心理动力学诊断与治疗：边缘型人格障碍
BORDERLINE PERSONALITY DISORDER边缘边缘型人格障碍型人格障碍DESCRIPTIVE VERSUS DYNAMIC对比描述性和动力性Hoch - Polatin, Grinker,Gunderson descriptive: refer to DSM霍克-波拉汀，格林科，冈德森 描述性：参考DSMKernberg dynamic: Ego weakness; low anxiety tolerance, impulsivity, no subliminatory channels 肯伯格 动力性： 自我脆弱性；低焦虑容忍度，冲动性，缺乏升华渠道Shift to primary process thinking 转向初级思考过程Defensive operations: splitting, primitive idealization, projective identification 防御操作：分裂、原始理想化、投射性认同 Pathological internal object relations all good/all bad 病理性的内化客体关系 全好/全坏SYMPTOMATOLOGY症状学Beginning with early adulthood :Pervasive instability: affects, self image, relations, impulsivity始于成人早期；广泛的不稳定性：情感、自我意象、关系、冲动性Fears of Abandonment 害怕被抛弃Idealization/devaluation 理想化/贬低Identity disturbance 认同障碍Impulsivity 冲动性Affect instability, anger, fights 情感不稳定、愤怒、争执Suicidal behavior/gestures 自杀行为/自杀姿态Emptiness 空虚Transient psychosis 暂时性的精神病DEMOGRAPHICS AND COURSE 人口学特征和病程General population : 0.7% 1.8 % 一般人群流行率：0.7% 1.8 % Clinical population: 15% - 25% 临床人群流行率： 15% - 25% Woman men 女性高于男性Most patients do well 大部分病人预后良好PSYCHODYNAMIC UNDERSTANDING精神动力学理解Early theories: Maternal overinvolvement versus neglect早期理论：母亲过度干涉对比母亲的忽视Contemporary theories 当代理论 Maternal relationship: conflicted, distant, uninvolved 母亲的关系：冲突、疏远、不参与 Fathers absence 父亲的缺失 Disturbed relationship with both parents 与父母双方的关系困扰Sexual abuse, childhood trauma 性虐待，儿童期创伤MENTALIZATION 心智化BPD associated with preoccupied or unresolved/disorganized subtypes of insecure attachment边缘型人格障碍与不安全依恋的先占或未解决/紊乱的亚型相关NEUROBIOLOGY神经生物学HPA axis 肾上腺轴Left amygdala activation; negatively interpret neutral faces左侧杏仁核活化；负面地解释中性面部表情Reading the facial expression 读取面部表情MRI: reduced hippocampus, amygdala volumes核磁共振成像：海马体、杏仁核体积减少Decreased left orbitofrontal volumes 左侧视额叶体积减少BPD HAS A MULTIFACTORIAL ETIOLOGY !边缘型人格障碍有多种病因！Traumatic home environment 创伤性家庭环境Biologically based vulnerable temperament 生物学基础的易感气质Triggering events 诱发事件PHARMACOTHERAPY COMBINED WITH PSYCOTHERAPY药物合并心理治疗BASIC PRINCIPLES OF PSYCHOTHERAPY心理治疗的基本原则Maintain flexibility 保持弹性Establish conditions that make therapy viable建立使治疗可行的情景Avoid passive stance 避免被动的立场Allow transformation into bad object 允许被转化为坏的客体Empathize with the pain that is under the anger 共情病人愤怒之下的痛苦Promote mentalization 促进心智化BASIC PRINCIPLES OF PSYCHOTHERAPY心理治疗的基本原则Set Limits when needed 在需要的时候设立限制Help the patient introject the projected aspects of self 帮助病人内摄自体被投射出去的部分Establish/maintain therapeutic alliance 建立/保持治疗联盟Countertransference feelings 反移情感受EFFECTIVE THERAPIES 有效的治疗方法 (BY RANDOMIZED TRIALS)（通过随机试验）Psychodynamic 精神动力学: MBT 基于心智化的治疗 TFP 以移情为焦点的心理治疗 DDP 动力解构疗法 GPM 一般精神科管理Other其他: DBT 辨证行为疗法 STEEPS SCHEMA-FOCUSED THERAPY 图式聚焦治疗
