Personality disorders of the model of psychotherapeutic care. Personality disorders in modern psychotherapy

Personality disorder- This is a type of pathology of mental activity. This disorder is a personality type or behavioral tendency that is characterized by significant discomfort and deviation from the norms established in this cultural and social environment. A personality disorder is considered to be a severe pathology of an individual's behavioral tendencies or character constitution, usually involving several personality structures. It is almost always accompanied by social and personal disintegration. Usually this deviation occurs at the older children's age, as well as in the puberty period. Its manifestations are noted in the mature period. The diagnosis of personality disorder is not made in the presence of isolated social abnormalities without the presence of personality dysfunction.

Causes of Personality Disorders

Severe pathology of the patterns of perception of individuals and their response to various conditions that make the subject incapable of social adjustment is a disease of personality disorder. This ailment can manifest itself spontaneously or be a sign of other mental disorders.

Describing the causes of personal pathologies, first of all, it is necessary to focus on functional deviations in the main areas of the personality: mental activity, perception, relationships with the environment, emotions.

As a rule, personality defects are congenital and manifest throughout life. In addition, the described disorder may occur during puberty or older age. In the case of this kind of illness, it can be provoked by the transfer of a strong stressful effect, other deviations in mental processes, diseases of the brain.

Also, a personality disorder can occur as a result of a child suffering violence, abuse of an intimate nature, neglect of his interests and feelings, living in crumbs in the conditions of parents' alcoholism and their indifference.

Numerous experiments indicate that in mild manifestations, a personality disorder is observed in ten percent of adults. In forty percent of patients in psychiatric institutions, this deviation manifests itself either as an independent disease, or as an integral element of another pathology of the psyche. Today, the reasons that provoke the development of personal deviations have not been fully clarified.

Numerous scientific studies also show that the male part of the population is more susceptible to personality pathology. Besides, this disease it is more common among disadvantaged families and low-income segments of the population. Personality disorder is a risk factor for committing a suicide attempt, intentional self-harm, drug or alcohol addiction, in some cases, provokes the progression of specific mental pathologies, such as depressive states, obsessive-compulsive disorder. Although manifestations and impulsiveness decrease with age, the inability to build and maintain close contacts is characterized by greater persistence.

Diagnosis of personality disorders is characterized by particular specificity due to two reasons. The first reason is the need to clarify the period of occurrence of the disorder, that is, whether it arose at an early stage of formation or persisted at an older age. It is possible to find out this only when communicating with a close relative of the patient who knows him from birth. Communication with a relative makes it possible to get a complete picture of the nature and pattern of relationships.

The second reason is the difficulty in assessing the factors that provoke a violation of the personality's adaptation and the degree of severity of deviations from the norm in behavioral response. Also, often, it is difficult to draw a clear boundary line between the norm and deviation.

Usually, a personality disorder is diagnosed when there is a significant discrepancy between the individual's behavioral response to his sociocultural level, or it causes tangible suffering to the environment and the patient himself, and also complicates his social and work activities.

Symptoms of personality disorders

People with a personality disorder are often characterized by an inadequate attitude to the problems that have arisen. What provokes difficulties in building harmonious relationships with relatives and a significant environment. Typically, the first signs of a personality disorder are found during puberty or in early adulthood. Such deviations are classified according to the degree of severity and severity. Usually mild severity is diagnosed.

Signs of a personality disorder are manifested, first of all, in relation to the individual to others. Patients do not notice inadequacy in their own behavioral response as well as in their thoughts. As a result, they rarely seek professional psychological help on their own.

Personality disorders are characterized by the stability of the flow, involvement in the structure of the behavior of emotions, personal characteristics of thinking. Most individuals suffering from personality pathologies are dissatisfied with their own existence, have problems in social situations and in communicative interaction at work. In addition, many individuals have a mood disorder, increased anxiety, and an eating disorder.

Among the main symptoms are:

• the presence of negative feelings, for example, a feeling of trouble, anxiety, uselessness or anger;
• difficulty or inability to manage negative feelings;
• avoidance of people and feelings of emptiness (patients are emotionally disconnected);
• frequent confrontations with the environment, threats of reprisals or insults (often developing into assault);
• difficulty in maintaining stable relationships with relatives, especially with children and marriage partners;
• periods of loss of contact with reality.

These symptoms may worsen with stress, for example, as a result of stress, various experiences, menstruation.

People with a personality disorder often have other mental health problems, most commonly depressive symptoms, drug abuse, alcohol or drug abuse. Most personality disorders are of a genetic nature, manifested as a result of the impact of education.

The formation of the disorder and its growth from an early age period is manifested in the following order. Initially, a reaction is observed as the first manifestation of personal disharmony, then development occurs when a personality disorder is clearly expressed when interacting with the environment. Then comes the disease personality disorder, which is decompensated or compensated. Personal pathologies usually become pronounced at the age of sixteen.

Allocate typical stable personality deviations characteristic of persons deprived of liberty for a long time, who have suffered violence, deaf or deaf-mutes. So, for example, deaf-mutes are characterized by light delusional ideas, and those who were in prison - explosiveness and basic distrust.

Personality anomalies in families tend to accumulate, which increases the risk of development in the next generation of psychosis. The social environment can contribute to the decompensation of implicit personality pathologies. After fifty-five years, under the influence of involutional transformations and economic stress, personality anomalies are often brighter than in middle age. This age period a specific “pension syndrome” is characteristic, which is expressed in the loss of prospects, a decrease in the number of contacts, an increase in interest in one’s health, an increase in anxiety and a feeling of helplessness.

Among the most likely consequences of the described disease are:

• the risk of developing dependence (for example, alcohol), inadequate sexual behavior, suicidal attempts are possible;
• offensive, emotional and irresponsible type of child education, which provokes the development of mental disorders in children of a person suffering from a personality disorder;
• due to stress, mental breakdowns occur;
• the development of other disorders of mental activity (for example,);
• the sick subject does not take responsibility for his own behavior;
• distrust develops.

One of the pathologies of the psyche is multiple personality disorder, which is the presence in one individual of at least two personalities (ego states). At the same time, the person himself does not suspect the simultaneous existence of several personalities in him. Under the influence of circumstances, one ego-state is replaced by another.

The causes of this disease are serious emotional trauma that occurred to the individual in early childhood, recurring sexual, physical or emotional abuse. Multiple personality disorder is an extreme manifestation of psychological defense (dissociation), in which the individual begins to perceive the situation as if from the outside. The described defense mechanism allows a person to protect himself from excessive, unbearable emotions. However, with excessive activation of this mechanism, dissociative disorders are born.

With this pathology, depressive states are observed, suicidal attempts are not uncommon. The patient is prone to frequent sudden changes in mood, anxiety. He may also experience various phobias and sleep and eating disorders, less often.

Multiple personality disorder is characterized by a close relationship with psychogenic, characterized by memory loss without the presence of physiological pathologies in the brain. This amnesia is a kind of protective mechanism by which a person acquires the ability to repress a traumatic memory from his own consciousness. In the case of multiple disorder, the described mechanism helps to "switch" the ego states. Excessive activation of this mechanism often leads to the formation of common everyday memory problems in people suffering from multiple personality disorder.

Types of personality disorders

In accordance with the classification described in the international guidelines on mental illness, personality disorders are divided into three fundamental categories (clusters):

• Cluster "A" - these are eccentric pathologies, they include schizoid, paranoid, schizotypal disorder;
• Cluster B is emotional, theatrical or fluctuating disorders, which include borderline, hysterical, narcissistic, antisocial disorder;
• Cluster C is anxiety and panic disorders: obsessive-compulsive disorder, dependent and avoidant personality disorder.

The described types of personality disorders differ in etiology and mode of expression. There are several types of classifications of personality pathologies. Regardless of the classification used, various personality pathologies can simultaneously be present in one individual, but with certain limitations. In this case, the most pronounced is usually diagnosed. The types of personality disorders are detailed below.

The schizoid type of personality pathology is characterized by the desire to avoid emotionally vivid contacts with the help of excessive theorizing, flight into fantasy, and isolation in oneself. Also, schizoid individuals often tend to disregard prevailing social norms. Such individuals do not need love, they do not need tenderness, they do not express great joy, intense anger, or other emotions, which alienates the surrounding society from them and makes close relationships impossible. Nothing can provoke an increased interest in them. Such individuals prefer a solitary type of activity. They have a weak response to criticism, as well as to praise.

Paranoid personality pathology consists in increased sensitivity to frustrating factors, suspicion, expressed in constant dissatisfaction with society, vindictiveness. Such people tend to take everything personally. With the paranoid type of personality pathology, the subject is characterized by an increased distrust of the surrounding society. It always seems to him that everyone is deceiving him, plotting against him. He tries to find a hidden meaning or a threat to himself in any of the simplest statements and actions of others. Such a person does not forgive insults, is vicious and aggressive. But she is able to temporarily not show her emotions until the right moment, in order to then take revenge very cruelly.

Schizotypal disorder is a disorder that does not correspond to diagnostic features diagnosis of schizophrenia: either all the necessary symptoms are absent, or they are weakly manifested, erased. People with the described type of deviation are distinguished by anomalies of mental activity and the emotional sphere, eccentric behavior. In schizotypal disorder, the following may be present: inappropriate affect, withdrawal, eccentric behavior, or appearance, poor interaction with the environment with a tendency to alienate people, strange beliefs that change behavior to be incompatible with cultural norms, paranoid ideas, intrusive thoughts and etc.

With the antisocial type of personality deviation, the individual is characterized by ignoring the norms established in the social environment, aggressiveness, and impulsiveness. Affected people have an extremely limited ability to form attachments. They are rude and irritable, very conflicted, do not take into account the moral norms and rules of public order. These individuals always blame the surrounding society for all their own failures, constantly find an explanation for their actions. They do not have the ability to learn from personal mistakes, are unable to plan, are characterized by deceit and high aggressiveness.

Borderline personality pathology is a disorder that includes low, impulsiveness, emotional instability, unstable connection with reality, increased anxiety and strong degree. An essential symptom of the described deviation is self-injurious or suicidal behavior. The percentage of suicidal attempts, completed with a fatal outcome, with this pathology is about twenty-eight percent.

A frequent symptom of this disorder is a lot of low-risk attempts due to minor circumstances (incidents). Suicidal attempts are predominantly triggered by interpersonal relationships.

Differential diagnosis of personality disorders of this type can cause certain difficulties, since the clinic is similar to bipolar disorder type II due to the fact that this type of bipolar disorder lacks easily detectable psychotic signs of mania.

Hysterical personality disorder is characterized by an endless need for attention, overestimation of the importance of gender, unstable, theatrical behavior. It is manifested by a very high emotionality and demonstrative behavior. Often the actions of such a person are inappropriate and ridiculous. At the same time, she always strives to be the best, but all her emotions and views are superficial, as a result of which she cannot draw attention to her own person on long time. People suffering from this type of ailment are prone to theatrical gestures, subject to other people's influence and easily suggestible. They need an "auditorium" when they do something.

The narcissistic type of personality anomaly is characterized by a belief in personal uniqueness, superiority over the environment, a special position, and talent. Such individuals are characterized by high self-conceit, preoccupation with illusions about their own successes, expectation of an exceptionally good attitude and unconditional obedience from others, inability to express sympathy. They always try to control public opinion About Me. Patients often devalue almost everything that surrounds them, while they idealize everything with which they associate their own person.

Avoidant (anxiety) personality disorder is characterized by a person's constant striving for social isolation, a feeling of inferiority, increased sensitivity to negative evaluation by others, and avoidance of social interaction. Individuals with this personality disorder often think that they do not know how to communicate or that their persona is not attractive. Due to being ridiculed, outcast, patients avoid social interaction. As a rule, they present themselves as individualists alienated from society, which makes social adaptation impossible.

Dependent personality disorder is characterized by an increased sense of helplessness, lack of viability due to lack of independence, incompetence. Such people constantly feel the need for the support of other people, they strive to shift the decision of important issues of their own lives onto other people's shoulders.

Obsessive-compulsive personality pathology is characterized by an increased tendency to caution and doubt, excessive perfectionism, preoccupation with details, stubbornness, recurrent or compulsions. Such people want everything around them to happen according to the rules they have established. In addition, they are incapable of doing any work, since the constant deepening into details and bringing them to perfection simply does not make it possible to complete what they started. Patients are deprived of interpersonal relationships, because there is no time left for them. In addition, relatives do not meet their overestimated requirements.

Personality disorders can be classified not only by cluster or criteria, but also by impact on social functioning, severity and attribution.

Treatment of personality disorders

The treatment of personality disorders is an individual and often very lengthy process. As a rule, the typology of the disease, its diagnosis, habits, behavioral response, and attitude to various situations are taken as the basis. In addition, clinical symptoms, personality psychology, and the patient's desire to make contact with a medical worker are of some importance. Contact with a therapist is often quite difficult for dissocial personalities.

All personality deviations are extremely difficult to correct, so the doctor needs to have the proper experience, knowledge and understanding of emotional sensitivity. Treatment of personality pathologies should be comprehensive. Therefore, the psychotherapy of personality disorders is practiced in close connection with drug treatment. The primary task of the medical worker is to alleviate the depressive clinic and reduce. Works great with this drug therapy. In addition, reducing the impact of external stress can also quickly relieve symptoms and anxiety.

Thus, in order to reduce the level of anxiety, relieve depressive symptoms and other concomitant symptoms, drug treatment is prescribed. In depressive states and high impulsivity, the use of selective serotonin reuptake inhibitors is practiced. Outbursts of anger and impulsivity are corrected by anticonvulsants.

In addition, an important factor influencing the effectiveness of treatment is the patient's family environment. Since it can either aggravate the symptoms or reduce the patient's "bad" behavior and thoughts. Often, family intervention in the treatment process is key to achieving results.

Practice shows that psychotherapy helps patients suffering from personality disorders most effectively, since drug treatment does not have the ability to influence character traits.

For an individual to realize his own incorrect beliefs, features of maladaptive behavior, as a rule, repeated confrontation is necessary in long-term psychotherapy.

Maladaptive behavior, manifested in recklessness, emotional outbursts, lack of confidence, social isolation, can change over many months. In changing inappropriate behavioral responses, participation in self-help group methods helps. Behavioral changes are especially significant for those suffering from a borderline, avoidant or antisocial type of personality pathology.

Unfortunately, there is no quick cure for a personality disorder. Individuals with a history of personality pathology, as a rule, do not look at the problem from the standpoint of their own behavioral response, they tend to pay attention solely to the results of inadequate thoughts and the consequences of behavior. Therefore, the psychotherapist must constantly emphasize the undesirable consequences of their mental activity and behavior. Often the therapist may impose restrictions on behavioral responses (for example, he may say that you should not raise your voice in moments of anger). That is why the participation of relatives is important, since with such prohibitions they can help reduce the severity of inappropriate behavior. Psychotherapy aims to help subjects understand their own actions and behaviors that lead to problems in interpersonal interaction. For example, a psychotherapist helps to realize dependence, arrogance, excessive distrust of the environment, suspicion and manipulativeness.

In changing socially unacceptable behavior (eg, lack of confidence, social withdrawal, anger), group psychotherapy for personality disorders and behavior modification is sometimes effective. Positive results can be achieved after a few months.

Dialectical behavioral therapy is considered effective for borderline personality disorder. It consists in conducting weekly sessions of individual psychotherapy, sometimes in combination with group psychotherapy. In addition, telephone consultations between sessions are considered mandatory. Dialectical behavioral therapy is designed to teach subjects to understand their own behavior, prepare them to make independent decisions and increase adaptability.

For subjects suffering from pronounced personality pathologies, manifested in inadequate beliefs, attitudes and expectations (for example, obsessive-compulsive syndrome), the classic is recommended. Therapy can have a duration of at least three years.

Solving problems of interpersonal interaction, as a rule, takes more than one year. The foundation of effective transformations in interpersonal relationships is individual psychotherapy, aimed at the patient's awareness of the sources of his troubles in interaction with society.

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Clinical Guidelines for Psychotherapy of Patients with Borderline Personality Disorders

PSYCHOANALYTICAL BULLETIN
№ 8, 1990

Michael H. Stone

Michael X. Stone (M. Stone) - American psychoanalyst, MD, professor clinical psychology Columbia Medical and Surgical College in New York, attending psychiatrist at the Mid-Hudson Forensic Psychiatric Hospital, visited St. Petersburg in 1999 as a visiting professor at the East European Institute of Psychoanalysis. Text of a lecture delivered at the East European Institute of Psychoanalysis in 1999.

Translation from English by S. Pankov

The concept of "borderline" has existed in psychiatric terminology for more than a hundred years. In one of my works, I tried to trace all the stages of evolution that this term has experienced over such a long period of its existence.
It took many years for this once rather approximate concept, originally used to describe a condition balancing "between neurosis and psychosis", to acquire its modern meaning as a definition of a disorder characterized by pronounced tendencies to emotional lability, impulsiveness, irritability and self-destructiveness. (Stone, 1980, 1986). For sixty years, from the 1920s to 1980, when the third edition of the Diagnostic and Statistical Handbook (DSM-III) was published, the term "borderline" was in wide use in psychoanalytic circles rather than among adherents of traditional psychiatry. . The basis for the new definition was the extensive excerpts from the work of Adolf Stern (A. Stern, 1938), indicating the possibility of successfully overcoming the emotional collapse caused by stress. This was followed by the more precise, although at the same time quite extensive Kernberg criteria (Kernberg, 1967), and later - succinctly formulated and practical criteria proposed by Gunderson and Singer (Gunderson & Singer, 1975).

When the concept of borderline personality disorder was first introduced in a new section ("Axis-II") of the third edition of the Diagnostic and Statistical Handbook, the eight-paragraph article was a fusion of Kernberg and Gunderson's language. The current definition in the fourth edition of the Diagnostic and Statistical Manual (DSM-IV) is similar to the first, with the exception of one additional paragraph based on Gunderson's research regarding "brief psychotic episodes."

Due to the fact that the Diagnostic and Statistical Handbook is widely used in clinical practice, diagnostic criteria have now become more stringent (compared to the Kernberg criteria). According to modern "standards", a more serious degree of pathology is considered a convincing basis for making a diagnosis of borderline personality disorder. This is primarily due to the fact that borderline personality disorder, in essence, is by no means characteristic of all patients whose condition meets the Kernberg criteria, among which, along with the blurring of identity and a decrease in the ability to adequately assess reality, Kernberg calls impulsiveness, hypersensitivity to stress and the inability to overcome the consequences of severe stress through wellness treatments. This state Kernberg himself calls the "frontier organization of personality."

The Diagnostic and Statistical Handbook's definition of borderline personality disorder is now considered standard within general psychiatry, although many psychoanalysts still use Kernberg's broader criteria. Most patients with borderline personality disorder are characterized by increased aggressiveness, a tendency to demonstrative suicidal actions, as well as impulsiveness in communicating with others, especially with loved ones. However, even in the absence of these signs, the patient's condition may correspond to diagnostic criteria borderline personality organization, although the majority of patients are characterized by a full set of the mentioned features. This distinction is of particular importance for clinical practice.
Therapeutic methods recommended in the psychoanalytic literature and promoted by clinicians such as Helene Deutsch (1942), Melitta Schmideberg (1947), Robert Knight (1953), John Frosch (1960), Otto Kernberg (Otto Kernberg, 1967; 1975), Robert Wallerstein (Robert Wallerstein, 1986), and others (Clarkin, Yeomans & Kernberg, 1999) are generally intended for patients who exhibit more moderate self-destructiveness and irritability than individuals with borderline personality disorder. The condition of the patients described in the psychoanalytic literature on this subject fits more or less into the clinical picture, which Kernberg, in his article published in 1967, calls the borderline personality organization, and only a small proportion of such patients show a tendency to self-mutilate ( opening veins, cauterizing the skin with cigarettes, etc.) or commit demonstrative suicidal acts. In addition, as a rule, patients who have received a good education and occupy a stable social and financial position appear in psychoanalytic works, although by no means all patients suffering from borderline personality disorder meet these criteria. These significant differences will be discussed below when we consider a variety of modern therapeutic methods, each of which has proven itself better in working with a specific group of patients suffering from borderline personality disorder.

Various manifestations of borderline personality disorder

Before looking at the particular therapies that are currently in widespread use, let us turn to the problems associated with heterogeneity among patients with borderline personality disorder. Even limiting ourselves to cases of borderline personality disorder - not to mention borderline personality organization - one cannot fail to note the diversity of etiological and social factors, as well as clinical subtypes, which largely determine the therapy strategy. Thus, the clinical approach must take into account the individual characteristics of each patient in a borderline condition.

With regard to etiological factors, borderline personality disorder usually affects those patients whose impulsiveness and increased irritability were a reaction to a trauma suffered in childhood, in particular, to incest. Women become victims of incest more often than men, and in connection with this, the number of women suffering from borderline personality disorder exceeds the number of men with a similar disorder by two times, and in some cases - 5-6 times (Stone, 1989; Zanarini, 1990 ; Paris, 1993). Another factor that contributes to the gender disproportion among patients with borderline personality disorder is the greater predisposition of women to depression. Under the influence depressive states in combination with increased irritability can also occur clinical picture borderline personality disorder. For example, according to the results of a long-term follow-up study conducted at the New York State Psychiatric Institute, many patients who suffered from borderline personality disorder and were not victims of incest had severe depression, and various manic-depressive diseases were constantly inherited in their families ( Stone, 1990). In other groups of patients with borderline personality disorder, the main factors influencing the formation of pathology were predisposition to attention disorder in combination with hyperactivity, the tendency to "episodic" lose control of oneself, which was more often observed in young men (Andrulonis et al., 1981), or affective disorders, including manic depression (Akiskal, 1981; Stone, 1990).

The task of choosing the optimal type of therapy is complicated by various comorbidities and "impurities" of other disorders that are characteristic of almost all patients whose condition, according to the criteria proposed in the fourth edition of the Diagnostic and Statistical Handbook, allows a diagnosis of borderline personality disorder. The most common comorbidity or complication is major affective disorder, which can take the form of severe or manic depression. The second place in a number of concomitant diseases is occupied by an eating disorder, which is more common among women. It is primarily about anorexia nervosa and bulimia nervosa. In some cases, attacks of anorexia and bulimia alternate. It is not uncommon for women with borderline personality disorder to experience an exacerbation of symptoms (depression and irritability) during the premenstrual period (Stone, 1982). In list pathological conditions Symptoms of borderline personality disorder can also be called panic disorder, obsessive-compulsive disorder, and dissociative disorder, although the symptoms of these disorders are less common. In addition, it has been noted that many patients with borderline personality disorder show a tendency to abuse either alcohol or marijuana, but often do not limit themselves to a specific stimulant and use a variety of drugs (cocaine, LSD, angel dust, PSP, heroin, etc. .). In each of the above cases, it is necessary to apply special methods of treatment. Such an approach would be ideal in the treatment of patients with latent borderline personality disorder.

Many of these symptomatic disorders are associated with unhealthy "cravings" for food, drugs, etc. The optimal type of treatment for such disorders are special 12-step treatment programs: the organization of Alcoholics Anonymous (in the case of alcoholism) and Narcotics Anonymous (in the case of heroin and cocaine addiction), as well as an anonymous program for people prone to overeating (in case of bulimia), etc. Currently, special treatment programs have been created that are intended even for people who show an unhealthy addiction to gambling and sex (for example, the program " Sexaholics Anonymous). In other cases, the clinician usually has the opportunity to turn to drug therapy. In the treatment of patients suffering from borderline personality disorder in combination with an affective disorder, antidepressants and tranquilizers, alone or in combination, are often successfully used. The use of serotonin blockers is advisable in the treatment of patients suffering from borderline personality disorder in combination with post-traumatic stress disorder, as well as patients suffering from obsessive-compulsive disorders or depression (Markowitz et al., 1991). Patients with borderline personality disorder often exhibit "impulsive aggression", which is an indicator for the use of serotonin blockers (Coccaro & Kavoussi, 1997). To mitigate the symptomatic reaction in the premenstrual period, a variety of drugs (including antidepressants, anxiolytics and bromocriptine) can be used, which should be chosen empirically, taking into account the individual susceptibility of each patient.

It should be noted that cases of "pure" borderline personality disorder (and even more so borderline personality organization) are extremely rare. Based on the data presented by Oldham and colleagues (Oldham et al., 1992), borderline personality disorder may accompany more than three other personality disorders listed in the Diagnostic and Statistical Handbook. Borderline personality disorder is “dramatic” in nature, so it seems quite natural that the personality disorders associated with it are for the most part included in the so-called Dramatic Cluster, Cluster B, where, along with “borderline”, there are narcissistic, histrionic and antisocial personality disorders (Zanarini, Frankenberg, et al., 1998). However, patients with borderline personality disorder may exhibit other tendencies, such as addiction, avoidance, obsessions, and paranoia. Kernberg pointed out this characterological diversity as early as 1967. In a published article he listed some common subtypes within the borderline personality organization, in particular, "infantile" (or histrionic, in the terminology of the Diagnostic and Statistical Handbook), hypomanic, paranoid and depressive-masochistic . In the treatment of patients belonging to the depressive-masochistic subtype, the prognosis is usually more favorable than in the treatment of patients showing hypomanic or histrionic tendencies, regardless of whether the criteria proposed in the Diagnostic and Statistical Handbook are used in making the diagnosis, or the Kernberg criteria. Roy Grinker and his colleagues (Roy Grinker et al., 1968) also noted the presence of a wide range of types of borderline disorder in their scheme, mentioning, among others, the subtype "as if" and the anaclitic-depressive type, which is closest in a functional sense to neurotic disorders. . In the case of borderline anaclitic-depressive disorder, the prognosis seemed to be the most favorable. In my long-term follow-up study of 299 patients with borderline personality disorder, of which 206 patients met the criteria specified in the third edition of the Diagnostic and Statistical Handbook, the least successful compared to other types of personality disorder, with the exception of antisocial, in which the treatment results were quite naturally the most insignificant, it was possible to achieve in the treatment of individuals who showed increased irritability and excitability. In general, patients with borderline personality disorder, who are characterized by bitterness and hostility, regardless of the type of disorder, are less amenable to treatment, if only because sometimes the very fact of being forced to separate from those on whom they depend, whether either relatives, close friends or therapists.

In addition, clinicians should be aware that the results of therapy and, to some extent, the choice of therapeutic methods are influenced by some other factors related to the patient, but not related to the characteristics of his personality. For example, according to McGlashan's (1986, Chestnut Lodge) study and my own long-term P.I. to self-discipline. In the case when patients suffering from borderline personality disorder combined with alcoholism joined the society of Alcoholics Anonymous and found the strength to follow the proposed recommendations to the end, the results of therapy were successful. Obviously, in this case, we should talk not only about a high degree of motivation to overcome the disorder, in which the presence of the disease is not denied, but recognized, but also about the ability to self-discipline. Self-discipline and motivation can be seen as positive personal factors along with giftedness and good looks. At the same time, all these features should be taken only as auxiliary therapeutic agents, regardless of the type of therapy.

Therapeutic Approaches to the Treatment of Borderline Personality Disorder

Currently, a variety of approaches have been developed within the framework of conversational psychotherapy, which are widely used in the treatment of patients suffering from borderline personality disorder. Therapists do not have a universal method of treatment. However, some basic methods show their best exclusively or predominantly in the treatment certain patients. Therefore, in the process of treating other patients, the therapist may rely on one therapeutic approach (especially since in the course of training, therapists master one specific method of treatment), from time to time, if necessary, additionally using other therapeutic methods. The combination of different therapeutic methods is of particular importance in the treatment of inpatients with borderline personality disorder, when the clinical picture is complex: multiple symptomatic disorders, frequent suicide attempts, overt impulsiveness, drug addiction. In such cases, it is necessary not only to carry out complex treatment, but also correctly outline the sequence of application various methods.
The main therapeutic approaches can be divided into three broad categories:
1. Supportive psychotherapy.
2. Psychotherapy of psychoanalytic orientation.
3. Cognitive / behavioral psychotherapy.
Each of the above categories lends itself to further subdivision. For example, psychoanalytically oriented psychotherapy includes a number of therapeutic approaches, notably Gunderson's exploratory therapy, Kernberg's transference-focused therapy, Kohut's (1971) therapy based on principles of self-psychology, and therapies developed earlier by Edith Zetzel (Edith Zetzel, 1971), Melitta Schmiedeberg (Melitta Schmiedeberg, 1947) and others. Due to the fact that one of the essential features of borderline psychopathology is impulsivity, which is mentioned in all definitions of "borderline state" (Stone 1980, p. 273) and the "cure" for which is the setting to limit, the importance of this aspect of therapy is noted in within any approach. In his book Supportive Psychotherapy: A Dynamic Approach, Rockland (1992) mentions the limiting mindset as one of the other essential interventions to support the patient. Kernberg (1993) emphasizes the importance of the limiting mindset in the context of transference-focused psychotherapy, while Gunderson (1984) does the same when talking about psychoanalytically oriented psychotherapy. In a monograph on the problems of dialectical-behavioral therapy, Linehan (1993) also points out the importance of regulation and the necessary restrictions. Despite the fact that, from the point of view of tactics, such an attitude is essentially a part of behavioral therapy, the significance of this method in the treatment of patients with borderline personality disorders is so great that it can hardly be considered an element of only one of the above therapeutic approaches.

Supportive psychotherapy

In the context of psychotherapy for patients with borderline personality disorder, Rockland (1989) mentions a number of support methods in addition to the limiting mindset. In general, supportive psychotherapy is more goal-oriented than psychoanalytic therapy. Meanwhile, the therapeutic alliance plays a key role in all types of psychotherapy, and within the framework of supportive psychotherapy, the therapist, already at the initial stage of treatment, in order to create such an environment, directly indicates that the patient and the therapist will make joint efforts to solve the patient's problems, focusing the attention of the latter that the therapist is "here" for the patient and is therefore extremely interested in helping and cooperating with him. As a result, the patient begins to feel less alone and helpless.

Among the methods of support that have proven themselves in the treatment of patients with borderline personality disorders include a contract for the procedure of therapy, which is concluded between the therapist and the patient before starting treatment, encouragement, the ability to reassure and encourage, the provision of advice and recommendations, the creation of a kind of "container "(in the words of Winnicott) for powerful emotional outbursts of the patient, indirect intervention (for example, involving the patient's relatives in urgent cases), revisiting the patient's statements from a more realistic point of view (similar to the explanation in psychoanalytic therapy), willingness to praise the patient for real achievements, strengthening its protection, the provision of intellectual interpretations (helping to shed light on the causes of some conflicts and in doing so avoid "deep" analysis, the inertia of which may be insurmountable), as well as the use of "approximate interpretations" (Glover, 1931) in the event that the EU whether such interpretations, despite their inaccuracy, help to relieve anxiety. Another significant element of supportive therapy is education, which is not always limited to advice and recommendations. Quite often, patients with borderline personality disorder do not follow the rules of behavior (they are late for sessions, react inadequately to various situations, forget to pay for treatment, etc.). In addition, patients with borderline personality disorder may ignore the risk of contracting a sexually transmitted disease and be unaware of what behavior is dangerous. In such cases, training is of particular importance.

As a rule, supportive psychotherapy for patients with borderline personality disorder includes one therapy session per week, which varies from half an hour to an hour, although sometimes two sessions per week are carried out at the initial stage of treatment. Given the fact that many patients with borderline personality disorder have experienced childhood trauma, and the vulnerability of such individuals and the turmoil in their current lives, it must be recognized that a "quick cure" is hardly possible. Under ideal conditions, a therapy that takes several years (from five to ten) leads to a complete stabilization of the patient's condition, regardless of the therapeutic approach.

Cognitive and Behavioral Psychotherapy

In the context of the treatment of patients with borderline personality disorder, cognitive and behavioral therapy uses a number of fundamental strategies that are unparalleled in supportive or psychoanalytic psychotherapy. The general "philosophy" and specific methodology of cognitive and behavioral therapy are detailed by Aaron Beck and Arthur Freeman in a book on the treatment of personality disorders (A. Beck & A. Freeman, 1990). Practitioners of behavioral therapy and psychoanalytically oriented psychotherapists alike emphasize the need to "identify and overcome key problems" (p. 4), but approach this task differently. From the point of view of psychoanalysis, key issues and conflicts are unconscious (and therefore difficult to access). Practitioners of cognitive therapy assume that such problems are mostly conscious. Therefore, the task of cognitive therapy is to increase the level of conscious understanding of hidden problems. As Beck and Freeman note, the practitioner's work as a cognitive therapist "is carried out simultaneously at the level of symptomatic structure (obvious problems) and at the level of 'underlying schema' (implied structure)" (p.4). It is believed that the behavior of the individual, including the inadequate behavior of patients suffering from personality disorders, is built in accordance with these schemes.
For patients suffering from borderline personality disorder, certain patterns of insufficient adaptation are characteristic, which are formed under the influence of childhood experiences. Beck and Friedman note nine such schemas, with specific features inherent in each of them: 1) alienation and loss (the specific expression of which are subjective feelings associated with loneliness and lack of support from others); 2) inability to love (due to which the individual is convinced that not a single person from those who know him well will want to get close to him); 3) excessive dependence; 4) subordination; 5) lack of trust (combined with fears that others are always ready to take advantage and offend this individual); 6) lack of self-discipline (which is expressed in impulsiveness and inability to control oneself); 7) fear associated with the risk of losing control over emotions; 8) a sense of guilt (which is expressed in the fact that the individual condemns himself as a "bad" person); 9) emotional deprivation (the individual's conviction that no one can understand him).

Patients with borderline personality disorder are more likely than others to have a condition that Beck (1976) calls dichotomous thinking. The latter is a special case of cognitive deviation, as a result of which the events of everyday life are perceived by the individual as either unconditionally good or unconditionally bad. Due to the lack of the ability to capture the midtones of black and white flowers patients with borderline personality disorder, as a rule, show increased sensitivity to the most insignificant remarks of relatives and lovers, dramatically changing their idea of ​​\u200b\u200bthe "offender", who at once turns into a disgusting and hostile personality for them. Meanwhile, pleasant episodes associated with a long-term relationship between the patient and his partner are forgotten in the face of momentary disappointment. Of course, this tendency also manifests itself in the course of psychotherapy. At the moment of positive experiences, patients adhere to an equally extreme position. At the same time, the idealization of a partner seems to be just as unrealistic as the hatred that arises in connection with negative experiences. Extremes in reactions result in equally exaggerated emotions and extremes in behavior (impulsivity, destructive behavior: promiscuity, drunkenness, aggressiveness), which is characteristic symptom"border state". The task of cognitive and behavioral therapy is to help the patient to distinguish between halftones of black and white colors and learn to respond more calmly to unpleasant events in everyday, professional and intimate life.

AT last years one of the most prominent representatives of this therapeutic direction was Marsha Linehan. She proposed a detailed methodology for the treatment of patients with borderline personality disorder who (like most such patients) self-mutilate and commit suicidal acts. The proposed method is designed to allow patients to gradually get rid of destructive tendencies and make a choice in favor of more acceptable ways of interacting with others. The principles of such therapeutic intervention are outlined in Linehan's Dialectical Behavioral Therapy (DBT, 1993). In addition, a practical guide to dialectical behavior therapy has now been released. In practice, dialectical behavior therapy is a treatment program that is carried out, as a rule, with a frequency of one individual session per week and one group session per week. In this case, the patient gets the opportunity to call the therapist on the phone if he is close to committing one or another self-destructive action. Telephone contacts are allowed, provided that such an act has not yet been made, since the purpose of these contacts is to help the patient find a more acceptable solution to a particular problem. (In brackets, we note that women open their veins more often than men.) At the very beginning of therapy, during the preliminary session, the patient is informed of the terms of the mutual agreement, according to which he does not have the right to call the therapist if the act has already been committed. This relationship pattern acts as a kind of conditioning mechanism: self-control is encouraged by allowing telephone contact with the therapist, and impulsiveness entails the prohibition of such contact. Linehan and her colleagues report that their methods have proven to be effective. Patients treated with dialectical behavior therapy experienced a greater reduction in self-destructive behavior and suicide attempts than controls with borderline personality disorder treated with "traditional therapy" (usually supportive care).
It should be noted that the "traditional therapy" mentioned in Linehan's report included significantly fewer individual sessions during the week. Therefore, the question arises whether the superiority of dialectical behavioral therapy is due to the effectiveness new methodology or the frequency of individual sessions with a therapist who could achieve equally impressive results by practicing supportive therapy or psychoanalytically oriented psychotherapy with the same frequency? In addition, we do not have stability data therapeutic effect, achieved by Linehan and her colleagues, since no information has yet been received on long-term follow-up studies (for 10 years or more) focused on such a technique.

If we consider the restriction mindset as a method of "support", then it must be recognized that dialectical behavior therapy (as well as any form of effective therapy for patients with borderline personality disorder) borrowed tactics from supportive therapy. As a rule, within the framework of cognitive and behavioral therapy (including dialectical behavioral therapy), transference and countertransference experiences are hardly taken into account. However, Linehan uses countertransference interpretations to great effect.

An illustration is provided by a case study described by Linehan. We are talking about a patient who constantly expressed a desire to commit suicide due to severe professional stress, hinting along the way that Dr. Linehan could not even imagine the full horror of the situation, since she had succeeded in her professional activity and is already “out of reach” for such stressful experiences. After listening to this patient, Dr. Linehan objected, “Believe me, I can understand you. I have to deal with stress all the time. You can't imagine how difficult it is to associate with people who tirelessly threaten to kill themselves” (p. 395). This phrase by Linehan belongs to the category of paradoxical reactions that are included in the arsenal of dialectical behavioral therapy along with other strategies described in the same work (p. 296). A practitioner of dialectical behavior therapy may use metaphors, play the role of a "devil's advocate", defend compromises (when communicating with patients suffering from a typical borderline personality disorder and prone to extremes), make generalizations (similar to interpretations within psychoanalytic psychotherapy) etc.

From a theoretical point of view, the objectives of dialectical behavioral therapy are dictated by clinical observations, which allow us to conclude that, in general, the problems characteristic of patients suffering from borderline personality disorder fall into two main categories: problematic behavior and limitation. Problematic behavior is often associated with increased irritability, which complicates close relationships, and also takes the form of self-destructive actions, whether demonstrative and genuine suicide attempts or self-mutilation, such as cuts and burns. Limitation is expressed in the form of insufficient emotional regulation, distorted ideas about sexual life and interpersonal relationships, awkwardness in communicating with friends and colleagues. Individual sessions, which are part of the course of dialectical behavior therapy, are focused primarily on changing problem behavior, while communication skills training is designed to eliminate limitation. Individual therapy focuses on a careful analysis of the behavior caused by insufficient adaptation. The therapist invites the patient to analyze these or those difficult situations after the fact and choose a more effective way to solve the problems associated with them, or gives the patient relevant advice, recognizing that finding a way out of the current situation was not easy, but at the same time pointing out the need for changes and developing a more constructive approach . During the therapeutic process, in connection with the discussion of issues related to a "more constructive approach" and learning more effective ways solving various problems, the patient gradually (partly due to group therapy) begins to learn new communication skills, as can be judged by a change in his behavior.

Psychotherapy of psychoanalytic orientation

The development of a psychoanalytic approach to the treatment of patients with borderline personality disorder has a long history, which is reflected in the relevant scientific literature. In one of my papers (Stone, 1980) I listed the various names that have been given to this approach since the 1920s. The terms exploratory psychotherapy (Gunderson, 1984), expressive psychotherapy (Kernberg, 1975), and transference-focused psychotherapy (Clarkin, Yeomans, & Kernberg, 1999) are now widely used.

It should be noted that these approaches have much more in common than differences. This applies to all therapeutic techniques that do not correspond to the classical model of psychoanalysis: during the session, the patient is in a sitting position, and not lying on the couch; the therapist is much more actively involved in the dialogue with the patient and often allows himself to interrupt the patient's long pauses in the first session with remarks; explanation and interpretation are focused more on what is happening "here and now" than on childhood experiences; the therapist is more willing to intervene in the event of signs of danger and alarming symptoms; in general, the therapist takes a more active position than is customary in working with patients who are characterized by a relatively stable state (corresponding, according to Kernberg, to a neurotic, and not to a borderline level of personality organization).

Other approaches to the treatment of patients with borderline personality disorder include the interpersonal method developed by Harry Sullivan3 (Harry Stack Sullivan, 1953) and his followers, among which Harold Searls (Harold Searls, 1986) should be especially noted, as well as the Heinz method of self psychology. Kohut (Heinz Kohut, 1971). In defining "marginal state", the above authors use less stringent criteria than Kernberg and the authors of the corresponding section of the Diagnostic and Statistical Handbook, although in general their criteria are closer to Kernberg's lengthy definition. Essentially, Kohut was stating a "borderline" not from the initial interview (as is customary for diagnosis), but rather from the lack of an adequate response on the part of the patient after several months of therapy in a traditional psychoanalytic setting using the couch. Searles draws Special attention on countertransference, considering the latter as an indicator of repressed emotions, redirected to the therapist (through the protective mechanism of projective identification).

For example, a young woman suffering from borderline personality disorder and consumed by jealousy of her older sister, a more attractive and balanced person, refuses to acknowledge her jealousy and talks incessantly about the incomparable virtues of her former friend, not allowing the therapist to say a word. As a result, the therapist becomes jealous of this paragon of manhood, in comparison with which the therapist looks much more modest in the eyes of the patient. Finally noticing his jealousy, the therapist understands that this is an "extraneous emotion" that the patient deliberately aroused in him. This observation, in turn, allows him to bring up the topic of jealousy in conversation (for example, in the following way: “Do you think there is any connection between the jealousy that I feel when you praise your friend and your personal life?” ). It is only after this that the patient for the first time begins to talk about the fact that she feels jealousy for her more successful sister, which she hid for a long time and refused to admit.

Transference-focused psychotherapy

In the process of refining the expressive therapy developed by Otto Kernberg and his colleagues (Kernberg, 1975, 1984; Kernberg, Selzer, et al., 1989), practical techniques were developed for this therapeutic approach, now called transference-centered psychotherapy (Clarkin, Yeomans, & Kernberg, 1999).
From a theoretical point of view, the basis for transference-centered psychotherapy was the object relations theory, the principles of which were expounded by Kernberg in many articles published since the mid-1960s (Kernberg, 1967, 1975, 1980). According to Kernberg's theory, patients in a borderline state (which is viewed through the prism of a broader category of borderline personality organization or its subtype - borderline personality disorder), unlike those suffering from psychoses, are able to distinguish themselves from another person, but cannot combine in their perception of the positive and negative aspects of their own personality or the personality of an important participant in the relationship. Due to the fact that the individual uses the primitive defense mechanism of "splitting", the ability of a realistic and holistic perception of one's own personality and the personality of another person is reduced.
Clinicians observe this defense mechanism in action when a patient with borderline personality disorder judges others, including the therapist, as being exceptionally positive (“idealized”) or exceptionally bad people, without discerning the nuances of interpersonal relationships. In addition, often patients with borderline personality disorder drastically change their opinion about a particular person, they can throw mud at someone who was idolized a minute ago, and vice versa. The patient may completely deny unwanted and unacceptable feelings (without being aware of them), renounce such feelings (that is, be aware but not acknowledge them), or project these feelings onto another person, such as a therapist, similar to the aforementioned jealous patient.

According to Kernberg, patients with borderline personality disorder tend to have abnormalities related to impulsivity, affect, and identity, either alone or in various combinations. Although impulsiveness can manifest itself in many ways, its characteristic feature is the rapid transition from thought to action (which leads to what is called in French psychiatry "passer a l'act"). In such cases, the action is, as a rule, thoughtless and inappropriate. affective disorder it is expressed, as a rule, in the form of emotional lability and a tendency to abrupt changes in mood and opinion about the people around them (“idealization” is replaced by contempt, and exaggerated tenderness - by unjustified hatred).

Emotional dysregulation often plays a key role in the process of identity blurring: the emotional life of patients with borderline personality disorder consists of many short and contrasting episodes replacing each other, each of which is dictated by the last, positive or negative, experience in communication with a loved one. At the same time, a completely trivial event can serve as the cause of the appearance of hatred for a loved one. For example, a woman with borderline personality disorder may change her mind about her husband dramatically if he doesn't notice that she styled her hair differently. The patient, who is vaguely aware of his propensity for rapid mood swings, finds it difficult to determine his "true" attitude towards this or that person and asks questions: "Do I love him or hate him?". "Am I a good person or a scoundrel?" The main task of transference-centered psychotherapy is to eliminate this "split" and to help the patient develop a more holistic view of himself and others, which, in turn, leads to desirable changes in his behavior.

Understanding the functioning of the protective mechanisms inherent in patients suffering from borderline personality disorder allows you to choose the right direction for therapy. In order for the patient to be able to form a more complete picture of himself and others, it is necessary to eliminate the "splitting". Thanks to this, the relationship between the patient and people close to him - relatives, sexual partners, spouse, friends, work colleagues - become more harmonious. The propensity for extremes and abrupt mood swings soon manifests itself in the transference situation. Constant fluctuations between idealization and contempt, love and hate, self-abasement and arrogance become a characteristic feature of the relationship to the therapist. Patients with borderline personality disorder rely on "transference actualization" rather than understanding it. In other words, they try to turn the therapeutic relationship into a friendship or love affair, or into a real enmity, from which you can only escape. In order to eliminate such tendencies, the patient should be helped to refuse actions and learn to express in words those emotions that push him to unacceptable actions.

As already mentioned, some of the most common unacceptable behaviors that are characteristic of patients with borderline personality disorder include suicide attempts and self-mutilation. In addition, such patients often exhibit risky sexual behavior (eg, casual sex with strangers), alcoholism, drug use, anorexia, or bulimia. It is not uncommon for patients with borderline personality disorder to create a tense relationship with the therapist by refusing to leave the office after the session is over, threatening the therapist, throwing objects at the therapist, skipping sessions without warning, not paying bills, making overt attempts to seduce the therapist, or refusing to complete the course. therapy.

Under ideal conditions, transference-focused psychotherapy is given at a frequency of 2-3 sessions per week. Before starting treatment, the therapist and the patient enter into a mutual agreement that specifies the procedure for conducting therapy: the frequency of sessions, the conditions for telephone contacts, etc. The therapist informs the patient about the primary tasks that will be solved during the treatment. Attention is paid primarily to those problems that cause the patient the greatest concern and are potentially dangerous. During each session, the degree of impact of such affects on the patient is assessed through the use of three channels of communication: verbal communication, non-verbal communication (gestures, facial expressions of the patient, etc.) and countertransference.

When choosing priorities, the therapist can rely on the practical recommendations of Linehan and Kernberg, which represent a kind of algorithm for this technique. As such, the proposed algorithms form the basis of any effective therapy and therefore cannot be considered a specific feature of transference-focused psychotherapy or dialectical behavior therapy. According to Linehan, threats or acts associated with suicidal tendencies should be taken into account in the first place, since ignoring these problems can have sad consequences. Secondly, the therapist must remember that such patients can interrupt the course of therapy at any moment, as they are characterized by impulsiveness and lack of patience. Thirdly, attention should be paid to symptomatic conditions that threaten the patient's health: drug addiction, anorexia, severe depression. Fourth, it is necessary, as far as possible, to eliminate or mitigate symptoms that do not pose an immediate threat to the patient's life: dysthymia, increased irritability in the premenstrual period, bulimia, social phobia. Fifth, attention should be paid to the characteristic features of the patient's personality, associated with a lack of adaptive abilities and preventing optimal functioning. Sixth, it is necessary to analyze the patient's ambitions, his hopes and aspirations (determining the degree of their realism).

In transference-centered psychotherapy, the problem of suicidal (or aggressive) tendencies is also considered a high priority. The second place in a number of priority tasks is given to the elimination of the obvious threat of premature termination of therapy. Then, in descending order of importance, there are problems related to deceit or concealment (in which any intervention by the therapist fails), as well as violation of the contract between the patient and the therapist (for example, non-compliance with prescribed medications). The next item is symptomatic behavior in sessions, such as refusing to leave the room after the session is over, being late, trying to seduce the therapist, etc. In addition, some importance is attached to issues related to acting out between sessions and the desire to reduce to Minimize session content by talking about casual and superficial topics. The latter questions are more related to the psychoanalytic aspects of transference-centered psychotherapy. However, as noted above, in connection with the algorithm of dialectical behavioral therapy, practitioners of transference-focused psychotherapy also pay attention to the severe and less severe symptoms seen in patients with borderline personality disorder.

According to the leading theorists of transference-based psychotherapy (Clarkin, Yeomans, & Kernberg, pp. 9-10), this type of therapy is characterized by features characteristic of most forms of psychodynamic psychotherapy, namely, a strict framework of therapy, more active participation of the therapist than in analysis of patients suffering from neurosis, containment of hostile feelings and aggressive emotions of the patient, the desire to eradicate the tendency to self-destructive behavior through confrontation, the use of interpretations that make it possible to establish a connection between feelings and actions, a focus on what is happening "here and now", an attitude to limit and close attention to countertransference experiences (Waldinger, 1987).

Unlike Kohut's methods, transference-focused psychotherapy does not involve counseling or other supportive interventions. In addition, transference-based psychotherapy pays more attention to negative transference. Along with methods of explanation and interpretation, methods of confrontation play a key role in transference-centered psychotherapy (with obvious contradictions in the patient's statements, with inconsistent statements regarding certain participants in the relationship, with the threat of self-destructive behavior or behavior that is dangerous for therapy). That's why this species therapy differs from other forms of therapy for patients with borderline personality disorder.

Of course, confrontation in practice has nothing to do with the use of torture during cross-examination with prejudice. The point is that the therapist invites the patient to reconsider his own contradictory statements, the paradoxical nature of which the patient could not guess. For example, the therapist might say, “As I noticed, at first you claimed that the death of your father was the loss of the most precious person in the world, but the next moment you claimed that your father sexually harassed you when you were a teenager. It seems strange to me that, remembering your father, you called him only a “dear” person.

As noted by Clarkin and colleagues (Clarkin et al., p. 2), important strategies for transference-centered psychotherapy include: analyzing the underlying principles of the patient's object relations as they manifest themselves in the transference situation; analysis of "role reversal" in the course of therapy; combining strictly separated positive and negative ideas about oneself and others. Patients with borderline personality disorder tend to periodically switch roles during therapy. In one session, the patient, with all his appearance and behavior, tries to emphasize a respectful attitude towards the therapist, and in the next session, he seeks to humiliate the therapist with insulting remarks, as if the patient has turned into a “grumpy parent”, and the therapist plays the role of the “pupil” that the patient himself was in childhood. In order to help the patient to free himself from the tendency to rapid reversal of roles, to understand the nature and causes of this phenomenon, the therapist encourages the development of integrative processes on which the success of therapy depends. In this way, the therapist prepares the ground for a more constructive and harmonious relationship, which is an important step in the process of healing patients with borderline personality disorder, taking into account their inherent sense of loneliness.

Group psychotherapy

As part of the treatment program for patients with borderline personality disorder, it is widely practiced different kinds group psychotherapy. The opinion is often expressed that group psychotherapy is an important additional element of individual psychotherapy (based, as a rule, on one of the approaches described above) and has proven itself, in particular, at the initial stage of pharmacotherapy, when symptoms corresponding to the “second axis” predominate ( "Axis II").

As Avicenna said, the doctor has three main tools: the word, the medicine and the knife. In the first place, of course, is the word - the most powerful way to influence the patient. That doctor is bad, after a conversation with which the patient did not feel better. A spiritual phrase, support and acceptance of a person with all his vices and shortcomings - this is what makes a psychiatrist a true healer of the soul.

The above applies to all specialties, but most of all to psychotherapists.

Psychotherapy can be used either alone or in combination with medication. Psychotherapy has the greatest effect on patients with neurotic spectrum disorders (anxiety-phobic and obsessive-compulsive disorders, panic attacks, depression, etc.) and psychogenic diseases.

Classification of psychotherapy

Today, there are three main areas of psychotherapy:

• Dynamic
• Behavioral (or behavioral)
• Existential-humanistic

All of them have different mechanisms of influence on the patient, but their essence is the same - the focus is not on the symptom, but on the whole personality.

Depending on the desired goal, practical psychotherapy can be:

• supportive. Its essence is to strengthen and support the patient's defenses, as well as to develop patterns of behavior that will help stabilize the emotional and cognitive balance.
• Retraining. Full or partial reconstruction of negative skills that impair the quality of life and adaptation in society. The work is carried out by supporting and approving positive forms of behavior in the patient.

According to the number of participants, psychotherapy is individual and group. Each option has its pros and cons. Individual psychotherapy is a springboard for patients who are not prepared for group sessions or refuse to participate in them due to their nature. In turn, the group option is much more effective in terms of mutual communication and exchange of experience. A special variety is family psychotherapy, which involves working together with two spouses.

Spheres of therapeutic influence in psychotherapy

Psychotherapy is good method treatment through three areas of influence:

Emotional. The patient is given moral support, acceptance, empathy, the opportunity to express their own feelings and not be judged for it.

Cognitive. There is an awareness, "intellectualization" of one's own actions and aspirations. At the same time, the psychotherapist acts as a mirror that reflects the patient himself.

Behavioral. During psychotherapy sessions, habits and behaviors are developed that will help the patient to adapt in the family and society.

A good combination of all the above areas is practiced in cognitive-behavioral psychotherapy (CBT).

Types and methods of psychotherapy: characteristics

One of the pioneers of psychotherapy and psychoanalysis was the famous Austrian psychiatrist and neurologist Sigmund Freud. He formed the psychodynamic concept of the emergence of neuroses based on the oppression of the needs and requirements of the individual. The task of the psychotherapist was the transfer of unconscious stimuli and their awareness by the client, due to which adaptation was achieved. In the future, Freud's students and many of his followers found their own schools of psychoanalysis with principles that differ from the original doctrine. This is how the main types of psychotherapy that we know today arose.

Dynamic Psychotherapy

Formation of dynamic psychotherapy as effective method We owe the struggle against neuroses to the works of K. Jung, A. Adler, E. Fromm. The most common version of this direction is person-centered psychotherapy.

The healing process begins with a long and meticulous psychoanalysis, during which the patient's internal conflicts are clarified, after which they move from the unconscious to the conscious. It is important to lead the patient to this, and not just voice the problem. For effective treatment The client needs long-term cooperation with the doctor.

Behavioral psychotherapy

Unlike supporters of the psychodynamic theory, behavioral psychotherapists see the cause of neurosis as incorrectly formed habits of behavior, and not hidden stimuli. Their concept says that a person's behavior patterns can be changed, depending on which his state can be transformed.

Methods of behavioral psychotherapy are effective in the treatment of various disorders (phobias, panic attacks, obsessions, etc.). Worked well in practice confrontation and desensitization technique. Its essence lies in the fact that the doctor determines the cause of the client's fear, its severity and connection with external circumstances. Then the psychotherapist conducts verbal (verbal) and emotional influences by means of implosion or flooding. In this case, the patient mentally represents his fear, trying to paint his picture as brightly as possible. The doctor reinforces the patient's fear so that he feels the reason and gets used to it. A psychotherapy session lasts about 40 minutes. Gradually, a person gets used to the cause of the phobia, and it ceases to excite him, that is, desensitization occurs.

Another type of behavioral technique is rational-emotional psychotherapy. Here the work is carried out in several stages. At the first, the situation and the emotional connection of a person with it are determined. The doctor determines the irrational motives of the client and ways of his way out of a difficult situation. Then he evaluates the key points, after which he clarifies (clarifies, explains) them, analyzes each event together with the patient. Thus, irrational actions are realized and rationalized by the person himself.

Existential-humanistic psychotherapy

Humanistic therapy is the newest method of verbal influence on the patient. Here, an analysis is made not of deep motives, but of the formation of a person as a person. The emphasis is on the highest values ​​(self-improvement, development, achieving the meaning of life). A major role in existentialism was made by Viktor Frankl, who saw the lack of realization of the individual as the main cause of human problems.

There are many subspecies of humanitarian psychotherapy, the most common of which are:

Logotherapy- a method of dereflection and paradoxical intention, founded by W. Frankl, which allows you to effectively deal with phobias, including social ones.

Client Centered Therapy- a special technique in which the main role in the treatment is performed not by the doctor, but by the patient himself.

Transcendental Meditation- a spiritual practice that allows you to expand the boundaries of the mind and find peace.

Empiric Therapy- the patient's attention is focused on the deepest emotions experienced by him earlier.

The main feature of all the above practices is that the line in the doctor-patient relationship is blurred. The therapist becomes a mentor, as equal as his client.

Other types of psychotherapy

In addition to the verbal way of communication with the doctor, patients can attend classes in music, sand, art therapy, which help them relieve stress, show their creativity and open up.

Clinical Psychotherapy: Conclusions

Psychotherapy has an invaluable influence on the patient during treatment and rehabilitation. Disorders of the neurotic spectrum are more effectively amenable to drug correction, if it is combined with the work of a psychotherapist or psychologist, and sometimes even without medication, psychotherapy can lead to the complete disappearance of painful manifestations. In the future, patients move from taking drugs to using the skills acquired in psychotherapy sessions. In this case, it acts as a stepping stone from pharmacotherapy to self-control over painful manifestations (phobias, panic attacks, obsessions) and the mental state of the patient. Therefore, work with a psychotherapist must necessarily be carried out with patients and their relatives.

Personality disorders are a range of mental disorders that are accompanied by disturbances in consciousness, feelings, thoughts and actions. Previously, such a deviation was called constitutional psychopathy.

general information

A person with a personality disorder has a complete change in behavior. In social circles, behavior may differ from the generally accepted and "normal". This type of psychopathy is accompanied by the destruction of consciousness. Every person has a different disorder. More "light" forms only distort the idea of ​​the world and people, and the severe course of psychopathy leads to antisocial behavior and uncontrollability of one's actions. The symptoms of the disorder are as follows:

Causes

Personality disorder most often manifests itself in adolescents. In this case, the disease progresses and worsens the condition of a person at a more mature age.

According to the WHO (World Health Organization, marking F60-F69), every 20th person suffers from constitutional psychopathy.

As a rule, chronic and severe forms appear quite rarely.

The following aspects influence the development of the disorder:

Are personality disorders treatable?

It is impossible to answer this question unambiguously. To do this, you need to study 3 types of personality disorder. Their treatment is prescribed individually, based on the degree and type of disease:

A personality disorder is treated if a mental disorder has been detected on early stage. As a rule, many are embarrassed or afraid to visit a psychotherapist who would help fight internal "demons".

In 80% of cases, psychopathy ends with serious complications, which are accompanied by inappropriate behavior, communication problems. It all depends on the type and type of disorder. If there is a genetic predisposition, then the treatment will be difficult, long and ineffective. If psychopathy is acquired, then with the help of regular psychological assistance, attendance at trainings and the use of medications, a person will be able to lead a full-fledged lifestyle.

What is avoidant personality disorder?

In clinical psychology, this type of psychopathy is called anxious or avoidant. Most often occurs in adolescents and young people aged 16 to 25 years. The reason is indifference, aggression, violence from parents, guardians and peers.

Manifestations of anxiety disorder:

This type of psychopathy is a serious disorder that is rarely evaluated and treated. Deviation can only be detected in a clinical setting.

Diagnosis of psychopathy

Only a psychiatrist can make a clinical diagnosis and prescribe treatment. If the cause of the personality disorder is a head injury or neoplasm on the soft tissues, then the patient is referred to a neurologist and a surgeon, as well as to collect an anamnesis: X-ray examination, MRI and CT.

In which cases diagnostics is needed are listed below:

Before making a diagnosis, a psychiatrist conducts dozens of tests and observes the patient. At this point, it is very important to be open and open about your past, especially if the issues involve relationships with parents and peers.

Treatment for a personality disorder

Two techniques are used to cure personality disorder. Treatment methods consist of medications and psychotherapy.

Medical treatment is prescribed if psychological help Does not help. Indications for use: depression, anxiety and paranoia. As a rule, selective serotonin reuptake inhibitors (SSRI labeling), anticonvulsants and sedatives are used. For example, the most effective antidepressant is Amitriptyline. It not only reduces anxiety, but also affects the central nervous system as an antiserotonin drug. Antipsychotics include Haloperidol, Aminazine, Olanzapine and Rispolept.

Antipsychotics are psychotropic drugs that help with hallucinatory, paranoid, and delusional disorders. Antipsychotics are prescribed for the treatment severe forms personality disorders, which are accompanied by depression, manic excitations. The most powerful drugs are determined by the amount of the substance chlorpromazine and its antipsychotic action. The weakest are estimated at 1.0 coefficient, the strongest reach 75.0.

It is a proven fact that medical preparations do not cure the root cause, but only drown out and soothe the emotional state.

Also medicines designed to relieve painful symptoms (anxiety, apathy, anger). The work of a psychiatrist is to analyze the patient and draw up an overall picture.

In order for the treatment to be effective, rules are introduced. For example, control aggression or anger, change thinking and attitude to life. With a personality disorder, individual therapy is recommended first so that the specialist gains confidence in the patient. Then there are group sessions. On average, psychotherapy takes 2-4 years.

If mental health problems are ignored, it can lead to the development of new mental illnesses. Against the background of constitutional psychopathy, schizophrenia appears, paranoid, expansive and fanatical personalities develop, as well as psychosis, delusional disorder and Asperger's syndrome. It is important to remember that with a personality disorder, one cannot self-medicate, ignore warning signs and avoid the help of specialists.

The method of applying dynamic psychotherapy for personality disorders is not much different from that used for neuroses. Such treatment can be carried out individually or in a group (see Chapter 18).

There are some differences in emphasis in the individual treatment of personality disorders compared to the treatment of neuroses. Less attention is paid to the reconstruction of past events and more to the analysis of behavior in the present. In the so-called character analysis, one studies in detail how the patient relates to other people, how he copes with external difficulties and how he controls his own feelings. This approach is more directive than classical methods of analyzing neurotic symptoms, although transference analysis remains an essential element. In order to emphasize the discrepancy between the patient's usual attitude towards other people and the real life situation, the doctor must reveal himself to a greater extent than is usually accepted in classical analysis. At the same time, the analysis of the doctor's emotional attitude towards the patient can serve as an important indicator of the likely reaction of other people to the patient.

Histrionic Personality Disorder

Murphy and Guze (1960) did interesting message about the difficulties that arise in the treatment of patients with hysterical personality disorder. They describe the direct and indirect demands that such patients may make to the doctor. Direct demands include unreasonable requests for medical treatment, frequent requests for reassurances of continued readiness to help, phone calls at the most inopportune times, and attempts to impose unrealistic treatment conditions. Indirect requirements are expressed in various forms e.g. in seductive behavior, threats of dangerous actions such as taking an overdose of medication, repeated unfavorable comparisons between current treatment and past treatment. The physician must be alert to the first signs of such demands and establish a framework for the relationship, making it clear to what extent he intends to tolerate the patient's behavior. This must be done before the requirements of the latter increase excessively.

obsessive personality disorder

Patients with personality often express a great willingness to please the doctor. However, in this type of personality disorder, psychotherapy usually does not work well, and its inappropriate use can lead to excessive painful introspection, resulting in the condition worsening rather than improving.

Schizoid personality disorder

The inherent desire to avoid close personal contacts in schizoids makes it difficult to use any kind of psychotherapy. Often, after several sessions, the patient stops attending them; if he continues treatment, he tends to intellectualize his problems and there are doubts about the scientific validity of the methods used in the clinic.

The doctor must try to gradually penetrate these "intellectual barriers" and help the patient become aware of his emotional problems. Only then can the doctor start looking for ways to solve them. It is a slow process at best and often ends in failure.

borderline personality disorder

Patients with borderline personality disorder do not positive reaction to exploratory psychotherapy, besides, attempts at such treatment can worsen their emotional control and strengthen them. It is usually better to use supportive care, focusing all efforts on turning towards practical goals related to solving everyday problems.