Using Theory & Clinical Observation to Generate … · Borderline personality disorder ... Socially...
Transcript of Using Theory & Clinical Observation to Generate … · Borderline personality disorder ... Socially...
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Using Theory & Clinical Observation to Generate Testable Hypotheses
A New Perspective on Personality Disorders
Patricia M. Crittenden, Ph.D.
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I. THEORYDynamic-Maturational Modelof Attachment & Adaptation
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Central unique feature of the DMM
The organizing function of exposure to danger to:
• Regulate attention
• Organize the mind
• Organize behaviour
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The DMM as a comprehensive theory of development & adaptation
From Bowlby Psychoanalytic General systems theory Evolutionary biology Cognitive information processing Cognitive neurosciences On-going integration of theories
From Ainsworth Naturalistic observation The Strange Situation as a
standardized assessment The ABC patterns of
attachment Empirical grounding of
attachment theory On-going expansion of the model
DMM additions Epigenetics Neurobiology Temperament Sociobiology Developmental psychology Behavioral learning theory Piaget cognitive development Eriksonian development Social learning theory Theory of mind Cognitive psychology (Behavioral, Constructivist)
Vygotsky – ZPD Transactional theory Family systems theory Vygotsky/Bronfenbrenner:
Social ecology
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Biology
Context
Relationships
Psychology
Neurology
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DMM understanding of behavior as a complex interactive process
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Two sources of information1
COGNITION Temporal order → causal attributions Learning theory & contingencies
AFFECT Intensity → arousal Anger, fear, desire for comfort Fight, flight, or freeze
1 Genetic & epigenetic information constitute internal sources of information.
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Cognitive information Inhibit that which leads predictably to
punitive consequences (danger) Doing what you want Showing negative affect (anger, fear, desire
for comfort)
Exhibit that which leads predictably to desirable consequences (safety) Doing what adults want Showing positive affect
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Affect Arousal, i.e., changed body state
(feelings), motivates action Comfort → continuing activity
Anger → approach with aggression
Fear → escape
Desire for comfort → affectionate approach
Tiredness → no action
Sadness → no action
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Intensity, Arousal, & Affect
Death Mania & Pain Fear Anger Desire for comfort Alert & comfortable Bored Tired Sleep Depressed Unconscious Death
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Intensity, Arousal, & Affect:Normative
Anger Desire for comfort Alert & comfortable Bored Tired
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Intensity, Arousal, & Affect:Severe Pathology
Mania & Pain Fear
Sleep Depressed Unconscious
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Two Basic DMM Self-protective Strategies
Type A: Very COGNITIVE; little affect
Type C: Little cognition; intense AFFECT
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DMM Strategies in Adulthood
Compulsively Caregiving/Compliant
Delusional Idealization/
ExternallyAssembled
Self
Compulsively Promiscuous/Self-Reliant
Socially Facile/Inhibited
ComfortableB3
ReservedB1-2 B4-5
Reactive
A1-2
A3-4
A7-8
A5-6
C7-8
C5-6
C3-4
C1-2Threatening/
Disarming
Aggressive/Feigned Helpless
Punitive/Seductive
Menacing/ParanoidAC
Psychopathy
A/C
True Cognition True Negative Affect
False Positive Affect False Cognition
Integrated Transformed Information
Integrated True Information
Delusional Cognition Delusional Affect
Denied Negative Affect Denied True Cognition
Distorted Cognition & Omitted Negative Affect
Distorted Negative Affect& Omitted Cognition
Compulsively Caregiving/Compliant
Delusional Idealization/
ExternallyAssembled
Self
Compulsively Promiscuous/Self-Reliant
Socially Facile/Inhibited
ComfortableB3
ReservedB1-2 B4-5
Reactive
A1-2
A3-4
A7-8
A5-6
C7-8
C5-6
C3-4
C1-2Threatening/
Disarming
Aggressive/Feigned Helpless
Punitive/Seductive
Menacing/ParanoidAC
Psychopathy
A/C
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Types A & C are psychological opposites
Type A: Reduce limbic arousal, increase repetition of sensorimotor sequences
Type C: Increase limbic arousal, create unpredicted consequences
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Strathearn, et al. DMM-AAI & fMRI data Strathearn, L., Fonagy, P., Amico, J.A., &
Montague, P.R. (2009). Adult attachment predicts mother's brain and peripheral oxytocin response to infant cues. Neuropsychopharmacology, 34, 2655-66.
Shah, P. E., Fonagy, P. & Strathearn, L. (2010). Exploring the mechanism of intergenerational transmission of attachment: The plot thickens. Clinical Child Psychology and Psychiatry, 15, 329-346.
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Mothers’ brain responses to own vs. unknown baby: Prefrontal cortex
Type A Type B
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Maternal Brain Response to Own Baby’s Crying Face
-0.8
-0.6
-0.4
-0.2
0
0.2
0.4
0.6
0.8
1%
BO
LD s
igna
l cha
nge
R Nuc Acc L LingualGyrus
L Inf FrontalGyrus
R Insula R MiddleFrontalGyrus
L PostcentralGyrus
Secure Dismissing
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Types A & C behave differently when faced with danger Type A:
Inhibits feelings Does what others want Blames self Feels shame Sometimes explodes with anger or fear Has no explanation for explosive behaviour
Type C: Exaggerates anger and fear Behaves vengefully and deceptively Blames others Considers the self innocent Offers elaborate false reasoning
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II. Clinical ObservationFrom uncertainty to irrationality
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Type C1
Eliciting conditions: Unpredictable, intermittent positive reinforcement of negative affect
Cognition: Inability to predict effects
Affect: High, alarming arousal
Strategy: Intensify affective display to:
Attract attention
Elicit a response that can be shaped behaviourally
1 The Type C strategy is too complex & variable to be fully articulated here.
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C1-2: Threatening/Disarming Condition:
Little or no danger, Lack of comfort, Unpredictable attention.
Strategic behaviour: Heightened signals of feelings to elicit response.
Unresolved problem: set aside and go on, with repetition.
Outcome: Problem is not put in words and resolved.
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C3-4: Aggressive/Helpless Condition:
Over-solicitous parent who fails to perceive child’s need for limits and protection.
Under-responsive parent who struggles over who will be the object of attention, i.e., the ‘child.’
Strategic behaviour: Provocative behaviour & risk-taking Pseudo-resolution through deception of the child.
Irresolvable problem that defines the relationship.
Outcome: child uses extreme behaviour to bring parent toward the norm.
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C5-6: Punitive/Seductive Condition:
Feeling of being misunderstood; Lack of predictive generalizations.
Strategic behaviour: Dangerous behaviour Intense battle for recognition. Dismissal of others’ perspectives/feelings.
Problem-solving: Self-deception Deception of others Avoidance of talk; non-verbal communication Rationalizing use of language.
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Depression in Type A (depressed)
Affect: Low arousal, non-motivating affect
Cognition: Low expectation that one’s behavior will have any effect( i.e., non-contingency between self & outcomes)
Absence of strategic behavior of either an inhibitory or arousing sort.
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Depression in Type C (agitated)
Affect: Chronic high negative arousal, not tied to changes in circumstances
Cognition: Low expectation that one’s behavior will have a predictable and desired effect( i.e., lack of predictability).
Active withdrawal or aggressive behaviour in anticipation of frustration.
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Unresolved trauma Commonly acknowledged to ‘cause’ an
array of disorders.
Evidence of trauma is sought by both patients and professionals to explain the symptomatic behaviour.
Such evidence is generally lacking in the personality disorders (excluding borderline and anti-social personality disorder)
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Three sets of AAI data
Eating disorders (N=66)
Avoidant personality disorder (N=18)
Borderline personality disorder (N=15)
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Adult Attachment Interview (AAI) 1 hour, semi-structured, about childhood
relationships, particularly threat
Discourse analysis (not content)
Yield: Strategy Current psychological trauma Overall states of mind like depression
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DMM & Eating Disorders1. Very short AAIs
2. Wordless, silent, lack of recall, ‘sorry’, very awkward for interviewer
3. No evidence of psychological trauma
4. Inexplicable behaviour/strategy
5. Mother’s AAI clarified the nature of the unspeakable problem.
Ringer, F. & Crittenden, P. (2006). Eating disorders & attachment: Effects of hidden processes on eating disorders. European Eating Disorders Review. 14, 1-12.
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DMM & Eating Disorders1. Utr(i) C3-4(5-6) Δ
2. Utr(i) C5-6 & [A]/C5-6 Δ (most)
3. Utr(i) A3-4 Δ (fewest)
4. Wordless triangulation around family secrets
Ringer, F. & Crittenden, P. (2006). Eating disorders & attachment: Effects of hidden processes on eating disorders. European Eating Disorders Review. 14, 1-12.
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Family secrets Secrets
Parental discord (triangulation) Parents’ psychological trauma Parental sexual behaviour (adultery, paternity)
Parent intention to protect child
Effects in childhood Unpredictable parent behaviour Breaches in interaction.
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Effect on adolescent/adult behaviour (EDs) Individuals had mixed feelings
Angry with parent Desired attention/comfort from parent
Could not express their feelings because the parent so needed silence and approval
Felt guilty for feelings
Sought both a reason (trauma) and predictability
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DMM & Personality Disorders
Avoidant Personality Disorder: [A] C5-6 Δ
Crittenden, P & Kulbotten, G. (under review). Avoidant personality disorder and attachment.
Crittenden, P. M., & Kulbotton, G. R. (2007). Familial contributions to ADHD: An attachment perspective. Tidsskrift for Norsk Psykologorening, 10, 1220-1229.
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Mothers with BPDM&G DMMUt Ds1 Dp Ul(dx) Utr(b)pa Ut(p)sibling abuse A7-8/C6 [ina-anger]Ut Ds1 Dp Ut(ds)aban (ds)PA A6/C5-6Ut Ds1 dp Ut(ds,p)F's vio, DV (ds)N (I)F vio A7M C6FUt Ds1 Dp Ut(dp)PA, CSA A4-(+) C+ [ina]Ut Ds1 Dp Ut(b)CSA (ds)PA A4-,(7?)8 C5-6 [ina]hUt Ds3 Dp Ut(p+ds) PA, (b) SA, Ul(p) son, A+ (7GF) C5 [ina pain X2]Ut D2 dp Ut(p&i)CSA A7C6Ut D2 dp Ut(p,ds) broken arm A/C5Ut E1 Dp Ut(p&ds) EN A4-C5-6 [ina]hUt E3 Dp Ut(p,ds)PN (p,ds)aban (dx)PA,PN, l(p)B A8C5 [ina]?Ut & l E3 Dp Ut(dx)SA, aban tr(dpl)SA l(dx)M A+/C5 ) [ina]Ut E3 dp Ut(p&ds)DV,CSA A4 C5-6∆ [ina]?Ut E3 Dp Ul(dx)F+many (p)bullied A7C5(7?) [ina]?Ut E3 dp Ut(p&ds)PA, aban, families l(p & ds) many A3-4,5(8)/C5-6 ∆ [ina]hUt E3 dp Ul(p)F, GF,teach, t(p & dpl)F sui A+(4)7 C5 [ina](Crittenden & Newman, 2010)
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DMM & Borderline Personality Disorder
BPD: Dp Utr A+ C5-6Δ [ina]
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DMM & Borderline Personality Disorder
Component patterns:Psychoses: Dp Utr(ds) A+ [ina]
ED & PD: Utr(i) [A] C5-6 Δ
BPD: Dp Utr A+ C5-6Δ [ina]
BPD reflects the intersection of ‘psychoses’ and ‘personality disorder’ patterns.
Crittenden, P. M. & Newman, L. (2010). Comparing models of borderline personality disorder: Mothers’ experience, self-protective strategies, and dispositional representations. Clinical Child Psychology and Psychiatry, 15, 433-452.
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III. Developing an Hypothesis
Integrating information from several sources
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Eating disorders & avoidant personality disorders (not BPD or APD)
Symptoms
Resentfulness
Poor intimate relationships
Expanding problems: work, social relationships
Poor response to standard treatments
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Eating disorders & avoidant personality disorder
AAI data Absence of traumatic events Confusion regarding why other people act as they do Obsessive strategy that is expected to fail Feeling that one has tried everything (pseudo-Type A) Intense effort to find causal relations tied to oneself Focus ‘speakable’ problems Inability to find invisible/unspeakable problems Dp Utr(i) C5-6
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A Functional Formulation of PD Chronic inability to understand
interpersonal processes leading to:
Mixed negative feelings
Unmet expectations
Feelings of being insignificant to others
Negative expectations
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A Functional Formulation of PD Resolution requires
Current social skills Attention to feelings as information (affect) Understanding of why things happened as they
did (cognition) to yield: The opportunity to feel valued by parents The opportunity to find rational explanations to
events Confidence in one’s own perceptions Predictable sequences of interaction Perspective-taking Reflective functioning Forgiveness
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Biology
Context
Relationships
Psychology
Neurology
↕
Integrating Theories of Change
↕
↕
↕
Genetic, epigenetic Tx
Pharmacological
Psychotherapies, CBT
Family Systems, Parent-infant work
Community Tx, Advocacy
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Treatment of PD’s
Medication
Long-term psychotherapy
Day treatment in skill groups (5day/18mo)
Short-course day treatment (4day/6wk, Dal) Self-report data Short-term data Not psychological processes or strategies
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Hypothesis Most cases of PD will be associated with a failing
C5-6 attachment strategy, with Utr(i) Cases of BPD will use an A/C strategy, with serious
Utr (Dp Utr A+ C5-6Δ [ina]) Effective treatment will address:
Social skills Interpersonal processes (affect & cognition) Unspeakable information
Treatment will address Current relationships Past family processes
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IV. Testing the Hypothesis
Multi-group, multi-method design
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Comparing the DMM & Bartholomew's 4-factor model
Comfortable
B3
B1-2
A1-2A5-6
A7-8
AC
C7-8
C5-6 C1-2
B4-5
Reserved
Socially Facile/ Inhibited
Compulsively Promiscuous/ Self-reliant
Delusional Idealization/ Externally Assembled Self
Psychopathy
Menacing/ Paranoid
Punitive/ Seductive
Threatening / Disarming
Reactive
SecureFearful
Preoccupied
Dismissive
I’m OKYou’re OK
I’m Not OKYou’re OK
I’m Not OKYou’re Not OK
I’m OKYou’re Not OK
High Anxiety Low Avoidance
Low AnxietyHigh Avoidance
A3-4
C3-4
Compulsively Caregiving/ Compliant
Aggressive/ Feigned Helplessness
Comfortable
B3
B1-2
A1-2A5-6
A7-8
AC
C7-8
C5-6 C1-2
B4-5
Reserved
Socially Facile/ Inhibited
Compulsively Promiscuous/ Self-reliant
Delusional Idealization/ Externally Assembled Self
Psychopathy
Menacing/ Paranoid
Punitive/ Seductive
Threatening / Disarming
Reactive
SecureFearful
Preoccupied
Dismissive
I’m OKYou’re OK
I’m Not OKYou’re OK
I’m Not OKYou’re Not OK
I’m OKYou’re Not OK
High Anxiety Low Avoidance
Low AnxietyHigh Avoidance
A3-4
C3-4
Compulsively Caregiving/ Compliant
Aggressive/ Feigned Helplessness
Comfortable
B3
B1-2
A1-2A5-6
A7-8
AC
C7-8
C5-6 C1-2
B4-5
Reserved
Socially Facile/ Inhibited
Compulsively Promiscuous/ Self-reliant
Delusional Idealization/ Externally Assembled Self
Psychopathy
Menacing/ Paranoid
Punitive/ Seductive
Threatening / Disarming
Reactive
SecureFearful
Preoccupied
Dismissive
I’m OKYou’re OK
I’m Not OKYou’re OK
I’m Not OKYou’re Not OK
I’m OKYou’re Not OK
High Anxiety Low Avoidance
Low AnxietyHigh Avoidance
A3-4
C3-4
Compulsively Caregiving/ Compliant
Aggressive/ Feigned Helplessness
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Design
2 group comparisons (Tx and not)
Pre-post treatment assessment
Multi-method, multi-informant Bartholomew self-report
Symptom self-report
AAI: blind coding & greater differentiation
Blind professional symptom report.
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For further reading on the DMM: Crittenden, P. & Landini, A. (2011). The Adult Attachment
Interview: Assessing psychological and interpersonal strategies. New York: Norton.
Crittenden, P. M. (2008). Raising parents: Attachment, parenting, and child safety. Collumpton, UK: Routledge/Willan Publishing.
Special DMM issue of Clinical Child Psychology and Psychiatry (CCPP), 15, 2010.
Crittenden, P. M. (2006). A dynamic-maturational model of attachment. Australian and New Zealand Journal of Family Therapy, 27, 105-115.
Crittenden, P.M., & Dallos, R. (2009). All in the family. CCPP, 14, 387-407.
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For other downloads, see
www.patcrittenden.com