Psychopathologie und Behandlung der Borderline-Persönlichkeitsstörung

Zusammenfassung Das Wissen über Psychopathologie, Ätiopathogenese und Behandlungsmöglichkeiten der Borderline-Persönlichkeitsstörung (BPS) hat sich in den letzten Jahren deutlich verbessert. Heute sehen die meisten Wissenschaftler eine generalisierte Störung der Affektregulation im Zentrum der BPS, deren Ursachen in Wechselwirkungen zwischen genetischen Faktoren, traumatischen biographischen Erfahrungen und dysfunktionalen Verhaltensmustern liegen. Störungsspezifische Therapieverfahren, insbesondere die Dialektisch Behaviorale Therapie (DBT) nach Linehan, flankiert von psychopharmakologischer Behandlung, zeigen gute Behandlungsergebnisse sowohl im stationären als auch im ambulanten Bereich. In jüngster Zeit wurden viel versprechende Konzepte zur Behandlung schwerer komorbider Störungen [Alkohol und Drogenabhängigkeit, Posttraumatische Belastungsstörung (PTBS)] entwickelt.     

Persönlichkeitsstörung und Intelligenzminderung

There have previously been only few objective investigations on the combined occurrence of intellectual disability and personality disorder. Despite this difficulty, from the current clinical viewpoint there is no doubt that at least people with mild intellectual disability can also develop personality disorders. In slight degrees of intellectual disability it is possible to psychopathologically describe the typical symptoms objectively. For the disorder symptomatic of combined personality disorder in people with an intellectual disability, there are no confirmed facts, publications or diagnostic rules. The diagnostic assignment of behavioral abnormalites as combined personality disorder with dependent and infantile components in people with intellectual diasabilities still does not seem to be justified. In people with medium to severe mental disorders only the comprehensive term “behavioral abnormalities” should be applied.     

Aufmerksamkeitsdefizit-/Hyperaktivitätsstörung (ADHS) im Jugendalter

Attention deficit–hyperactivity disorder (ADHD) in children and adolescents is a common and severe psychiatric disorder with a prevalence between 2 and 6%. In a high percentage of cases, there is a positive family history. In almost all sufferers, persistent functional limitations that impact everyday life are observed. The prognosis for untreated ADHD is very poor, being associated with social decline, drug addiction, and delinquency. Diagnosis is complex. Typical symptoms are often “hidden”. They are age specific and are mainly associated with inattention, impulsiveness associated with aggression and delinquency, and dangerous risk-taking behavior. More than half of patients also have additional comorbid disorders. The treatment concept always includes nonpharmacological interventions, which are often supplemented with drugs.     

Psychopathie,antisoziale Persönlichkeitsstörung und Sexualdelinquenz

In today’s field of forensic psychiatry, psychopathy is seen as a subtype of antisocial personality disorder and includes manipulative behavior, egocentric and arrogant characteristics, high-risk behavior as well as a lack of empathy. Empirical data on the prevalence of psychopathy and antisocial personality disorder among offenders greatly vary depending on the study design and the composition of the sampled population. Offenders who committed both violent and sex offenses seem to have antisocial traits with a higher probability than offenders who committed only violent or only sex offenses. In the context of criminal responsibility and risk assessment for sex offenders, antisocial and psychopathic traits have a negative impact on the prediction of recidivism. Many study results, even though not all, additionally indicate that the combination of psychopathic traits and sexual deviance (i.?e. for example a paraphilic disorder such as sexual sadism) in sex offenders may be associated with a particularly high risk to reoffend. Due to the specific interpersonal characteristics (e.?g., dominant, provocative behavior, exaggerated self-esteem), therapeutic treatment of sex offenders with antisocial and psychopathic traits is often difficult. The regular supervision by the therapist is considered to be crucial to avoid harmful relationship dynamics or distorted perception of the therapist.     

Die Behandlung von Borderline-Persönlichkeitsstörungen

Zusammenfassung Bereits 1681 beklagte sich ein englischer Arzt in einem Brief über Patienten, die ohne jedes Ma? jene lieben, die sie alsbald ohne jeden Grund hassen würden. Weiterhin seien pl?tzliche Ausbrüche von Wut, Schmerz, Angst oder ?hnlichen Emotionen zu beobachten. Mit dieser frühen Beschreibung typischer Borderline-Symptome wird die Darstellung der Entwicklung der Theorie der Borderline-St?rung von den Anf?ngen bis heute eingeleitet. Vor diesem Hintergrund werden der Stand der Diagnostik und die derzeit wichtigen Behandlungskonzepte umrissen, und zwar die psychodynamischen, verhaltenstherapeutischen und klientenzentrierten Ans?tze. Es wird dargelegt, welche Antworten es auf die Frage gibt, was das angemessene therapeutische Setting ist, insbesondere mit Blick auf station?re Behandlungskonzepte. Die vorliegenden empirischen Studien best?tigen die Wirksamkeit von Psychotherapie bei Borderline-St?rungen. Die geringe Zahl der Studien belegt aber auch die Schwierigkeit der empirischen Forschung in diesem Bereich. Der abschlie?ende Ausblick in die Zukunft der Psychotherapie der Borderline-Pers?nlichkeitsst?rungen prognostiziert eine weitere Zunahme von Pers?nlichkeitsst?rungen im Spektrum psychiatrischer Erkrankungen und eine zunehmende Differenzierung des Behandlungsangebots bzw. Spezialisierung der Behandler.      

Narzisstische Persönlichkeitsstörung

Narcissism is a multifaceted term which encompasses traits of normal personality as well as a specific personality disorder. While much research has been concerned with narcissism as a trait there are only few empirical studies on narcissistic personality disorder (NPS). The current diagnostic system of NPS according to DSM-5 (section II) focuses on grandiose narcissism whereas vulnerable narcissism, which is emphasized by clinicians and researchers, has not yet been recognized. While treating NPD patients an increased suicide risk has to be taken into consideration. Psychotherapy of narcissistic patients mainly focuses on processes during patient-therapist interactions, the analysis and processing of grandiose and vulnerable schemas, emotion regulation techniques and a correction of narcissistic behavior in favor of prosocial interactions.     

Identit?t, Identit?tsdiffusion, Identit?tsst?rung

Identity takes place in the transitional space between the individual and society. It means that the individual has the feeling to be a unique being with past and future, to be different from others but also to be similar to them in many aspects and share a great deal with them. This sense of coherence and continuity in the context of social relatedness shapes life. A differentiation is made between primary identity, personal identity and current identity. The development is essentially determined by preverbal interpersonal processes. If the balance which sustains the feeling of identity becomes lost then disturbances of the identity occur, which compromise the sense of identity especially in social contexts. An identity diffusion arises. Depending on the fixation, a differentiation is made between phase-specific identity crisis, developmental disorder and reactive identity disturbance.     

Psychodynamische Kurzzeittherapie bei dependenter und vermeidender Persönlichkeitsstörung

Although dependent and avoidant personality disorders are frequent in patient populations, there are only few studies in which the efficacy of psychotherapeutic interventions for these two personality disorders was reviewed. The purpose of this study was to examine whether psychodynamic short-term therapy based on the model of the cyclic maladaptive pattern (CMP) is effective for reducing the mental impairment of patients diagnosed with a dependent or an avoidant personality disorder. Data were collected via a self-report scale (Symptom-Checklist, SCL) and expert ratings by therapists [Global Assessment of Functioning (GAF) Scale and Severity of Impairment-Score (Beeinträchtigungsschwere-Score, BSS)]. In the study 20 patients received 25 sessions of outpatient therapy. Mental impairment decreased significantly from the beginning to the end of the therapy; moreover this decrease remained stable over a 2-year period following completion of the therapy. The findings show that psychodynamic short-term therapy can lead to an enduring improvement in the mental health of patients with a dependent or an avoidant personality disorder.     

Diagnostik und Therapie Dissoziativer (Identitäts-) Störungen

In North America, dissociative disorders have gained a central position in psychiatric research of the last 20 years. Their most severe form, the dissociative identity disorder has been explored with utmost thoroughness. The dissociative identity disorder seems to be a complex posttraumatic disorder with a central etiological role of sexual traumatizations in early childhood. Critics, however, expressed their doubts about the validity of the posttraumatic model and the psychiatric diagnosis itself. They assume it to be a matter of the cultural and suggestive impact of the media and of improper psychotherapy. In the present article evidence is provided about the arguments of the socio-cognitive model being scientifically unsubstantiated. A bulk of empirical results supports the assumption that dissociative identity disorder and similar diseases regularly occur both in North America and Europe, but they are rather rarely diagnosed. Therefore, it seemes both to make sense and be necessary to develop diagnostic and treatment programs for dissociative identity disorders and to promote their implementation.     

Dissoziative Störungen (Konversionsstörungen)

The ICD-10 diagnostic category of dissociative disorders encompasses very different clinical pictures. The so called dissociative disorders of consciousness are characterized by functional disturbances to the psychic domains of consciousness, identity, autobiographic memory and experience of self and the world. The core features of conversion disorders are functional alterations in the sensorimotor systems. The phenomenological heterogeneity is reflected by prevalence rates ranging from very rare to 30% in clinical populations. Traumatic experiences play a crucial role in the etiology and pathogenesis of these disorders. High rates of comorbid disorders, a tendency to a chronic course and a somatic illness concept in patients with conversion disorders complicate the psychotherapeutic approach. Depending on the therapeutic goals, both psychodynamic and cognitive-behavioral treatment forms are suitable.     

Psychotherapeutischer Prozess und Persönlichkeitsstörungen

This paper begins with a cursory overview of psychotherapy outcome research for personality disorders; however, relatively little is known about process research or process outcome relationships. It then focuses on relevant patient and therapist variables. Significant controversies in personality disorder treatment techniques are examined. Initially, studies generally associated transference interpretation with less favorable therapy outcomes. Recent work supports the possibility of differentiated correlations. There is increasing evidence that a moderate amount of transference interpretation and perhaps even a therapeutic alliance that is not so good, maybe indicative of an inner conflict with the therapist relationship, could ultimately be beneficial. This association most probably does not exist in cluster C personality disorders. A problem with this type of research is that clear definitions are often lacking. This complicates comparisons between studies and the influence of other mediating variables remains vague.     

Die Antisoziale Persönlichkeitsstörung des DSM-IV-TR - Befunde, Untergruppen und Unterschiede zu Psychopathy

The diagnosis of Antisocial Personality Disorder (ASPD) is based on robust scientific evidence identifying a group of individuals who display antisocial behaviour from a very young age that remains stable across the life-span. This population of persons with ASPD is heterogeneous, composed of distinct sub-types defined by comorbid disorders. Evidence indicates that ASPD is distinct from both psychopathy, as defined by the PCL-R, and from Dissocial Personality Disorder, as defined by ICD-10. Studies of the prevalence of ASPD are reviewed, highlighting the difficulties inherent in designing and conducting investigations of community samples that derive accurate estimates. The few studies of the socio-demographic correlates of ASPD are presented followed by a review of the evidence on disorders that are comorbid with ASPD. Finally, a hypothesis is presented for orienting future research on the aetiology of ASPD and the development of effective programmes for reducing violence among persons with ASPD.     

Multimodale Psychotherapie der dissozialen Persönlichkeitsstörung: aktuelle Konzepte in der Straftäterbehandlung

The frequent equalization of antisocial personality disorder with habitual criminality has led to the fact that therapeutic pessimism still pervades and many psychotherapists are reluctant to treat patients with antisocial personality disorder because of widespread belief that such patients are frequently untreatable. There is increasing evidence, however, that antisocial personality disorders can absolutely be successfully treated. Meta-analyzes have shown that successful treatment programs are modularized and thus highly structured thematically according to therapy priorities. Furthermore, therapy optimism of therapists could be repeatedly demonstrated as an additional factor, which at the same time implies significant positive effects on a favorable therapist-patient relationship. In this article the most important research results from recent studies are summarized and discussed. Treatment planning in detail is then discussed, based on thorough assessment of the individual’s personality characteristics to determine prognosis, risk management, and appropriate treatment.     

Alkoholismus und Selbstzerstörung

First, the development of addiction theory in psychoanalysis is recapitulated on the basis of the works of W.D. Rost and A. Heigl-Evers. For the understanding of alcoholism two concepts are fundamental. The ego-psychological concept postulates addiction as an attempt of a weak ego to help itself, while the object-psychological concept of Rost considers some forms of alcoholism as an expression of unconscious self-destruction.The author of the present article examines on the basis of a case study of autodestructive alcoholism the strength and weak points of the approach of Rost and proposes certain expansions of the model regarding first the object relations of the addict and the counter-transference, where a strong entanglement of the therapist with the destructivity of the patient is obvious. In addition, further considerations about the role of the superego are necessary, which faces the ego with hostility. Finally, the nature of the primary object of the addict person and the nature of the substance as transferential object should be examined. In the case of these inner objects there is a strange mixture of positive and negative aspects having in their consequence a great destructive potential for the person. This constellation bears resemblance to the pathological personality organisation as understood in Kleinian literature.     

Die Bedeutung der Aufmerksamkeitsdefizit-/Hyperaktivitätsstörung für die Entstehung und Prognose von Störungen des Sozialverhaltens im Kindes- und Jugendalter

Attention Deficit/Hyperactivity Disorder (ADHD) and Conduct Disorder (CD) are two of the most common neurobehavioral disorders of childhood. Despite of their high comorbidity rate both disorders can be reliably differentiated. Especially the comorbid condition is associated with a poor outcome and some of the affected children develop an Antisocial Personality Disorder. This article summarizes diagnostic criteria and epidemiological data of both disorders and emphasises the role of ADHD in the aetiology and pathogenesis of antisocial behavior. ADHD seems to have a negative impact particular in children of the early-starter subtype of CD. Findings from genetic, psychophysiological and neuroimaging studies emphasise the relevance of biological risk factors in the etiological models and developmental pathways of antisocial behavior. We present so far unpublished data of children with ADHD and ADHD/disruptive behavior disorders which indicate group-specific neurocognitive impairments in the comorbid condition. ADHD and CD seem to constitute a synergistic and interactive relationship in that each disorder aggravates the other. Recent findings point to a “true hybrid” of ADHD/CD. Considering the negative outcome of the comorbid condition, several findings suggest that high-quality treatments may have considerable impact on restoring ADHD children to better functioning.