人格障礙—李孟潮自編

1、人格障礙(personality disorders),李孟潮www.limengchao.com,人格障礙概述(Personality Disorders: An Overview),,3,What is a personality disorder?,maladaptive personality traits traits are relatively enduring features of a person that a

2、re 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 tha

3、n egodystonic,,DSM－IV強(qiáng)調(diào)病人在認(rèn)知、情感、人際關(guān)系和沖動(dòng)控制方面的偏離，指出這種偏離類型在長(zhǎng)時(shí)間內(nèi)相當(dāng)穩(wěn)定，至少可以追溯到青少年或早期成年時(shí)。,5,Personality Disorders: Facts and Statistics,Prevalence of Personality DisordersAbout 0.5% to 2.5% of the general population6-9% （Kat

4、hleen ，1986）0.13‰（我國(guó)，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 pers

5、onality 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 Distributi

6、on and Gender BiasGender bias exists in diagnosisCriterion vs. assessment gender bias,,DSM-IV將10種人格障礙劃分為3大類群:A類群：行為古怪、奇異Cluster AOdd or eccentric Examples include paranoid, schizoidB類群：戲劇化、情感強(qiáng)烈、不穩(wěn)定Cluster BDrama

7、tic, emotional, erraticExamples include antisocial, borderlineC類群：緊張、焦慮行為Cluster CFearful or anxious Examples include avoidant, obsessive-compulsive,分類DSM-IV and DSM-IV-TR Personality Disorder Clusters,人格障礙類型,cluste

8、r A cluster B cluster C偏執(zhí)型表演型 回避型分裂型自戀型 依賴性分裂樣反社會(huì)型 強(qiáng)迫型邊緣型,9,,10,PERSONALITY DISORDERSHistorical perspective,Roots in psychoanalysis – narcissism, masochism, etc. Karl Abraham – firs

9、t 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 reliab

10、ility of diagnosis,12,PERSONALITY DISORDERSEtiology – Theoretical perspectives,Psychodynamic theory Attachment theory – particularly for dramatic, emotional, erratic Cognitive-behavioural perspectives Biological – pa

11、rticularly for odd, eccentric and dramatic, emotional, erratic,13,,偏執(zhí)型人格障礙（paranoid PD),1、臨床特征2、形成原因3、治療,臨床特征,主要特征：猜疑、偏執(zhí)表現(xiàn)為對(duì)他人持久的不信任，社會(huì)隔離，過分警惕臨床發(fā)現(xiàn)男性居多,16,,0.5-2.5% of the population.o Men > Women.o Higher incide

12、nce 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 u

13、njustified 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 hidde

14、n 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 n

15、ot 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 P

16、sychotic Disorder and is not due to a general medical condition.,形成原因,生物學(xué)原因在精神分裂癥患者親屬中較多心理分析偏執(zhí)來自無意識(shí)中強(qiáng)烈的仇恨和敵意的外向投射認(rèn)知的觀點(diǎn)與歪曲的認(rèn)知或想法有關(guān)文化因素特殊人群，如犯人、難民、有聽力障礙的人等易形成這種人格障礙,22,,23,,治療,建立信任關(guān)系非常重要心理動(dòng)力學(xué)治療認(rèn)知治療Acknowledge mis

17、takes.Be open and honest.Have a professional and not overlywarm style.Don‘t confrontSet limits.Clearly explain procedures,medications and results.,25,summary: Paranoid Personality Disorder,Overview and Clinical F

18、eaturesPervasive and unjustified mistrust and suspicionThe CausesBiological and psychological contributions are unclearEarly learning that the world is a dangerous placeTreatment Options Few seek professional help

19、on their ownTreatment focuses on development of trustCognitive therapy to counter negativistic thinkingLack good outcome studies,分裂樣人格障礙（Schizoid PD）,1、臨床特征2、形成原因3、治療,臨床特征,特征：社會(huì)隔絕、情感疏遠(yuǎn)表現(xiàn)為孤單、冷淡的沉默，不介入日常事務(wù)，不交際，不關(guān)心他人。

20、將精力投注于非人類的事物（如數(shù)學(xué)）患病率美、德等國(guó)采用PDQ（人格障礙診斷問卷）、SCID等得到的患病率為0.7－1.6％男性多見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. Alm

21、ost 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-degre

22、e 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 Per

23、vasive Developmental Disorder and is not due to a general medical condition.,,生物學(xué)可能有與孤獨(dú)癥類似的生理機(jī)能缺陷心理動(dòng)力學(xué)基本的接觸需要沒有獲得滿足認(rèn)知治療不能有效的關(guān)注周圍的情況來獲得準(zhǔn)確的感知社會(huì)心理在早期學(xué)習(xí)、人際交往中形成問題,形成原因,33,,治療,心理治療發(fā)展對(duì)社會(huì)關(guān)系的興趣，認(rèn)識(shí)社會(huì)關(guān)系的價(jià)值社交技能訓(xùn)練 Understa

24、nd their need for isolation. Minimize new contacts and intrusions Maintain a quiet, reassuring, and considerate interest in them. Don’t insist on reciprocal responses,分裂型人格障礙（schizotype）,1、臨床特征2、形成原因3、治療,臨床特征,特征社會(huì)隔

25、絕、情感疏遠(yuǎn)、古怪行為、多疑表現(xiàn)為認(rèn)識(shí)或感知方面的歪曲以及古怪的行為患病率可能高于精神分裂癥和其他人格障礙 3% of the population.Sex ratio is unknown.Greater association among biological relatives of schizophrenic patients.The premorbid personality of the schiz

26、ophrenic 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 cla

27、irvoyance, telepathy, or the sixth sense!±Unusual perceptual experiences, including bodilyillusions.Odd thinking and speech (e.g.vague,circumstantial, metaphorical, overelaborate, or stereotyped).Suspiciousness

28、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 t

29、hat 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 Develop

30、mental Disorder.,形成原因,生物學(xué)的解釋精神分裂癥親屬中有較高的此型患病率,41,,42,,43,,44,,治療,心理治療：社交技能訓(xùn)練幫助其與人交往，減少對(duì)他人的不信任感藥物治療：治療精神分裂癥的藥物可使其癥狀有中等程度的改善o Similar to Schizoid PD.o Misperceptions of physical symptoms and treatment.o Do not ridic

31、ule or judge.o Respect their need for privacy.,表演型人格障礙（Histrionic PD）,1、臨床特征2、形成原因3、治療,臨床特征,又稱癔癥型、尋求注意型、或心理幼稚型特征 人格不成熟、情緒不穩(wěn)定表現(xiàn)：需要情愛和注意、依賴性、作弄他人的傾向患病率美、德等國(guó)采用PDQ、SCID等臨床調(diào)查表、定式檢核表等工具得到的為1.3－3.0％女性2倍于男性2-3%.D

32、iagnosed 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 wi

33、th 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.

34、,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 circumstance

35、s.Considers relationships to be more intimate that they actually are.,形成原因,對(duì)其原因或治療的研究少心理分析理論作為對(duì)內(nèi)心低自尊感的一種反抗，病人總是試圖成為他人的注意中心。,52,,53,,治療,對(duì)人際關(guān)系治療獎(jiǎng)勵(lì)與懲罰結(jié)合Similar to Borderline PD.o Medical illnesses threaten their sense

36、 of attractiveness and self-image.,自戀型人格障礙(Narcissistic PD),1、臨床特征2、形成原因3、治療,臨床特征,特征妄自尊大觀念表現(xiàn)：自我中心，夸大（幻想或行為），需要他人贊揚(yáng)患病率美、德等國(guó)：0－0.4％2-16% in the clinical population.1% in the general population.Number of cases incr

37、easing steadily.,形成原因,心理分析家長(zhǎng)對(duì)其子女不愛和不接受的行為方式行為和認(rèn)知模型過分積極的贊賞或?qū)檺凵鐣?huì)影響因素及時(shí)行樂、個(gè)人主義、競(jìng)爭(zhēng)和成功等觀念影響,59,,60,,Has a grandiose sense of self-importance (e.g.,exaggerates achievements and talents, expects to be recognized as superio

38、r 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,

39、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 automat

40、ic 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 nee

41、ds of others.Is often envious of others or believes that others are envious of him or her.Shows arrogant, haughty behavior or attitudes.,治療,對(duì)治療的研究非常有限心理治療主要集中于其被扭曲的自我（自我夸大感），對(duì)評(píng)價(jià)的病態(tài)的敏感等方面Handle criticism poorly.Becom

42、e easily enraged.Medical illnesses can be a blow to their self-esteem.Reinforce that they are respected and appreciated.Set limits on demanding behavior.,反社會(huì)型人格障礙(Antisocial PD),1、臨床特征2、形成原因3、治療,臨床特征,特征經(jīng)常發(fā)生違反社會(huì)規(guī)范的行

43、為表現(xiàn)：工作不良，婚姻不良，酒精與藥物濫用，情感膚淺、無情、自我中心，不誠(chéng)實(shí)、欺騙、作弄他人，沖動(dòng)性、攻擊性及法律問題等患病率Vaillant & Perry (1985) 在0.05-15% 之間男性多于女性3% in men and 1% in women.Most common in poor urban areas.75% in prison populations.Familial pattern pr

44、esent.,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

45、 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 other

46、s.,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,

47、 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

48、course of Schizophrenia or a Manic Episode.,形成原因,生物學(xué)因素 遺傳、神經(jīng)生物學(xué)的假說社會(huì)心理學(xué)家庭與社會(huì)環(huán)境的影響，缺乏情感和父母粗暴拒絕心理分析超我發(fā)展不完善認(rèn)知心理學(xué)在道德原則和推理能力上的發(fā)展滯后,70,,治療,傳統(tǒng)的心理治療和醫(yī)學(xué)治療均無顯著的效果行為治療學(xué)習(xí)對(duì)問題情境作新的反應(yīng)認(rèn)知治療提高其認(rèn)知能力，改善社會(huì)和道德行為Set firm limits.

49、Try not to be manipulated.Have high level of skepticism.Be careful not to prescribe excessive and/or unnecessary medications.,邊緣型人格障礙(Borderline PD),1、臨床特征2、形成原因3、治療,臨床特征,特征人際關(guān)系、自我形象和情感的不穩(wěn)定表現(xiàn)：人際關(guān)系不良，不能耐受孤獨(dú)，常感孤單和空虛

50、，易抑郁，情緒不穩(wěn)定，行為具沖動(dòng)性，易發(fā)生自傷、自殺行為，存在自我認(rèn)同障礙患病率美、德等國(guó)：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 Substan

51、ce 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 idea

52、lization 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,

53、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

54、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 an

55、ger,recurrent physical fights).Transient, stress-related paranoid ideation or severe dissociative symptoms.,形成原因,生物學(xué)的解釋 神經(jīng)系統(tǒng)或腦內(nèi)生物化學(xué)方面的異常心理動(dòng)力學(xué)的解釋父母對(duì)子女的不接納社會(huì)心理學(xué)對(duì)被遺棄的恐懼早期創(chuàng)傷，包括身體、性虐待,79,,治療,治療非常困難認(rèn)知行為治療心理動(dòng)力學(xué)治療

56、60;集體治療與若干個(gè)人形成較親密的依戀關(guān)系藥物治療可減緩其沖動(dòng)性，減輕抑郁等,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 consist

57、ent limits on acting out.,回避型人格障礙（Avoidant PD）,1、臨床特征2、形成原因3、治療,臨床特征,特征長(zhǎng)期和全面地脫離社會(huì)關(guān)系表現(xiàn)：對(duì)人回避、退縮，過分敏感，焦慮，對(duì)自我價(jià)值缺乏信心 患病率美、德等國(guó)：0.4-1.6％女性多于男性,84,,Infants with a timid temperament may be more likely to develop Avoidant P

58、D.,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.

59、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 beca

60、use 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 embarras

61、sing.,形成原因,生物學(xué)的解釋生物化學(xué)方面的異常、易患病的基因認(rèn)知行為模型的解釋習(xí)得性恐懼、不安的思維方式社會(huì)心理學(xué)的解釋羞恥感，與童年時(shí)期經(jīng)歷有關(guān),90,,治療,支持和共情非常重要心理動(dòng)力學(xué)揭示其癥狀的根源，使自我強(qiáng)壯起來認(rèn)知行為治療 認(rèn)知重建、社交技能訓(xùn)練和暴露療法集體治療結(jié)合使用暴露療法、角色扮演法等藥物治療降低焦慮,92,,Have patience and understanding.o Med

62、ical illnesses may be embarrassing.o Minimize new and unfamiliar staff contacts.o Respond with a calm and reassuring demeanor.o Do not criticize them.,依賴性人格障礙(Dependent PD),1、臨床特征2、形成原因3、治療,臨床特征,又稱不適當(dāng)型(inadequate)特

63、征缺乏自信、依附他人表現(xiàn)：輕微應(yīng)激即退卻，尋求幫助，需要保護(hù)，性關(guān)系不成熟，往往存在婚姻問題，缺乏親密朋友患病率美、德等國(guó)：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 decisio

64、ns 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 l

65、oss 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 ex

66、cessive 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

67、 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

68、因,社會(huì)心理學(xué)父母出于愛或獨(dú)裁的目的過分保護(hù)孩子認(rèn)知理論適應(yīng)不良信念,100,,治療,行為和認(rèn)知療法認(rèn)知重建、自信訓(xùn)練人本主義治療集體治療,102,,Respect their feelings of attachment.o Be careful when encouraging a patient to change the dynamics of an abusive relationship.o When med