人格障碍—李孟潮自编

人格障碍(personality disorders),李孟潮,人格障碍概述(Personality Disorders: An Overview),3,What is a personality disorder?,maladaptive personality traits traits are relatively enduring features of a person that are persistent over time and situations people with personality disorders tend to be: rigid and inflexible, show a restricted range of traits, have a dominant single trait personality disorders are egosyntonic, more than egodystonic,DSMIV强调病人在认知、情感、人际关系和冲动控制方面的偏离，指出这种偏离类型在长时间内相当稳定，至少可以追溯到青少年或早期成年时。,5,Personality Disorders: Facts and Statistics,Prevalence of Personality DisordersAbout 0.5% to 2.5% of the general population6-9% （Kathleen ，1986）0.13（我国，1986）Rates are higher in inpatient and outpatient settings。prevalence higher among people with other mental disorders 6-9% of population have one or more personality disordermost people with personality disorders never come to the attention of mental health professionals,6,Origins and Course of Personality DisordersThought to begin in childhoodRun a chronic courseComorbidity rates are high Gender Distribution and Gender BiasGender bias exists in diagnosisCriterion vs. assessment gender bias,DSM-IV将10种人格障碍划分为3大类群:A类群：行为古怪、奇异Cluster AOdd or eccentric Examples include paranoid, schizoidB类群：戏剧化、情感强烈、不稳定Cluster BDramatic, emotional, erraticExamples include antisocial, borderlineC类群：紧张、焦虑行为Cluster CFearful or anxious Examples include avoidant, obsessive-compulsive,分类DSM-IV and DSM-IV-TR Personality Disorder Clusters,人格障碍类型,cluster A cluster B cluster C偏执型表演型 回避型分裂型自恋型 依赖性分裂样反社会型 强迫型边缘型,9,10,PERSONALITY DISORDERSHistorical perspective,Roots in psychoanalysis narcissism, masochism, etc. Karl Abraham first theorist to focus on personality disorders,11,PERSONALITY DISORDERSDiagnostic issues,poor understanding of etiology of most personality disorders comorbidity and diagnostic overlap gender and cultural issues reliability of diagnosis,12,PERSONALITY DISORDERSEtiology Theoretical perspectives,Psychodynamic theory Attachment theory particularly for dramatic, emotional, erratic Cognitive-behavioural perspectives Biological particularly for odd, eccentric and dramatic, emotional, erratic,13,偏执型人格障碍（paranoid PD),1、临床特征2、形成原因3、治疗,临床特征,主要特征：猜疑、偏执表现为对他人持久的不信任，社会隔离，过分警惕临床发现男性居多,16,0.5-2.5% of the population.o Men Women.o Higher incidence in relatives ofschizophrenics.o Higher among minorities, immigrants,and the deaf.,17,18,19,Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her.Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates.Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her.Reads hidden demeaning or threatening meanings into benign remarks or events.,20,Persistently bears grudges, i.e., is unforgiving of insults, injuries, or slights.Perceives attacks on his or her character or reputation that are not apparent to others and isquick to react angrily or to counterattack.Has recurrent suspicions, without justification,regarding fidelity of spouse or sexual partner.Does not occur exclusively during the course of a Psychotic Disorder and is not due to a general medical condition.,形成原因,生物学原因在精神分裂症患者亲属中较多心理分析偏执来自无意识中强烈的仇恨和敌意的外向投射认知的观点与歪曲的认知或想法有关文化因素特殊人群，如犯人、难民、有听力障碍的人等易形成这种人格障碍,22,23,治疗,建立信任关系非常重要心理动力学治疗认知治疗Acknowledge mistakes.Be open and honest.Have a professional and not overlywarm style.Dont confrontSet limits.Clearly explain procedures,medications and results.,25,summary: Paranoid Personality Disorder,Overview and Clinical FeaturesPervasive and unjustified mistrust and suspicionThe CausesBiological and psychological contributions are unclearEarly learning that the world is a dangerous placeTreatment Options Few seek professional help on their ownTreatment focuses on development of trustCognitive therapy to counter negativistic thinkingLack good outcome studies,分裂样人格障碍（Schizoid PD）,1、临床特征2、形成原因3、治疗,临床特征,特征：社会隔绝、情感疏远表现为孤单、冷淡的沉默，不介入日常事务，不交际，不关心他人。将精力投注于非人类的事物（如数学）患病率美、德等国采用PDQ（人格障碍诊断问卷）、SCID等得到的患病率为0.71.6男性多见7.5% of the population.o A 2-to-1 male-to-female ratio.,29,30,Neither desires nor enjoys close relationships, including being part of a family. Almost always chooses solitary activities. Has little, if any, interest in having sexual experiences with another person. Takes pleasure in few, if any, activities.Lacks close friends or confidants otherthan first-degree relatives.,31,Appears indifferent to the praise and criticism of others. Shows emotional coldness, detachment, or flattened affectivity. Does not occur exclusively during the course of a Psychotic Disorder, or a Pervasive Developmental Disorder and is not due to a general medical condition.,生物学可能有与孤独症类似的生理机能缺陷心理动力学基本的接触需要没有获得满足认知治疗不能有效的关注周围的情况来获得准确的感知社会心理在早期学习、人际交往中形成问题,形成原因,33,治疗,心理治疗发展对社会关系的兴趣，认识社会关系的价值社交技能训练 Understand their need for isolation. Minimize new contacts and intrusions Maintain a quiet, reassuring, and considerate interest in them. Dont insist on reciprocal responses,分裂型人格障碍（schizotype）,1、临床特征2、形成原因3、治疗,临床特征,特征社会隔绝、情感疏远、古怪行为、多疑表现为认识或感知方面的歪曲以及古怪的行为患病率可能高于精神分裂症和其他人格障碍3% of the population.Sex ratio is unknown.Greater association among biological relatives of schizophrenic patients.The premorbid personality of the schizophrenic patient.,37,38,Ideas of reference (excluding delusions of reference).Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or the sixth sense!Unusual perceptual experiences, including bodilyillusions.Odd thinking and speech (e.g.vague,circumstantial, metaphorical, overelaborate, or stereotyped).Suspiciousness or paranoid ideation.,39,Inappropriate or constricted affect. Behavior or appearance that is odd, eccentric. Or peculiar Lack of close friends or confidants other than first-degree relatives.Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self.Does not occur exclusively during the course of a Psychotic Disorder or a Pervasive Developmental Disorder.,形成原因,生物学的解释精神分裂症亲属中有较高的此型患病率,41,42,43,44,治疗,心理治疗：社交技能训练帮助其与人交往，减少对他人的不信任感药物治疗：治疗精神分裂症的药物可使其症状有中等程度的改善o Similar to Schizoid PD.o Misperceptions of physical symptoms and treatment.o Do not ridicule or judge.o Respect their need for privacy.,表演型人格障碍（Histrionic PD）,1、临床特征2、形成原因3、治疗,临床特征,又称癔症型、寻求注意型、或心理幼稚型特征人格不成熟、情绪不稳定表现：需要情爱和注意、依赖性、作弄他人的倾向患病率美、德等国采用PDQ、SCID等临床调查表、定式检核表等工具得到的为1.33.0女性2倍于男性2-3%.Diagnosed more frequently in women than in men. Associated with Somatization Disorder and Alcohol Abuse/Dependence.,48,49,Is uncomfortable in situations in which he or she is not the center of attention.Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior.Displays rapidly shifting and shallow expression of emotions.Consistently uses physical appearance to draw attention to self.,50,Has a style of speech that is excessively impressionistic and lacking in detail.Shows self-dramatization, theatricality, and exaggerated expression.Is suggestible, i.e., easily influenced by others or circumstances.Considers relationships to be more intimate that they actually are.,形成原因,对其原因或治疗的研究少心理分析理论作为对内心低自尊感的一种反抗，病人总是试图成为他人的注意中心。,52,53,治疗,对人际关系治疗奖励与惩罚结合Similar to Borderline PD.o Medical illnesses threaten their sense of attractiveness and self-image.,自恋型人格障碍(Narcissistic PD),1、临床特征2、形成原因3、治疗,临床特征,特征妄自尊大观念表现：自我中心，夸大（幻想或行为），需要他人赞扬患病率美、德等国：00.42-16% in the clinical population.1% in the general population.Number of cases increasing steadily.,形成原因,心理分析家长对其子女不爱和不接受的行为方式行为和认知模型过分积极的赞赏或宠爱社会影响因素及时行乐、个人主义、竞争和成功等观念影响,59,60,Has a grandiose sense of self-importance (e.g.,exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements).Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.Believes that he or she is !special! and unique can only be understood by, or should associate with, other special or high-status people (or institutions).Requires excessive admiration.,61,Has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations.Is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends.Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others.Is often envious of others or believes that others are envious of him or her.Shows arrogant, haughty behavior or attitudes.,治疗,对治疗的研究非常有限心理治疗主要集中于其被扭曲的自我（自我夸大感），对评价的病态的敏感等方面Handle criticism poorly.Become easily enraged.Medical illnesses can be a blow to their self-esteem.Reinforce that they are respected and appreciated.Set limits on demanding behavior.,反社会型人格障碍(Antisocial PD),1、临床特征2、形成原因3、治疗,临床特征,特征经常发生违反社会规范的行为表现：工作不良，婚姻不良，酒精与药物滥用，情感肤浅、无情、自我中心，不诚实、欺骗、作弄他人，冲动性、攻击性及法律问题等患病率Vaillant & Perry (1985) 在0.05-15% 之间男性多于女性3% in men and 1% in women.Most common in poor urban areas.75% in prison populations.Familial pattern present.,65,66,Failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest.Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure.Impulsivity or failure to plan ahead.Irritability and aggressiveness, as indicated by repeated physical fights or assaults.Reckless disregard for safety of self or others.,67,Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations.Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another.The individual is at least age 18 years, and there is evidence of Conduct Disorder with onset before age 15 years.The occurrence of antisocial behavior is not exclusively during the course of Schizophrenia or a Manic Episode.,形成原因,生物学因素 遗传、神经生物学的假说社会心理学家庭与社会环境的影响，缺乏情感和父母粗暴拒绝心理分析超我发展不完善认知心理学在道德原则和推理能力上的发展滞后,70,治疗,传统的心理治疗和医学治疗均无显著的效果行为治疗学习对问题情境作新的反应认知治疗提高其认知能力，改善社会和道德行为Set firm limits.Try not to be manipulated.Have high level of skepticism.Be careful not to prescribe excessive and/or unnecessary medications.,边缘型人格障碍(Borderline PD),1、临床特征2、形成原因3、治疗,临床特征,特征人际关系、自我形象和情感的不稳定表现：人际关系不良，不能耐受孤独，常感孤单和空虚，易抑郁，情绪不稳定，行为具冲动性，易发生自伤、自杀行为，存在自我认同障碍患病率美、德等国：0.2-4.6女性多于男性,74,1-2% of the population.o Twice as common in women as in men.o Increased prevalence of Major Depressive Disorder, Alcohol Abuse/Dependence, and Substance Abuse found in first-degree relatives.,75,76,Frantic efforts to avoid real or imagined abandonment.A pattern of unstable and intense interpersonal relationships characterized by alternatingbetween extremes of idealization and devaluation.Identity disturbance: markedly and persistently unstable self-image or sense of self.Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex,substance abuse, reckless driving, binge eating).Chronic feelings of emptiness.,77,Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days).Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger,recurrent physical fights).Transient, stress-related paranoid ideation or severe dissociative symptoms.,形成原因,生物学的解释 神经系统或脑内生物化学方面的异常心理动力学的解释父母对子女的不接纳社会心理学对被遗弃的恐惧早期创伤，包括身体、性虐待,79,治疗,治疗非常困难认知行为治疗心理动力学治疗集体治疗与若干个人形成较亲密的依恋关系药物治疗可减缓其冲动性，减轻抑郁等,81,o Be aware of and anticipate defenses.o Often regress.o Open and continuous communication withstaff.o Stable and calm reaction.o Gently confront.o Set fair and consistent limits on acting out.,回避型人格障碍（Avoidant PD）,1、临床特征2、形成原因3、治疗,临床特征,特征长期和全面地脱离社会关系表现：对人回避、退缩，过分敏感，焦虑，对自我价值缺乏信心 患病率美、德等国：0.4-1.6女性多于男性,84,Infants with a timid temperament may be more likely to develop Avoidant PD.,85,86,Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection.Is unwilling to get involved with people unless certain of being liked.Shows restraint within intimate relationships because of the fear of being shamed or ridiculed.,87,Is preoccupied with being criticized or rejected in social situations.Is inhibited in new interpersonal situations because of feelings of inadequacy.Views self as socially inept, personally unappealing, or inferior to others.Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing.,形成原因,生物学的解释生物化学方面的异常、易患病的基因认知行为模型的解释习得性恐惧、不安的思维方式社会心理学的解释羞耻感，与童年时期经历有关,90,治疗,支持和共情非常重要心理动力学揭示其症状的根源，使自我强壮起来认知行为治疗 认知重建、社交技能训练和暴露疗法集体治疗结合使用暴露疗法、角色扮演法等药物治疗降低焦虑,92,Have patience and understanding.o Medical illnesses may be embarrassing.o Minimize new and unfamiliar staff contacts.o Respond with a calm and reassuring demeanor.o Do not criticize them.,依赖性人格障碍(Dependent PD),1、临床特征2、形成原因3、治疗,临床特征,又称不适当型(inadequate)特征缺乏自信、依附他人表现：轻微应激即退却，寻求帮助，需要保护，性关系不成熟，往往存在婚姻问题，缺乏亲密朋友患病率美、德等国：0.3-6.7,95,o More common in women than men.o Children with chronic physical illnesses may be more prone.,96,97,Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others.Needs others to assume responsibility for most major areas of his or her life.Has difficulty expressing disagreement with others because of fear of loss of support or approval.Has difficulty initiating projects or doing things on his or her own (because of a lack of self- confidence in judgment or abilities rather than a lack of motivation or energy).,98,Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant.Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself.Urgently seeks another relationship as a source of care and support when a close relationship ends.Is unrealistically preoccupied with fears of beingleft to take care of himself or herself.,形成原因,社会心理学父母出于爱或独裁的目的过分保护孩子认知理论适应不良信念,100,治疗,行为和认知疗法认知重建、自信训练人本主义治疗集体治疗,102,Respect their feelings of attachment.o Be careful when encouraging a patient to change the dynamics of an abusive relationship.o When medically ill they may become frustrated that they are not being helped.o Be active in the treatment planning.,强迫型人格障碍（Obsessive-Compulsive PD）,1、临床特征2、形成原因3、治疗,临床特征,特征情绪限制，秩序性、坚持执拗、完美表现：秩序性、固执、僵硬、异常节俭、谨小慎微、爱整洁、犹豫不决、严肃沉闷等美、德等国：1.7-6.4男性多于女性,105,More common in men than in women.Diagnosed more in oldest children.Often a history of harsh discipline as a child.,106,107,Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost.Shows perfectionism tha