第十一章 人格障碍与其治疗

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第十一章人格障 碍及其矫正

(personality disorders)

于丽琴

一、人格障碍概述(Personality Disorders: An Overview)

What is a personality disorder?

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maladaptive personality traits traits are relatively enduring features of a person that are persistent over time and situations people with personality disorders tend to be: rigid and inflexible, show a restricted range of traits, have a dominant single trait personality disorders are egosyntonic, more than egodystonic

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DSM-IV强调病人在认知、情感、人际关系和 冲动控制方面的偏离,指出这种偏离类型在 长时间内相当稳定,至少可以追溯到青少年 或早期成年时。

Personality Disorders: Facts and Statistics

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Prevalence of Personality Disorders

? About 0.5% to 2.5% of the general population

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6-9% (Kathleen ,1986)

? 0.13‰(我国,1986) ? Rates are higher in inpatient and outpatient settings。

prevalence higher among people with other mental disorders

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6-9% of population have one or more personality disorder most people with personality disorders never come to the attention of mental health professionals

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Origins and Course of Personality Disorders

? Thought to begin in childhood ? Run a chronic course ? Comorbidity rates are high

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Gender Distribution and Gender Bias

? Gender bias exists in diagnosis ? Criterion vs. assessment gender bias

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分类DSM-IV and DSM-IV-TR Personality Disorder Clusters

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DSM-IV将10种人格障碍划分为3大类群:

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A类群:行为古怪、奇异 Cluster A Odd or eccentric Examples include paranoid, schizoid

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B类群:戏剧化、情感强烈、不稳定 Cluster B

? Dramatic, emotional, erratic ? Examples include antisocial, borderline

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C类群:紧张、焦虑行为 Cluster C

? Fearful or anxious ? Examples include avoidant, obsessive-compulsive

人格障碍类型

cluster A

偏执型 分裂型 分裂样

cluster B

表演型 自恋型 反社会型 边缘型

cluster C

回避型 依赖性 强迫型

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PERSONALITY DISORDERS Historical perspective

Roots in psychoanalysis – narcissism, masochism, etc. ? Karl Abraham – first theorist to focus on personality disorders

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PERSONALITY DISORDERS Diagnostic issues

poor understanding of etiology of most personality disorders ? comorbidity and diagnostic overlap ? gender and cultural issues ? reliability of diagnosis

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PERSONALITY DISORDERS Etiology – Theoretical perspectives

Psychodynamic theory ? Attachment theory – particularly for dramatic, emotional, erratic ? Cognitive-behavioural perspectives ? Biological – particularly for odd, eccentric and dramatic, emotional, erratic

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(一)偏执型人格障碍(paranoid PD)

1、临床特征 2、形成原因 3、治疗

临床特征

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主要特征:猜疑、偏执

?表现为对他人持久的不信任,社会隔离,过分

警惕

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临床发现男性居多

0.5-2.5% of the population. ? o Men > Women. ? o Higher incidence in relatives of ? schizophrenics. ? o Higher among minorities, immigrants, ? and the deaf.

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Suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her. Is preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates. Is reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him or her. Reads hidden demeaning or threatening meanings into benign remarks or events.

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Persistently bears grudges, i.e., is unforgiving of insults, injuries, or slights. Perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack. Has recurrent suspicions, without justification,regarding fidelity of spouse or sexual partner. Does not occur exclusively during the course of a Psychotic Disorder and is not due to a general medical condition.

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形成原因

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生物学原因

? 在精神分裂症患者亲属中较多

心理分析

? 偏执来自无意识中强烈的仇恨和敌意的外向投射

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认知的观点

?与歪曲的认知或想法有关

文化因素

? 特殊人群,如犯人、难民、有听力障碍的人等易形成这

种人格障碍

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治疗

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建立信任关系非常重要 心理动力学治疗 认知治疗 Acknowledge mistakes. Be open and honest. Have a professional and not overly warm style. Don‘t confront Set limits. Clearly explain procedures, medications and results.

summary: Paranoid Personality Disorder

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Overview and Clinical Features

? Pervasive and unjustified mistrust and suspicion

The Causes

? Biological and psychological contributions are unclear ? Early learning that the world is a dangerous place

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Treatment Options

? Few seek professional help on their own ? Treatment focuses on development of trust ? Cognitive therapy to counter negativistic thinking ? Lack good outcome studies

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(二)分裂样人格障碍(Schizoid PD)

1、临床特征 2、形成原因 3、治疗

临床特征

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特征:社会隔绝、情感疏远

表现为孤单、冷淡的沉默,不介入日常事务,不交际,不关心他人。

将 精力投注于非人类的事物(如数学)

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患病率

? 美、德等国采用PDQ(人格障碍诊断问卷)、SCID等得

到的患病率为0.7-1.6%

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男性多见 7.5% of the population. o A 2-to-1 male-to-female ratio.

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Neither desires nor enjoys close relationships, including being part of a family. Almost always chooses solitary activities. Has little, if any, interest in having sexual experiences with another person. Takes pleasure in few, if any, activities. Lacks close friends or confidants other than first-degree relatives.

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Appears indifferent to the praise and criticism of others. ? Shows emotional coldness, detachment, or flattened affectivity. ? Does not occur exclusively during the course of a Psychotic Disorder, or a Pervasive Developmental Disorder and is not due to a general medical condition.

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形成原因

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生物学

?可能有与孤独症类似的生理机能缺陷

心理动力学

?基本的接触需要没有获得满足

? 认知治疗

?不能有效的关注周围的情况来获得准确的感知

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社会心理

?在早期学习、人际交往中形成问题

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治疗

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心理治疗

?发展对社会关系的兴趣,认识社会关系的价值 ?社交技能训练

Understand their need for isolation. Minimize new contacts and intrusions Maintain a quiet, reassuring, and considerate interest in them. Don’t insist on reciprocal responses

(三)分裂型人格障碍(schizotype)

1、临床特征 2、形成原因 3、治疗

临床特征

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特征

? 社会隔绝、情感疏远、古怪行为、多疑

表现为认识或感知方面的歪曲以及古怪的行为

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患病率

? 可能高于精神分裂症和其他人格障碍 ? 3% of the population. ? Sex ratio is unknown. ? Greater association among biological relatives of

schizophrenic patients. ? The premorbid personality of the schizophrenic patient.

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Ideas of reference (excluding delusions of reference). ? Odd beliefs or magical thinking that influences behavior and is inconsistent with subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or the sixth sense!± ? Unusual perceptual experiences, including bodily illusions. ? Odd thinking and speech (e.g.vague,circumstantial, metaphorical, overelaborate, or stereotyped). ? Suspiciousness or paranoid ideation.

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Inappropriate or constricted affect. Behavior or appearance that is odd, eccentric. Or peculiar Lack of close friends or confidants other than first-degree relatives. Excessive social anxiety that does not diminish with familiarity and tends to be associated with paranoid fears rather than negative judgments about self. Does not occur exclusively during the course of a Psychotic Disorder or a Pervasive Developmental Disorder.

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形成原因

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生物学的解释

?精神分裂症亲属中有较高的此型患病率

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治疗

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心理治疗:

? 社交技能训练

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帮助其与人交往,减少对他人的不信任感

药物治疗:治疗精神分裂症的药物可使其症状有中等程度的改善 ? o Similar to Schizoid PD. ? o Misperceptions of physical symptoms and treatment. ? o Do not ridicule or judge. ? o Respect their need for privacy.

(四)表演型人格障碍(Histrionic PD)

1、临床特征 2、形成原因 3、治疗

临床特征

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又称癔症型、寻求注意型、或心理幼稚型 特征

? 人格不成熟、情绪不稳定 ? 表现:需要情爱和注意、依赖性、作弄他人的倾向

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患病率

? 美、德等国采用PDQ、SCID等临床调查表、定式检核表等工具得到的为 1.3

-3.0% ? 女性2倍于男性

2-3%. Diagnosed more frequently in women than in men. Associated with Somatization Disorder and Alcohol Abuse/Dependence.

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Is uncomfortable in situations in which he or she is not the center of attention. Interaction with others is often characterized by inappropriate sexually seductive or provocative behavior. Displays rapidly shifting and shallow expression of emotions. Consistently uses physical appearance to draw attention to self.

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Has a style of speech that is excessively impressionistic and lacking in detail. Shows self-dramatization, theatricality, and exaggerated expression. Is suggestible, i.e., easily influenced by others or circumstances. Considers relationships to be more intimate that they actually are.

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形成原因

对其原因或治疗的研究少 ? 心理分析理论

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? 作为对内心低自尊感的一种反抗,病人总是试图成为他

人的注意中心。

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治疗

对人际关系治疗 ? 奖励与惩罚结合 ? Similar to Borderline PD. ? o Medical illnesses threaten their sense of attractiveness and self-image.

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(五)自恋型人格障碍(Narcissistic PD)

1、临床特征 2、形成原因 3、治疗

临床特征

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特征

? 妄自尊大观念 ? 表现:自我中心,夸大(幻想或行为),需要他人赞

扬 患病率 ? 美、德等国:0-0.4% ? 2-16% in the clinical population. ? 1% in the general population. ? Number of cases increasing steadily.

形成原因

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心理分析

?家长对其子女不爱和不接受的行为方式

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行为和认知模型

?过分积极的赞赏或宠爱

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社会影响因素

?及时行乐、个人主义、竞争和成功等观念影响

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Has a grandiose sense of self-importance (e.g.,exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements). Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love. Believes that he or she is !°special!± and unique can only be understood by, or should associate with, other special or high-status people (or institutions). Requires excessive admiration.

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Has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations. Is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends. Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others. Is often envious of others or believes that others are envious of him or her. Shows arrogant, haughty behavior or attitudes.

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治疗

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对治疗的研究非常有限 心理治疗主要集中于其被扭曲的自我 (自我夸大 感),对评价的病态的敏感等方面 Handle criticism poorly. Become easily enraged. Medical illnesses can be a blow to their selfesteem. Reinforce that they are respected and appreciated. Set limits on demanding behavior.

(六)反社会型人格障碍(Antisocial PD)

1、临床特征 2、形成原因 3、治疗

临床特征

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特征 ? 经常发生违反社会规范的行为 ? 表现:工作不良,婚姻不良,酒精与药物滥用,情感肤浅、无情、 自我中心,不诚实、欺骗、作弄他人,冲动性、攻击性及法律问题 等 患病率 ? Vaillant & Perry (1985) 在0.05-15% 之间 ? 男性多于女性 ? 3% in men and 1% in women. ? Most common in poor urban areas. ? 75% in prison populations. ? Familial pattern present.

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Failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest. Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure. Impulsivity or failure to plan ahead. Irritability and aggressiveness, as indicated by repeated physical fights or assaults. Reckless disregard for safety of self or others.

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Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations. Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another. The individual is at least age 18 years, and there is evidence of Conduct Disorder with onset before age 15 years. The occurrence of antisocial behavior is not exclusively during the course of Schizophrenia or a Manic Episode.

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形成原因

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生物学因素

遗传、神经生物学的假说

社会心理学

? 家庭与社会环境的影响,缺乏情感和父母粗暴拒绝

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心理分析

? 超我发展不完善

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认知心理学

? 在道德原则和推理能力上的发展滞后

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治疗

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传统的心理治疗和医学治疗均无显著的效果 行为治疗

? 学习对问题情境作新的反应

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认知治疗

? 提高其认知能力,改善社会和道德行为 ? Set firm limits. ? Try not to be manipulated. ? Have high level of skepticism. ? Be careful not to prescribe excessive and/or

unnecessary medications.

边缘型人格障碍(Borderline PD)

1、临床特征 2、形成原因 3、治疗

临床特征

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特征

? 人际关系、自我形象和情感的不稳定 ? 表现:人际关系不良,不能耐受孤独,常感孤单和空虚,

易抑郁,情绪不稳定,行为具冲动性,易发生自伤、自 杀行为,存在自我认同障碍

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患病率

?美、德等国:0.2-4.6% ?女性多于男性

1-2% of the population. ? o Twice as common in women as in men. ? o Increased prevalence of Major Depressive Disorder, Alcohol Abuse/Dependence, and Substance Abuse found in first-degree relatives.

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Frantic efforts to avoid real or imagined abandonment. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation. Identity disturbance: markedly and persistently unstable self-image or sense of self. Impulsivity in at least two areas that are potentially selfdamaging (e.g., spending, sex,substance abuse, reckless driving, binge eating). Chronic feelings of emptiness.

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Recurrent suicidal behavior, gestures, or threats, or selfmutilating behavior. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days). Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger,recurrent physical fights). Transient, stress-related paranoid ideation or severe dissociative symptoms.

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形成原因

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生物学的解释

神经系统或脑内生物化学方面的异常

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心理动力学的解释

? 父母对子女的不接纳

社会心理学

? 对被遗弃的恐惧 ? 早期创伤,包括身体、性虐待

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治疗

治疗非常困难 ? 认知行为治疗 ? 心理动力学治疗 ? 集体治疗

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?与若干个人形成较亲密的依恋关系

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药物治疗

?可减缓其冲动性,减轻抑郁等

o Be aware of and anticipate defenses. ? o Often regress. ? o Open and continuous communication with ? staff. ? o Stable and calm reaction. ? o Gently confront. ? o Set fair and consistent limits on acting out.

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(七)回避型人格障碍(Avoidant PD)

1、临床特征 2、形成原因 3、治疗

临床特征

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特征

?长期和全面地脱离社会关系

? 表现:对人回避、退缩,过分敏感,焦虑,对自我价值

缺乏信心

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患病率

?美、德等国:0.4-1.6% ?女性多于男性

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Infants with a timid temperament may be more likely to develop Avoidant PD.

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Avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection. ? Is unwilling to get involved with people unless certain of being liked. ? Shows restraint within intimate relationships because of the fear of being shamed or ridiculed.

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Is preoccupied with being criticized or rejected in social situations. Is inhibited in new interpersonal situations because of feelings of inadequacy. Views self as socially inept, personally unappealing, or inferior to others. Is unusually reluctant to take personal risks or to engage in any new activities because they may prove embarrassing.

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形成原因

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生物学的解释

?生物化学方面的异常、易患病的基因

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认知行为模型的解释

?习得性恐惧、不安的思维方式

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社会心理学的解释

?羞耻感,与童年时期经历有关

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治疗

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支持和共情非常重要 心理动力学

? 揭示其症状的根源,使自我强壮起来

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认知行为治疗

? 认知重建、社交技能训练和暴露疗法

集体治疗

? 结合使用暴露疗法、角色扮演法等

药物治疗

? 降低焦虑

Have patience and understanding. ? o Medical illnesses may be embarrassing. ? o Minimize new and unfamiliar staff contacts. ? o Respond with a calm and reassuring demeanor. ? o Do not criticize them.

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(八)依赖性人格障碍(Dependent PD)

1、临床特征 2、形成原因 3、治疗

临床特征

又称不适当型(inadequate) ? 特征

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?缺乏自信、依附他人 ?表现:轻微应激即退却,寻求帮助,需要保护,

性关系不成熟,往往存在婚姻问题,缺乏亲密朋 友

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患病率

?美、德等国:0.3-6.7%

o More common in women than men. ? o Children with chronic physical illnesses may be more prone.

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Has difficulty making everyday decisions without an excessive amount of advice and reassurance from others. Needs others to assume responsibility for most major areas of his or her life. Has difficulty expressing disagreement with others because of fear of loss of support or approval. Has difficulty initiating projects or doing things on his or her own (because of a lack of self- confidence in judgment or abilities rather than a lack of motivation or energy).

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Goes to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant. ? Feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for himself or herself. ? Urgently seeks another relationship as a source of care and support when a close relationship ends. ? Is unrealistically preoccupied with fears of being left to take care of himself or herself.

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形成原因

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社会心理学

?父母出于爱或独裁的目的过分保护孩子

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认知理论

?适应不良信念

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治疗

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行为和认知疗法

?认知重建、自信训练

人本主义治疗 ? 集体治疗

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Respect their feelings of attachment. ? o Be careful when encouraging a patient to change the dynamics of an abusive relationship. ? o When medically ill they may become frustrated that they are not being helped. ? o Be active in the treatment planning.

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(九)强迫型人格障碍(ObsessiveCompulsive PD)

1、临床特征 2、形成原因 3、治疗

临床特征

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特征

?情绪限制,秩序性、坚持执拗、完美

? 表现:秩序性、固执、僵硬、异常节俭、谨小慎微、爱

整洁、犹豫不决、严肃沉闷等

美、德等国:1.7-6.4% ? 男性多于女性

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More common in men than in women. ? Diagnosed more in oldest children. ? Often a history of harsh discipline as a child.

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Is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost. Shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overtly strict standards are not met). Is excessively devoted to work and productivity to the exclusion of leisure activities and friendships. Is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values.

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Is unable to discard worn-out or worthless objects even when they have no sentimental value. ? Is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things. ? Adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes. ? Shows rigidity and stubborness.

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Give precise and rational explanations. Value efficiency and punctuality. Medical illnesses create a disruption in the patient’s work, orderly lifestyle, and sense of control. Acknowledge the importance of work, but point out how avoiding treatment may have harmful consequences.

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形成原因

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心理动力学

? 对父母的控制加以反抗;或早期父母过分严格的管教

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认知治疗

? 歪曲的思维方式所致

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治疗

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心理动力学方法

?清楚地认识、体验和接受真实情感

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认知行为治疗

?纠正极端化的想法、完美主义、犹豫不决和做事

拖延的问题

Allow the patient to control his or her care as much as possible. ? Provide them with information. ? Avoid power struggles. ? Understand their need for order and control.

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Personality Disorder Not Otherwise Specified

Passive-Aggressive Personality Disorder. ? Depressive Personality Disorder. ? Specific traits or behaviors (sadism or masochism). ? Patient with features of more than one Personality Disorder.

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推荐影视

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说谎游戏(Deceiver)

?反社会型人格障碍

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怒焰狂花(Child of Rage)

?反社会型人格障碍

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分析(Analyze This)

?反社会型人格障碍

推荐影视

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骄阳似我(Good Will Hunting)

?边缘型人格障碍

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少女初体验(Prozac Nation)

?边缘型人格障碍

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被禁锢的女孩(Girl Interrupted)

?边缘型人格障碍


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