Answer 14

Because their emotional reaction doesn’t reflect a normal response. They are often dismissed but this is upsetting because they are genuinely distressed. This can cause their emotional arousal to increase.

Question 15

What often happens to a child that consistently had their emotions dismissed or was told they were overreacting?

Answer 15

Overtime they might find it difficult to know how they were feeling, or understand their emotions.

Question 16

What is a way that extreme emotional displays in a child might be reinforced?

Answer 16

Because the milder emotional displays might be ignored or dismissed but the extreme gestures are responded to with genuine care and concern. If the child was nurtured during heightened distress, that might reinforce their behaviour.

Question 17

What is the process involved in an episode of heightened emotional arousal in BPD?

Answer 17

1. Sensitivity (more likely to notice the emotional stimuli at a lower threshold than others).
2. Reactivity (have a stronger emotional reaction than others, go from 0-10 in a minute).
3. Slow to return to baseline.

Question 18

What is the APS?

Answer 18

The Australian Psychological Society. They release a review of all the literature every year, every psychologist needs to be ethical and thus, must follow APS guidelines on the best treatments.

Question 19

What is the only treatment for BPD that has APS level evidence? The second best treatment?

Answer 19

1. Dialectical Behaviour Therapy (DBT).

2. Schema Therapy.

Question 20

Who developed Dialectical Behaviour Therapy and when? How long does DBT last?

Answer 20

It was developed by Marsha Linehan in 1993. She has BPD herself. It follows a 12-month treatment protocol.

Question 21

In Dialectical Behaviour Therapy, what does ‘Dialectical’ mean? What does ‘Behaviour’ reflect?

Answer 21

• ‘Dialectical’ or dialectic is about a synthesis or integration of two opposites.
• ‘Behavioural’ is about using rewards to reinforce the likelihood of good behaviour. The patient needs to have their skills positively reinforced in order to keep progressing.

Question 22

What is the main dialectic in DBT?

Answer 22

The central dialectic in DBT is both ‘acceptance’ (I am doing my best) and ‘change’ (I can do work harder).

Question 23

What are the main goals of DBT?

Answer 23

To enhance behavioural, emotional, cognitive responses and interpersonal interactions.

Question 24

What are the four treatment components in Dialectical Behaviour Therapy?

Answer 24

1. Individual therapy (1 hour/week).
2. Group skills training (2.5 hours/week, takes 24 weeks, do the sessions twice).
3. Phone coaching (as needed 24/7).
4. Therapist consultation team (1-1.5 hours/week).

Question 25

According to the literature, what behaviour is most benefited by DBT? And what is a benefit that is currently being researched by Sydney Uni researchers?

Answer 25

The reduction of suicidal behaviours.

Sydney Uni researchers are pointing out that DBT is beneficial for emotional regulation.

Question 26

What are the four skill-sets taught in DBT?

Answer 26

1. Mindfulness (awareness and acceptance of the present moment).
2. Distress Tolerance (survive a crisis situation, accept reality and move forward from ordinary pain).
3. Emotion Regulation (act against your emotions, understand the way you feel, and reduce the unwanted emotions before they start).
4. Interpersonal Effectiveness (keeping and maintaining healthy relationships, teach assertiveness, maintain self-respect).

Question 27

In distress tolerance (a skill-set in DBT), what are some tangible ways to regulate emotions?

Answer 27

Can try regulate emotions by changing one’s physical state. A cold shower, exercise, distraction by watching something funny or holding onto an ice cube.

Question 28

What previous therapies was Schema Therapy drawn from?

Answer 28

Cognitive Therapy, Behavioural Therapy and Object Relations.

Question 29

In Schema Therapy for personality disorders, what are schemas?

Answer 29

Schemas are frameworks for how one views the world that arise from childhood experiences. Maladaptive schemas are in response to unmet emotional needs in childhood and adolescence, and are strengthened throughout adulthood.

Question 30

In the Schema Questionnaire there are 18 schemas developed that try to identify maladaptive behaviour. Try and name some.

Answer 30

• Abandonment (e.g. interpret a delayed text to mean that partner is disinterested).
• Mistrust.
• Emotional Deprivation.
• Defectiveness.
• Social Isolation.
• Dependence.
• Vulnerability to Harm.
• Enmeshment.
• Failure to achieve.
• Entitlement.
• Insufficient self-control.
• Negativism.
• Self-punitiveness.
• Emotional inhibition.
• Unrelenting standards.
• Subjugation.
• Self-sacrifice.
• Approval seeking.

Question 31

How are schemas expressed in the present moment?

Answer 31

Through thoughts, feelings, images, memories, and physical responses.

Question 32

People pay more attention to things that fit their maladaptive schema. What do they need to do more of?

Answer 32

Pay attention to the things that DON’T fit their schemas. Positive things that show how much they are loved.

Question 33

In schema theory, what are three dysfunctional coping modes/behavioural patterns that people might adopt?

Answer 33

• Surrender (compliant surrenderer).
• Avoid (detached protector, detached self-soother, avoidant protector).
• Overcompensate (self-aggrandiser, attention seeker, perfectionist overcontroller, paranoid overcompensator, bully & attach, conning).

Question 34

In Schema Therapy, how do people cope with their maladaptive schemas?

Answer 34

By adopting dysfunctional coping modes.

Question 35

In schema therapy, the dysfunctional coping modes are adopted to manage emotional pain, why is this problematic?

Answer 35

Because they actually maintain emotional pain. None are actually effective in helping the person get their needs met.

Question 36

In schema therapy, people can have multiple schemas and primary modes that are used to escape the multiple schemas. What does the therapy actually focus on?

Answer 36

The coping modes themselves - not necessarily the schemas.

Question 37

If someone has Narcissistic PD and their ‘dysfunctional coping mode’ is to self-aggrandise, what is the schema they are escaping?

Answer 37

Schema they are escaping: vulnerability.

Question 38

What is the basic goal in Schema Therapy? (keeping in mind that the therapist will target the coping modes).

Answer 38

The basic goal is to help the client get their needs by building a ‘healthy adult mode’.
This mode is designed to soothe the inner child and rewrite their schemas about the world.

Question 39

In schema therapy, what does ‘reparenting’ mean?

Answer 39

The therapist almost acts like the parent that is helping the inner child have their needs met. E.g., in a failure schema, the therapist might need to do a lot of encouragement.