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CBT & Personality Disorders

(7-27-06)

Views of personality and personality disorders

BPD

  • Names, ideology, respect, & terminology: Trying to speak/think clearly about something without making it worse or unnecessarily hurting people’s feelings
    • “The term ‘borderline personality disorder’ is experienced as offensive and unhelpful by many.'” (Krawitz & Watson, 2003, p. xi)
    • “people meeting diagnostic criteria for borderline personality disorder”
    • “complex post-traumatic stress disorder” (Herman, 1992), “complex disorders of stress”
      • 10% (Krawitz & Watson, 2003, p. 4) to 20-40% (Sperry, 2003, p. 86) do not report histories of childhood abuse
    • “emotion regulation disorder” (Krawitz & Watson, 2003, p. 4)
  • Perspectives on nature/core symptoms of BPD personality disorder
    • Gunderson (2001): intolerance of aloneness
      • “Aloneness is experienced as a terrifying loss of self(criterion 3) that the person with BPD may defend against by action (criterion 2) or by distorting reality (criterion 9). Aloneness can also be diminished either by the use of transitional objects (discussed in Chapter 12 of this book) or by another person’s providing reassuring evidence that he or she cares for the person with BPD.” (2001, p. 15)
    • Kroll (1988)
      • Two processes, which are enduring
        • cognitive style: “poorly focused thinking, self-rumination, transient dissociative states, disorganization under stress, and the use of impulsive action to short-circuit unpleasant mental states” (p. 31)
        • emotional intensity or lability: “felt by the patient as overwhelming.” (p. 31)
      • two key themes around which many of the behavioral symptoms are organized
        • victimization
        • loneliness/emptiness
    • Linehan (1987): dysfunction in emotional regulation
      • Dysfunction in emotional regulation
        • physiologically based & reinforced by experiences with significant others who discount the patient’s emotional experiences
        • develop poor or no skills in emotional regulation
      • results in dramatic overreaction and impulsivity
      • disparaging self-attitude
      • unrelenting crises
    • Young (1987): early maladaptive schemas
      • abandonment/loss
      • unlovability
      • dependence
      • subjugation/lack of individuationmistrust
      • inadequate self-discipline
      • fear of losing emotional control
      • guilt/punishment
      • emotional deprivation
    • Beck (Beck, Freeman, and associates, 1990)
      • basic assumptions:
        • “The world is dangerous and malevolent”
        • “I am powerless and vulnerable”
        • “I am inherently unacceptable”
      • dichotomous thinking
      • weak or unstable sense of identity
    • Turkat (1990)
      • problem-solving deficits

CBT treatment of BPD

Dialectical Behavior Therapy (Linehan): skill based, individual and group components often used, explicit therapy contracts

Developed out of work with chronic suicide attempters, predominately female: “parasuicide”: self-injurious behavior/deliberate self-harm: BPD

A history of trauma may predominate in this subpopulation of BPD patients; treatment implications

  • Mindfulness
    • Reasonable mind: remaining calm, gathering facts, using rational problem solving
    • Emotional mind: thinking and behavior based on current emotions
    • wise mind: joining together reasonable mind and emotional mind: “knowing the truth about something by logically thinking it through or observing it to be true.” (Osborne, & McComish, 2006, p. 45).
      • “what skills”: learning to observe, describe, and participate with awareness
      • “how skills”: looking at things nonjudmentally, doing things in the moment, and doing what is effective
  • Interpersonal effectiveness
    • Asking for what you need
    • Saying no
    • Coping with conflict
    • Maintaining a relationship
    • Maintaining self-respect
  • Emotional regulation
    • Identifying and describing emotions
    • Reducing vulnerability: tending to sleep and health needs
  • Distress tolerance
    • Focusing
    • Tolerating and surviving crisis
      • Distraction
      • Self-soothing
      • Improving the moment
      • Thinking of pros and cons
      • Accepting what you can’t change
  • Other CBT treatments of BPD
    • Young’s schema therapy (1999, 2003)
    • Sperry’s structured skill treatment (1999, 2003)
    • Sharoff’s cognitive coping therapy 2002)
  • CBT treatments of other personality disorders
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