PERSONLIGHEDSFORSTYRRELSER - hvad nyt?

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1 Un tr ea t ed PERSONLIGHEDSFORSTYRRELSER - hvad nyt? Hvad vil jeg sige noget om? Ringgården 1. november 2012 Erik Simonsen Professor, ph.d., dr.h.c. Forskningschef, overlæge Psykiatrisk Forskningsenhed Region Sjælland Ny viden om hyppighed Nye diagnoser og ny klassifikation Nye teorier Ny viden om årsagsforhold Ny viden om behandling Ny viden om forløb 1 Prevalence of PDs in a Community Sample (N=2053) Personality Disorder Present Prevalence Hyppighed af personlighedsforstyrrelser 12 psykiatriske populationer Help seeking vs. helprejecting eller komorbiditet? Paranoid 2.4 Schizoid 1.7 Schizotypal Borderline 0.7 Histrionic 2.0 Narcissistic 0.8 Avoidant 5.0 Dependent 1.5 Obsessive-Compulsive 2.0 Passive-Aggressive 1.7 Self-Defeating par sch typi dys bor his nar æng dep tva Torgersen, Kringlen, Cramer; 2001 Erik Simonsen, Forskningschef - Psykiatrisk Forskningsenhed, Region Sjælland Prævalens af personlighedsforstyrrelse Jens Drachman Bukh, 2010 Total (en eller flere) Evasiv Dependent Obsessiv-kompulsiv Passiv-aggressiv Depressiv Paranoid Skizotypal Skizoid Histrionisk Narcissistisk Borderline Cluster A Cluster B Cluster C N (%) 96 (31.9) 30 (10.0) 12 (4.0) 19 (6.3) 10 (3.3) 26 (8.6) 3 (1.0) 3 (1.0) 3 (1.0) 0 1 (0.3) 35 (11.6) 9 (3.0) 9 (3.0) 38 (12.6) 51 (16.9) 1 or > PD Passive-aggressive Obsessive-compulsive Avoidant Dependent Narcissistic Histrionic Borderline Schizoid Schizotypal Personlighedsforstyrrelser hos misbrugere Normals Misbrugere Paranoid 0% 10% 20% 30% 40% 50% 60% Erik Simonsen, Forskningschef - Psykiatrisk Forskningsenhed, Region Sjælland Per Nielsen,

2 Hvorfor er vi tilbageholdende med at stille PF diagnoser? Hvad ved vi om de kategorielle diagnoser PF diagnosesystemet er for kompliceret og svært at lære Der er ikke investeret i indlæring og anvendelse af standardiserede metoder eller spørgeskemaer Personlighedsdiagnoser er ikke pålidelige Diagnoser er ikke relevant for behandlingsplan Det er for tidskrævende at beskrive personlighed En personlighedsdiagnose stigmatiserer patienten Almindelige kliniske interview tenderer resulterer i lavere frekvenser af PF end ved standardiserede metoder Klinikere tenderer til kun at anvende 1 PF diagnose, mens strukturerede interview giver flere diagnoser Klinikere spørger sjældent om personlighedstræk, men tenderer til at stille diagnosen efter at have lyttet til patientens narrativ (Westen 1999) IPTP s testkatalog 2012 SELVRAPPORT Quick Personality Assessment Schedule (PAS-Q) Standardised Assessment of Personality: Abbreviated Scale (SAPAS) IPTP s testkatalog 2012 De (semi)strukturerede interview NEO Personality Inventory-Revised (NEO-PI-R) Millon Clinical Multiaxial Inventory (MCMI III) Millon Adolescent Clinical Inventory (MACI) Minnesota Multiphasic Personality Inventory-2 (MMPI-2) Dimensional Assessment of Personality Pathology Basic Questionnaire (DAPP-BQ) McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD) Temperament and Character Inventory (TCI) Severity Indices of Personality Problems (SIPP-118) Schizotypal Personality Questionnaire (SPQ) Personality Assessment Inventory (PAI) Structured Clinical Interview for DSM-IV Personality Disorders (SCID-II) International Personality Disorder Examination (IPDE) Zanarini Rating Scale for Borderline Personality Disorder (ZAN-BPD) Structured Interview for the Five-Factor Model of Personality (SIFFM) Hare Psychopathy Checklist-Revised (PCL-R) Comprehensive Assessment of Psychopathic Personality (CAPP) Karolinska Psychodynamic Profile (KAPP) Affective Neurosciences Personality Scales (ANPS) DSM akser Institut for PersonlighedsTeori og Psykopatologi (IPTP) AXIS IV Psychosocial Stressor Axis II Personality Disorder Axis I Clinical Syndrome (Anxiety, Dysthymia = Fever, Cough) (Borderline, Histrionic = Immune System) (Marital, Economic = Infectious Agents) 2

3 Trait versus state Relationen mellem sårbarhed og udfordrende begivenheder (Zubin & Spring, 1977) Vulnerability as a relatively permanent, enduring trait.. while disease are waxing and waning states (Zubin & Spring, 1977) The Dimensional Approach advantages and limitations Advantages No information lost Permits graded description of psychopathology Encourage representation of individuality Permits assessment of unusual cases and more subtle aspects Detailed description facilitates treatment planning Limitations: No well-established system (competing models) Can become a closed system Personality structure is a dynamic, highly interrelated and coordinated system Fractionate the intrinsic unity of personality into separate rows and columns of uncoordinated traits Grouping needed for communication Advantages: The Categorical Approach advantages and limitations Limitations: Højere ordens domæner personlighedsforstyrrelser Consistent with medical diagnoses Familiar and easy to use Clinical decisions are binary Some evidence (Borderline, Schizotypal, Psychopathy) Well-established typologies Restore the unity of self, the patient as a person Excessive diagnostic co-occurence Inadequate coverage Heterogeneity within diagnoses Arbitrary and unstable diagnostic boundaries Inadequate scientific base Extrovert Aggressiv Hæmmet Emotional stabil Introvert Dependent Impulsiv Emotionel dysreguleret Widiger & Simonsen, JPD (2005) 3

4 * Levels of personality functioning: self & interpersonal No impairment extreme * 6 PD types: Borderline Avoidant Obsessive-Compulsive Narcissistic antisocial/psychopathic; avoidant; narcissistic; borderline; * 26 traits (5 trait domains) negative affect; detachment; DSM 5 PD work group proposal (by March 2011): Core levels of functioning Self identity: unique, clear boundaries. Coherent in time and history, accuracy in selfappraisal and self-esteem, capacity for range of emotional reactions self-direction: coherent short-term and long term goals, utilization of constructive prosocial behavior, productive self-reflect Interpersonal empathy: comprehension and appreciation of others experiences, tolerance of different perspectives, understanding of social causality intimacy: depth and duration of connection with others, desire for closeness, mutality of regard reflected in interpersonal behavior Personality traits (DSM V proposal June 2011) Mentaliseringsevne (Fonagy & Bateman) 1 Submissiveness 2 Depressivity 3 Separation insecurity 4 Anxiousness 5 Emotional lability 6 Suspiciousness 7 Restricted affectivity 8 Withdrawal 9 Intimacy avoidance 10 Anhedonia 11 Manipulativeness 12 Deceitfulness 13 Hostility 14 Callousness 15 Attention seeking 16 Grandiosity 17 Irresponsibility 18 Impulsivity 19 Recklessness 20 Distractibility 21 Perseveration 22 Rigid perfectionism 23 Risk aversion 24 Eccentricity 25 Perceptual dysregulation 26 Unusual beliefs/experiences Den normale evne til at tillægge hensigter og mening til menneskelig adfærd Refererer adfærd til følelser, tanker, hensigt og behov Skaber vores forståelse af andre og os selv Central for menneskers kommunikation og relationer Understøtter vores kliniske forståelse og terapeutiske relationer Psykopatologiforståelse har brug for et udviklings- og livsperspektiv Amygdala hyperreaktivitet Kapitel 4. Udviklingspsykopatologi Susanne Harder & Erik Simonsen Amygdala Hyperreactivity in Borderline Personality Disorder: Implications for Emotional Dysregulation 4

5 Emotionel sensitivitet Heightened sensitivity to facial expressions of emotion in borderline personality disorder. Lynch et al. Emotion 2006;6(4): Enhanced 'Reading the Mind in the Eyes' in borderline personality disorder compared to healthy controls. Fertuck et al. Psychological Medicine 2009;39(12): Examples from the Reading the Mind in the Eyes (Baron-Cohen et al., 2001) surprised sure about something Negative bias in fast emotion discrimination in borderline personality disorder. Dyck et al. Psychological Medicine 2009;39(5): joking happy Examples from the Reading the Mind in the Eyes (Baron-Cohen et al., 2001) Performance on Eyes Test and Physical Abuse friendly sad Eye test scores surprised worried Little or none Some (Fonagy & Stein, 2001) Moderate Marked Physical abuse Pearson r=.43, p<.005 Performance on eyes test and sexual abuse Emotionel dysregulering ved Borderline (opsummering) Eye test scores Little or none Some Moderate Marked Sexual abuse Lav tærskel for følelsesbetonet response (Herpetz, 1997) Overfølsom for ethvert negativt stimulus (Arntz, 2000) Undgår at cope med negative emotioner (Chapman, 2005) Manglende evne til at udelade/undertrykke forstyrrende emotionellle forhold (Domes, 2006) Hurtigt skift fra positive til negativ stemning (Ebner-Priemer, 2007) Mangelfuld evne til at opleve og beskrive forskellige typer af emotioner (Wolff, 2007) Anxiety sensitivity (Gratz, 2008) Højt baseline følelsesmæssig arousal (Kuo & Linehan, 2009) Mere intense negative reaktioner (Jacob, 2009) Pearson r=.46, p<.005 5

6 Birth cohort of ~ 1000 children from Dunedin Maltreatment assessed at 3-11 yrs MAOA activity and antisocial behaviour assessed at 26 yrs Caspi et al. Science 297, 852 (2002) Farmakologiske behandling af PF Psykoterapi som hovedbehandling. Farmakologisk behandling målrettet symptomer ved dekompensation og sårbarhed. Anbefales en alogaritme målrettet kognitive-perceptuelle forstyrrelser (antipsykotika), affektive symptomer(ssri), impuls-adfærdsmæssige symptomer(ssri) APA guidelines, AJP, 2001 Dårlig evidens for farmakologisk behandling. Ingen anbefalinger. På det tidspunkt 3 RCT. Brink, Cochrane database, 2006 Affektiv dysregulation (Topimax, Lamotrigen, Valproat), impuls-adfærdsmæssig dysregulation (Lamotrigen, Topimax), kognitive-perceptuelle symptomer (Olanzepin, Ablify) Lieb, BJP, 2010 Spekulativ teoretisk model som ikke er testet empirisk (no hypothesis-driven studies). Ingen anbefaling mod kernesymptomer eller symptomclustre. NICE guidelines; Kendall, BJP 2010 Ingen definitive rekommendationer! Leichensering, Lancet, 2011 Behandling virker! Hvis du vil vide mere! Forløb af Borderline over 10 år: remission 6