1、第十一章人格障碍及其矫正 (personality disorders),于丽琴,一、人格障碍概述(Personality Disorders: An Overview),3,What is a personality disorder?,maladaptive personality traitstraits are relatively enduring features of a person that are persistent over time and situationspeople with personality disorders tend to be: rigid an
2、d inflexible, show a restricted range of traits, have a dominant single traitpersonality 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 Disorders About 0.5% to
3、 2.5% of the general population 6-9% （Kathleen ，1986） 0.13（我国，1986） Rates are higher in inpatient and outpatient settings。prevalence higher among people with other mental disorders6-9% of population have one or more personality disorder most people with personality disorders never come to the attent
4、ion of mental health professionals,6,Origins and Course of Personality Disorders Thought to begin in childhood Run a chronic course Comorbidity rates are high Gender Distribution and Gender Bias Gender bias exists in diagnosis Criterion 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 C
5、luster A Odd or eccentric Examples include paranoid, schizoid B类群：戏剧化、情感强烈、不稳定 Cluster B Dramatic, emotional, erratic Examples include antisocial, borderline C类群：紧张、焦虑行为 Cluster C Fearful or anxious Examples include avoidant, obsessive-compulsive,分类DSM-IV and DSM-IV-TR Personality Disorder Clusters,
6、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 DISORDERS Historical perspective,Roots in psychoanalysis narcissism, masochism, etc.Karl Abraham first theorist to focus on personality disorders,11,PERSONALITY DISORDERS Diagnostic issues,poor understandin
7、g of etiology of most personality disorderscomorbidity and diagnostic overlapgender and cultural issuesreliability of diagnosis,12,PERSONALITY DISORDERS Etiology Theoretical perspectives,Psychodynamic theoryAttachment theory particularly for dramatic, emotional, erraticCognitive-behavioural perspect
8、ivesBiological particularly for odd, eccentric and dramatic, emotional, erratic,13,（一）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 of schizophrenics. o Higher among minorities, immi
9、grants, 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 th
10、e 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
11、 to others and is quick 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
12、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 overly warm style. Dont confront Set limits. Clearly explain procedures, medications and results.,25,summary: Paranoid
13、 Personality Disorder,Overview and Clinical Features Pervasive and unjustified mistrust and suspicion The Causes Biological and psychological contributions are unclear Early learning that the world is a dangerous place Treatment Options Few seek professional help on their own Treatment focuses on de
14、velopment of trust Cognitive therapy to counter negativistic thinking Lack good outcome studies,（二）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-fem
15、ale 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 other
16、 than 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 co
17、ndition.,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 intrusionsMaintain a quiet, reassuring, and considerate interest in them.Dont insist on reciprocal
18、 responses,（三）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
19、,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 bodily illusions. Odd
20、 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.
21、 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,
22、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.,（四）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
23、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 othe
24、rs 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. Sh
25、ows 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 Borde
26、rline PD. o Medical illnesses threaten their sense of attractiveness and self-image.,（五）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：00.4 2-16% in the clinical population. 1% in the general population. Number of cases increasing steadily.,形成原因,心理分析 家长
27、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, be
28、auty, or ideal love. Believes that he or she is !special! and uniquecan 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 treatm
29、ent 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 ar
30、e 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
31、behavior.,（六）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.,6
32、5,66,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. Irr
33、itability 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 b
34、eing 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 Ma
35、nic 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 m
36、edications.,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/De
37、pendence, 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 alternating between extremes of idealization and devaluation. Identity disturbance: markedly and
38、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 behav
39、ior. 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
40、,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 re
41、gress. o Open and continuous communication with staff. o Stable and calm reaction. o Gently confront. o Set fair and consistent limits on acting out.,(七）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 temperam
42、ent 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 relati
43、onships 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 unusuall
44、y 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 un
45、derstanding. 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.,（八）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
46、 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
47、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 excess
48、ive 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
49、 support when a close relationship ends. Is unrealistically preoccupied with fears of being left 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.,（九）强迫型人格障碍（Obsessive-Compulsive PD）,1、临床特征 2、形成原因 3、治疗,
