Personality disorder- This is a type of pathology of mental activity. This disorder is a personality type or behavioral tendency characterized by significant discomfort and departure from the norms established in that cultural and social environment. A personality disorder is considered a severe pathology of an individual's behavioral tendencies or character constitution, usually involving several personality structures. It is almost always accompanied by social and personal disintegration. Typically, this deviation occurs in older childhood, as well as during puberty. Its manifestations are also observed in adulthood. The diagnosis of personality disorder is not made in the presence of isolated social deviations without the presence of personality dysfunction.
Causes of Personality Disorders
Severe pathology of individuals' patterns of perception and response to various conditions that render the subject incapable of social adjustment constitutes the disease personality disorder. This illness can manifest itself spontaneously or be a sign of other mental disorders.
When describing the causes of personality pathologies, first of all, it is necessary to focus functional deviations on the main areas of personality: mental activity, perception, relationships with the environment, emotions.
As a rule, personality defects are congenital and manifest themselves throughout life. In addition, the described disorder may begin during puberty or at an older age. In the case of this kind of illness, it can be triggered by exposure to severe stress, other abnormalities in mental processes, and diseases of the brain.
Also, a personality disorder can arise as a result of a child suffering violence, intimate abuse, neglect of his interests and feelings, or the child living in conditions of parental alcoholism and their indifference.
Numerous experiments indicate that mild manifestations of personality disorder are observed in ten percent of adults. In forty percent of patients in psychiatric institutions, this deviation manifests itself either as an independent disease or as a component of another mental pathology. Today, the reasons that provoke the development of personality deviations have not been fully elucidated.
Also, numerous scientific studies demonstrate that the male part of the population is more susceptible to personality pathology. In addition, this disease is more common among disadvantaged families and low-income segments of the population. Personality disorder is a risk factor for suicide attempts, deliberate self-harm, drug or alcohol addiction, and in some cases provokes the progression of specific mental pathologies, such as depressive states, obsessive-compulsive disorder. Despite the fact that manifestations and impulsivity weaken with age, the inability to build and maintain close contacts is characterized by greater persistence.
The diagnosis of personality disorders is particularly specific due to two reasons. The first reason is the need to clarify the period of onset of the disorder, that is, whether it arose at an early stage of formation or persisted into older age. It is possible to find out this only by communicating with a close relative of the patient who has known him since birth. Communication with a relative makes it possible to get a complete picture of the nature and pattern of relationships.
The second reason is the difficulty of assessing the factors that provoke disruption of personality adjustment and the severity of deviations from the norm in behavioral response. Also, it is often difficult to draw a clear boundary line between the norm and deviation.
Typically, a diagnosis of personality disorder is made when there is a significant discrepancy in the individual’s behavioral response to his sociocultural level or it causes significant suffering to those around him and the patient himself, and also complicates his social and work activities.
Symptoms of Personality Disorders
People with a personality disorder are often characterized by an inadequate attitude towards the problems that manifest themselves. What provokes difficulties in building harmonious relationships with relatives and significant others. Typically, the first signs of a personality disorder are detected during puberty or early adulthood. Such deviations are classified according to severity and severity. Mild severity is usually diagnosed.
Signs of a personality disorder are manifested, first of all, in the individual’s attitude towards others. Patients do not notice inadequacy in their own behavioral response as well as in their thoughts. As a result, they rarely seek professional psychological help on their own.
Personality disorders are characterized by a stable course, involvement of emotions in the structure of behavior, and personal characteristics of thinking. Most individuals suffering from personality pathologies are dissatisfied with their own existence and have problems in social situations and in communicative interaction at work. In addition, many individuals experience mood disorders, increased anxiety, and eating disorders.
Among the main symptoms are:
- having negative feelings, such as feelings of distress, anxiety, worthlessness, or anger;
- difficulty or inability to manage negative feelings;
- avoidance of people and feelings of emptiness (patients are emotionally disconnected);
- frequent confrontations with others, threats of violence or insults (often escalating to assault);
- difficulty maintaining stable relationships with relatives, especially children and marriage partners;
- periods of loss of contact with reality.
The listed symptoms may worsen under tension, for example, as a result of stress, various experiences, or menstruation.
People with a personality disorder often have other mental health problems, most often they experience depressive symptoms, abuse of psychoactive drugs, alcoholic beverages or narcotic substances. Most personality disorders are genetic in nature, manifested as a result of the influence of upbringing.
The formation of the disorder and its growth from an early age period manifests itself in the following order. Initially, a reaction is observed as the first manifestation of personal disharmony, then development occurs when the personality disorder is clearly expressed when interacting with the environment. After which a personality disorder occurs, which can be decompensated or compensated. Personality pathologies usually become pronounced at the age of sixteen.
There are typical stable personality deviations characteristic of persons imprisoned for long periods of time, those who have suffered violence, and those who are deaf or deaf-mute. So, for example, deaf and mute people are characterized by mild delusional ideas, and people who have been in prison are characterized by explosiveness and basic distrust.
Personality anomalies tend to accumulate in families, which increases the risk of developing psychosis in the next generation. The social environment can contribute to the decompensation of implicit personality pathologies. After fifty-five years, under the influence of involutionary transformations and economic stress, personality anomalies are often more pronounced than in middle age. This age period is characterized by a specific “retirement syndrome”, expressed in a loss of prospects, a decrease in the number of contacts, an increase in interest in one’s health, an increase in anxiety and a feeling of helplessness.
Among the most likely consequences of the described disease are:
- the risk of developing addiction (for example, alcohol), inappropriate sexual behavior, possible suicide attempts;
- abusive, emotional and irresponsible type of child upbringing, which provokes the development of mental disorders in children of a person suffering from a personality disorder;
- mental breakdowns occur due to stress;
- development of other mental disorders (for example);
- the sick subject does not accept responsibility for his own behavior;
- mistrust is formed.
One of the mental pathologies is multiple personality disorder, which is the presence of at least two personalities (ego states) in one individual. At the same time, the person himself is not aware of the simultaneous existence of several personalities within him. Under the influence of circumstances, one ego state is replaced by another.
The causes of this disease are serious emotional trauma that occurred to the individual in early childhood, constantly recurring sexual, physical or emotional abuse. Multiple personality disorder is an extreme manifestation of psychological defense (dissociation), in which the individual begins to perceive the situation as if from the outside. The described defense mechanism allows a person to protect himself from excessive, unbearable emotions. However, with excessive activation of this mechanism, dissociative disorders arise.
With this pathology, depressive states are observed, and suicidal attempts are common. The patient is subject to frequent sudden changes in mood and anxiety. He may also experience various phobias and, less commonly, sleep and eating disorders.
Multiple personality disorder is characterized by a close relationship with psychogenic disorder, characterized by memory loss without the presence of physiological pathologies in the brain. This amnesia is a kind of defense mechanism through which a person acquires the ability to repress traumatic memories from his own consciousness. In the case of multiple disorders, the described mechanism helps to “switch” ego states. Excessive activation of this mechanism often leads to general everyday memory problems in people suffering from multiple personality disorder.
Types of Personality Disorders
In accordance with the classification described in the International Guide to Mental Disorders, personality disorders are divided into three fundamental categories (clusters):
- Cluster “A” is eccentric pathologies, these include schizoid, paranoid, schizotypal disorder;
- Cluster “B” is emotional, theatrical or fluctuating disorders, which include borderline, hysterical, narcissistic, antisocial disorder;
- Cluster “C” is anxiety and panic disorders: obsessive-compulsive disorder, dependent and avoidant personality disorder.
The described types of personality disorders differ in etiology and mode of expression. There are several types of classifications of personality pathologies. Regardless of the classification used, various personality pathologies can simultaneously be present in one individual, but with certain limitations. In this case, the most pronounced symptoms are usually diagnosed. The types of personality disorders are described in detail below.
The schizoid type of personality pathology is characterized by the desire to avoid emotionally intense contacts through excessive theorizing, escape into fantasy, and withdrawal into oneself. Also, schizoid individuals often tend to disdain prevailing social norms. Such individuals do not need love, they do not need tenderness, they do not express great joy, strong anger, or other emotions, which alienates the surrounding society from them and makes close relationships impossible. Nothing can provoke increased interest in them. Such individuals prefer solitary activities. They have a weak response to criticism, as well as to praise.
Paranoid personality pathology consists of increased sensitivity to frustrating factors, suspicion, and is expressed in constant dissatisfaction with society and resentment. Such people tend to take everything personally. With the paranoid type of personal pathology, the subject is characterized by increased distrust of the surrounding society. It invariably seems to him that everyone is deceiving him and plotting against him. He tries to find hidden meaning or a threat to himself in any of the simplest statements and actions of others. Such a person does not forgive insults, is angry and aggressive. But she is capable of temporarily not showing her emotions until the right moment, so that she can then take revenge very cruelly.
Schizotypal disorder is a deviation that does not correspond to the diagnostic criteria of schizophrenia: either all the necessary symptoms are absent, or they are weakly manifested and erased. People with the described type of deviation are distinguished by anomalies in mental activity and emotional sphere, and eccentric behavior. In schizotypal disorder, the following symptoms may be observed: inappropriate affect, detachment, eccentric behavior or appearance, poor interaction with the environment with a tendency to alienate people, strange beliefs that change behavior incompatible with cultural norms, paranoid ideas, obsessive thoughts, etc.
With the antisocial type of personality deviation, the individual is characterized by ignoring the norms established in the social environment, aggressiveness, and impulsiveness. Sick people have an extremely limited ability to form attachments. They are rude and irritable, very conflict-ridden, and do not take into account moral norms and rules of public order. These individuals always blame the surrounding society for all their own failures and constantly find an explanation for their actions. They do not have the ability to learn from personal mistakes, are unable to plan, and are characterized by deceit and high aggressiveness.
Borderline personality pathology is a disorder that includes low personality, impulsivity, emotional instability, unstable connection with reality, increased anxiety and a strong degree. Self-harming or suicidal behavior is considered a significant symptom of the described deviation. The percentage of suicide attempts resulting in death with this pathology is about twenty-eight percent.
A common symptom of this disorder is a multitude of low-risk attempts due to minor circumstances (incidents). Mostly, the trigger for suicide attempts is interpersonal relationships.
Differential diagnosis of personality disorders of this type can cause certain difficulties, since the clinical picture is similar to bipolar disorder type II due to the fact that bipolar disorder of this type does not have easily detectable psychotic signs of mania.
Hysterical personality disorder is characterized by an endless need for attention, an overestimation of the importance of gender, unstable behavior, and theatrical behavior. It manifests itself in very high emotionality and demonstrative behavior. Often the actions of such a person are inappropriate and ridiculous. At the same time, she always strives to be the best, but all her emotions and views are superficial, as a result of which she cannot attract attention to her own person for a long time. People suffering from this type of illness are prone to theatrical gestures, susceptible to the influence of others and easily suggestible. They need an “audience” when they do something.
The narcissistic type of personality anomaly is characterized by a belief in personal uniqueness, superiority over the environment, special position, and talent. Such individuals are characterized by inflated self-esteem, preoccupation with illusions about their own successes, the expectation of exceptionally good attitude and unconditional obedience from others, and the inability to express sympathy. They invariably try to control public opinion about themselves. Patients often devalue almost everything that surrounds them, while they idealize everything they associate with.
Avoidant (anxious) personality disorder is characterized by a person’s constant desire to be socially withdrawn, a feeling of inferiority, increased sensitivity to negative evaluation by others, and avoidance of social interaction. Individuals with this personality disorder often think that they are poor communicators or that they are unattractive. Due to being ridiculed and rejected, patients avoid social interaction. As a rule, they present themselves as individualists, alienated from society, which makes social adaptation impossible.
Dependent personality disorder is characterized by an increased feeling of helplessness and lack of vitality due to lack of independence and incompetence. Such people constantly feel the need for the support of other people; they strive to shift the solution of important issues in their own lives onto the shoulders of others.
Obsessive-compulsive personality pathology is characterized by an increased tendency to caution and doubt, excessive perfectionism, preoccupation with details, stubbornness, periodic or compulsions. Such people want everything around them to happen according to the rules they have established. In addition, they are unable to do any work, since constant delving into details and bringing them to perfection simply does not make it possible to complete what they started. Patients are deprived of interpersonal relationships because there is no time left for them. In addition, loved ones do not meet their high demands.
Personality disorders can be classified not only by cluster or criteria, but also by impact on social functioning, severity and attribution.
Treatment of personality disorders
The treatment of personality disorders is an individual and often very lengthy process. As a rule, the typology of the disease, its diagnosis, habits, behavioral response, and attitude to various situations are taken as a basis. In addition, clinical symptoms, personality psychology, and the patient’s desire to make contact with a medical professional are of certain importance. It is often quite difficult for dissocial individuals to make contact with a therapist.
All personality deviations are extremely difficult to correct, so the doctor must have the proper experience, knowledge and understanding of emotional sensitivity. Treatment of personality pathologies should be comprehensive. Therefore, psychotherapy for personality disorders is practiced in close connection with drug treatment. The primary task of a medical professional is to alleviate the depressive symptoms and reduce them. Drug therapy copes well with this. In addition, reducing exposure to external stress can also quickly relieve symptoms and anxiety.
Thus, in order to reduce the level of anxiety, relieve depressive symptoms and other accompanying symptoms, drug treatment is prescribed. For depression and high impulsivity, the use of selective serotonin reuptake inhibitors is practiced. Outbursts of anger and impulsivity are treated with anticonvulsants.
In addition, an important factor influencing the effectiveness of treatment is the patient’s family environment. Because it can either aggravate symptoms or reduce the patient’s “bad” behavior and thoughts. Often, family intervention in the treatment process is key to achieving results.
Practice shows that psychotherapy helps patients suffering from personality disorder most effectively, since drug treatment does not have the ability to influence character traits.
For an individual to become aware of his own incorrect beliefs and the characteristics of maladaptive behavior, as a rule, repeated confrontation is necessary in long-term psychotherapy.
Maladaptive behavior such as recklessness, emotional outbursts, lack of confidence, and social withdrawal may change over many months. Participation in group self-help methods can help in changing inappropriate behavioral responses. Behavioral changes are especially significant for those suffering from borderline, avoidant, or antisocial personality pathology.
Unfortunately, there are no quick ways to cure a personality disorder. Individuals with a history of personality pathology, as a rule, do not look at the problem from the perspective of their own behavioral response; they tend to pay attention exclusively to the results of inappropriate thoughts and the consequences of behavior. Therefore, the therapist needs to constantly emphasize the undesirable consequences of their mental activity and behavior. Often, the therapist may impose restrictions on behavioral responses (for example, he may tell you not to raise your voice in moments of anger). That is why the participation of relatives is important, since with such prohibitions they can help reduce the severity of inappropriate behavior. Psychotherapy is aimed at helping subjects understand their own actions and behaviors that lead to interpersonal problems. For example, a psychotherapist helps to understand dependence, arrogance, excessive distrust of the environment, suspicion and manipulativeness.
Group psychotherapy for personality disorders and behavior modification are sometimes effective in changing socially unacceptable behavior (eg, lack of confidence, social withdrawal, anger). Positive results can be achieved after several months.
Dialectical behavior therapy is considered effective for borderline personality disorder. It consists of weekly sessions of individual psychotherapy, sometimes in combination with group psychotherapy. In addition, telephone consultations between sessions are considered mandatory. Dialectical behavioral psychotherapy is designed to teach subjects to understand their own behavior, prepare them to make independent decisions, and increase adaptability.
For subjects suffering from pronounced personality pathologies, manifested in inadequate beliefs, attitudes and expectations (for example, obsessive-compulsive syndrome), the classic one is recommended. Therapy can last for at least three years.
Resolving interpersonal problems usually takes more than one year. The foundation for effective transformations in interpersonal relationships is individual psychotherapy, aimed at making the patient aware of the sources of his troubles in interaction with society.
good work (7.7), freedom (7.95), which, in turn, demonstrates the personal orientation of the respondents.
The hierarchy of respondents with low levels of envy looks different. The following values occupied the first positions: health (2), having good and loyal friends (5.5), social recognition (6.5), freedom (6.5), love (7.5), development (7.5 ), self-confidence (7.5), i.e. socialization values, determined by orientation towards other people, integration in society, achieving a certain social status, i.e. aimed at social space and self-determination in it.
Thus, it can be noted that the level of envy also determines life direction. The hierarchy of values of respondents with a high and average level is aimed at the individual-personal space, while the hierarchy of values of respondents with a low level is aimed at the personal and social space.
Literature
1. Adler A. Understand human nature / trans. with him. E.A. Tsypina. St. Petersburg: Academic project, 1997. 256 p.
2. Beskova T.V. Social psychology of envy. Saratov: IC Nauka, 2010. 192 p.
3. Solovyova S.A. The value-semantic sphere of personality as the most important component of the formation of subjectivity in the professional training of teachers // Subjectivity in the personal and professional development of a person: materials of the II All-Russian. scientific-practical conf. / under general editorship G.V. Mukhametzyanova. Kazan: KSUI, 2005. pp. 191-192.
4. Freud 3. Basic principles of psychoanalysis: trans. with German, English M.: Refl-book; Kyiv: Wackler, 1998. 288 p.
5. Horney K. Collected works: in 3 volumes. T. 1. Psychology of women. Neurotic personality of our time: trans. from English M.: Smysl, 1997. 496 p.
6. Jung K.G. Psychology of the unconscious. M.: Kanon+, 1996. 399 p.
7. Rokeach M. The nature of human values. N.Y. : The Free Press, 1973. 438 p.
GORSHENINA NADEZHDA VIKTOROVNA - applicant for the academic degree of Candidate of Psychological Sciences, Department of Personality Psychology, Kazan (Volga Region) Federal University, Russia, Kazan ( [email protected]).
GORSHENINA NADEZHDA VICTOROVNA - a competitor of scientific degree of Psychological Sciences candidate, Personality Psychology Chair, Kazan (Volga) Federal University, Russia, Kazan.
UDC 159.9.072.422 BBK 88.37
R.D. MINAZOV
INDIVIDUAL PSYCHOTHERAPY FOR PERSONALITY DISORDERS
Key words: personality disorders, individual psychotherapy.
A model of individual psychotherapy for patients with personality disorders is described. The model is illustrated by a clinical case, which presents a patient’s self-report after the stage of psychotherapeutic cooperation.
INDIVIDUAL PSYCHOTHERAPY OF PERSONALITY DISORDERS
Key words: personality disorders, individual psychotherapy.
This paper describes a model of individual psychotherapy of patients with personality disorders. The model is illustrated by a clinical case where the patient's self-report is presented after the stages of psychotherapy cooperation.
Many patients with borderline disorders go through a so-called “medical labyrinth” before seeing a psychotherapist. With the development of paid medicine, it becomes unprofitable for medical institutions and private practitioners to miss a patient from follow-up.
Denia. As a result, numerous appointments with doctors of various specialties, overdiagnosis, unjustified laboratory tests, and sometimes observation by specialists in occult practices. All this aggravates the already difficult clinical condition of the patient. Sometimes, decades can pass from the first visit to an internist to the patient’s first visit to a psychotherapist.
The patient is usually concerned about psychopathological manifestations such as obsessive-compulsive disorders, panic, psychosomatic manifestations, eating disorders and much more. Personality disorder, being central to the clinical picture, remains in the shadows for the patient himself. Therefore, a mental health specialist may get carried away with the treatment of painful symptoms, losing sight of the pathological core of the personality.
For the first time, the clinic of personality disorders (psychopathy) was described in detail by P.B. Gannushkin. Since then, numerous changes have occurred in the classification and taxonomy of these diseases, but the approach to diagnosis is still relevant today. According to the author, psychopathy is stationary, i.e. non-progressive conditions. E. Kraepelin pointed out that pure psychopathy of the same type is quite rare, so mixed forms are often observed. Just as at the beginning of the 20th century, psychotherapy remains the main method of treating personality disorders. However, previously it was aimed at correcting “abnormal reactions to living and living conditions.” The modern concept of the formation of mental disorders determines bio-psycho-socio-spiritual targets for long-term psychotherapy. K. Jaspers reported that “we have not at all touched upon the question of what types of psychopathy and to what extent are identified in one or another period of time, in one or another era.” P.B. Gannushkin systematized psychopathy and also noted the influence of the era on the types of these disorders. It is not surprising that in REM-1U-TR, unlike ICD-10, narcissistic personality disorder is described, which reflects the spirit of the postmodern era, the internal and external conflicts of modern man.
In 2013, the American classification of mental disorders REM-U was published, which, to a greater extent than all its predecessors, is based on scientific evidence. Where fashion, expert authority, personal points of view and hotly defended but not scientifically proven theories previously played an important role in the development of classification, the emphasis has now shifted to scientific evidence. According to some researchers, the taxonomy of REM is constantly expanding, and “ordinary” variations in behavior are being labeled as diseases. Supporters of REM-U oppose, explaining that the modern classification is not diagnostic, but serves to describe human behavior.
Today, in patients with personality disorders, we observe the manifestation of a personality defect exclusively during a crisis period, as opposed to the totality described by P.B. Gannushkin. In contrast to the traditional teaching about psychopathy, these patients are sometimes socially adapted and can even be considered successful people in their chosen profession.
Not every patient can afford to undergo a course of recommended psychotherapy with open terms. The short-term nature of individual therapy is achieved by establishing a “psychotherapeutic diagnosis” and clearly identifying the “targets of psychotherapy.” The target of psychotherapy is a phenomenon manifested by the patient or assumed by the psychotherapist, a change
which in the process of psychotherapy is the conscious goal of interaction. Using the example of patients with neuroses, the authors describe the following groups of “targets”: 1st group - clinical psychotherapeutic targets (psychotherapeutic targets of nosological specificity); Group 2 - targets specific to the individual psychological and personal characteristics of the patient; Group 3 - targets specific to the psychotherapeutic process; Group 4 - psychotherapeutic targets specific to the clinical situation; Group 5 - targets specific to the psychotherapeutic method.
Primitive defenses, as well as diffuse identity, characteristic of persons with a borderline personality organization, make it difficult to work in a psychodynamic manner. And the methods of problem-oriented psychotherapy at the initial stage focus the patient on current life difficulties (the system of relationships with the external and internal world) and structure therapeutic sessions. This, on the one hand, allows you to create a spirit of cooperation in the doctor-patient relationship, on the other hand, it minimizes the emphasis on the diagnosis, which allows you to maintain your self-esteem. At further stages of psychotherapy, the concepts of “psychological defenses,” “resistance,” and “transfer” are introduced. The patient needs to focus on these phenomena and fill out an introspection diary. Working with these phenomena creates dynamics from the “periphery to the center” and creates new requests for psychotherapeutic cooperation. Here the affective sphere, internal and external conflicts and the connection with the patient's object relations can be studied in detail. The next stage is working with “character defects.” This term is taken from the 12-step model of addiction recovery, but is metaphorically understood by patients with personality disorders, especially when presented with a drawing of a tree like this. Activation of resources helps strengthen the ego, after which it is possible to discuss the diagnosis of a personality disorder. Isn’t it possible to agree on the concept of the disease earlier? Is this further unclear? Thus, the main diagnosis comes into the field of vision of the patient himself, henceforth being conscious. Let us present as an illustration the self-report of Z., 30 years old.
“When I first saw a psychiatrist, I was prescribed medication that made me sleepy all the time, so I looked for other ways to cope with my problems. At that time, I was worried about obsessive thoughts: “Did I run over someone while driving, did I get a needle or other sharp object in my eye.” All this distracted me from normal life, and at the same time there was something comforting about it... I worked a lot and began to drink at night to distract myself from obsessive thoughts and fall asleep. I didn’t notice how I started drinking more beer. That's how I became an alcoholic. There are women there, different ones every day, clubs, the social circle has changed. Several years passed, my wife left me because I humiliated her every day. Only later did I find out that I, it turns out, am not just a neurotic, an alcoholic, a sexaholic, but I am a border guard. Going to a psychotherapist was not easy for me; I doubted it for a long time, thinking about how chatting with him would help me. He demanded effective pills or healing hypnosis from him. For some reason, the doctor decided to take a break from my illnesses for a while, and I only wanted to talk about them, but somehow we smoothly moved on to the topics of my relationships with my subordinates, my wife, my sister, my mother. But the hardest thing for me was talking about my father. I liked working with postcards; I saw my experiences and thoughts reflected in them. I realized the connection between my symptoms and my current problems. What was more difficult was understanding the connection between my symptoms and my past. Then I realized that I was punishing myself for previous sins. It’s not for nothing that my symptoms used to manifest themselves in the fact that I simply could not get out of the shower, I was so thoroughly washing away the “past dirt” from myself. My father left this stain too. Drawing
family once again hammered a nail into my consciousness - the realization of what was really happening in our relationship. After some time, I decided to tell about my father; it didn’t happen as soon as I think he wanted. Immediately I remembered that I had always been bad for my father, not as ideal as he wanted me to be. He had big plans for me, I think that I had to do what he failed in life. But fate played a cruel joke on him, making me like this. This feeling that I am bad still lives with me. And, apparently, that’s why I always did everything to play this game and got carried away.... It was difficult to determine my main negative feeling. Then I drew a weight, I didn’t think that it was hanging on my neck and was called guilt. Dealing with guilt and my relationship with my father interrupted my work with a psychotherapist; perhaps I was not ready for such serious changes then. Then I learned what Comrade Resistance is and how it manifests itself, the doctor promised to assign me a specialty, at least as a psychologist, if I cope with the task of finding this “well-wisher” and monitoring his insidious plan. I understood that the Resistance is me, and I understood that inside I am not alone, there are many of us there. I was impulsive and therefore repeatedly interrupted our sessions, then returned. My emotions took precedence over everything, they controlled me all the time, as long as I can remember. Of course, I won’t leave myself, and I have to continue working.. I’ll be patient. Now I’ve been sober for 7 months, I sleep peacefully and can work.”
To intensify and structure the treatment process, methods are used that allow you to focus on basic personality conflicts. The nuclear conflict theme of relationships is an original version of short-term focal psychodynamically oriented psychotherapy, which was developed by the American psychologist Luborsky in the early 1990s. . The focus of psychotherapeutic intervention is the patient’s emotionally significant relationships in his reference environment. Nuclear conflict themes are derived from the patient's narrative. In the described clinical case, the patient was identified as having a protracted conflict with his father. Avoiding this topic slowed down the healing process. At the same time, the introduction at this stage of the concepts of “transfer” and “resistance” made it possible to keep the patient in an outpatient setting and expand his understanding of himself.
For a long time, patients with personality disorders were classified as incurable. In the last decade, the situation has changed, and we are seeing patients in therapeutic remission. Working with these patients places serious demands on the psychotherapist himself. Personal example, faith in the patient, professional competence, empathy, tolerance - this is not a complete list of conditions for successful therapy of patients with personality disorders.
Literature
1. Blaser A., Heim E, Ringer H., Tommen M. Problem-oriented psychotherapy. Integrative approach / trans. with him. L.S. Kaganova. M.: Klass, 1998. 272 p.
2. Gannushkin P.B. Clinic of psychopathy, their statics, dynamics, systematics. M.: Medical book, 2007. 124 p.
3. Korolenko T.P., Dmitrieva N.V. Personality disorders. St. Petersburg: Peter, 2010. 400 p.
4. Kulakov S.A. Psychotherapeutic diagnosis in the rehabilitation of patients dependent on psychoactive substances // Narcology. 2013. No. 9. pp. 85-91.
5. Lichko A.E. Psychopathy and character accentuations in adolescents. St. Petersburg: Rech, 2009. 256 p.
6. Lyuborsky L. Principles of psychoanalytic psychotherapy: A guide to supportive expressive treatment: trans. from English M.: Cogito-Center, 2003.
7. Nikolaev E.L., Chuprova O.V. Psychological features of the temporal perspective of the individual in the “dependent-codependent” system // Bulletin of the Chuvash University. 2013. No. 2. P. 102-105.
8. Typology of psychotherapeutic targets and its use to improve the quality of individual psychotherapeutic programs in the treatment of patients with neurotic disorders: method. recommendations / R.K. Nazyrov, S.V. Logacheva, M.B. Craft and others. St. Petersburg: Publishing house NIPNI im. V.M. Bekhtereva, 2011. 18 p.
9. Jaspers K. Collected works on psychopathology: in 2 volumes. M.: Academy; St. Petersburg: White Rabbit, 1996. 256 p.
10. De Man J. De DSM-5 in 1 oogopslag // De Psychiater. 2013. No. 5. P. 8-10.
11. DSM-5: wetenschappelijker onderbouwd dan ooit // De Psychiater. 2012. No. 3. P. 30-31.
MINAZOV RENAT DANISOVICH - candidate of medical sciences, psychotherapist, Insight clinic, Russia, Kazan, ( [email protected]).
MINAZOV RENAT DANISOVICH - candidate of medical sciences, psychotherapist, “Insight” Clinic, Russia, Kazan.
UDC 159.972+616.1 BBK 88.4
E.L. NIKOLAEV, E.YU. LAZAREV
FEATURES OF MENTAL DISADAPTATION IN CARDIOVASCULAR DISEASES
Key words: cardiovascular diseases, mental maladjustment, anxiety, depression, hypochondria.
Data are presented on the peculiarities of the structure of mental maladjustment in cardiovascular pathology, according to which mental disorders of the affective spectrum, manifested by symptoms of anxiety and depression, which can be combined with disorders of a hypochondriacal nature, are more common. In the genesis of mental maladjustment, a connection can be traced with stress, personal and psychosocial factors.
E.L. NIKOLAEV, E.Yu. LAZAREVA SPECIFIC FEATURES OF MENTAL MALADJUSTMENT IN CARDIOVASCULAR DISEASES Key words: cardiovascular diseases, mental maladjustment, anxiety, depression, hypochondria.
The review presents data on the structural features of mental maladjustment in cardiovascular diseases. Affective spectrum disorders manifesting with symptoms of anxiety and depression that can be combined with hypochondrical presentations are more often. Genesis of mental maladjustment is traced to life stressful influences, personal and psychosocial factors.
As noted in our previous publications, a person’s adaptive capabilities, including in a state of illness, are associated not only with the functional state of the body and its ability to adequately respond to adverse factors, but also with a certain set of individual psychological characteristics of the individual, as well as ways of processing intrapersonal conflicts. The importance of the factor of mental adaptation in cardiovascular diseases (CVD), as well as the high frequency of its violation - mental maladjustment, justifies the emergence of a separate interdisciplinary field - psychocardiology - located at the intersection of cardiology, psychology and psychiatry.
This work is devoted to a brief review of scientific reports on the features of the structure of mental maladaptation in patients with CVD, based on the most frequently identified psychopathological symptoms in common forms of cardiac pathology.
Thus, according to epidemiological studies, reliable relationships have been established between cardiac pathology and depression. There is increasing information about the relationship between anxiety and the development of CVD in the general population.
A multicenter three-year study conducted in Russia aimed at studying the frequency of anxiety and depressive symptoms in patients
The method of using dynamic psychotherapy for personality disorders is not much different from that used for neuroses. This treatment can be done individually or in a group (see Chapter 18).
In the individual treatment of personality disorders there are some differences in emphasis compared to the treatment of neuroses. Less attention is paid to the reconstruction of past events and more to the analysis of current behavior. So-called character analysis examines in detail how the patient relates to other people, how he copes with external difficulties and how he controls his own feelings. This approach is more directive than the classical methods of analyzing neurotic symptoms, although transference analysis remains an essential element. In order to highlight the discrepancy between the patient's usual attitude towards other people and the real life situation, the doctor must reveal himself to a greater extent than is usually customary in classical analysis. At the same time, an analysis of the doctor’s emotional attitude towards the patient can serve as an important indicator of the likely reaction of other people to the patient.
Histrionic personality disorder
Murphy and Guze (1960) made an interesting report on the difficulties encountered in treating patients with histrionic personality disorder. They describe the direct and indirect demands that such patients may make to the doctor. Direct demands include unreasonable requests for medication, frequent requests for reassurance that help will be available at all times, telephone calls at inopportune times, and attempts to impose unrealistic treatment conditions. Indirect demands come in a variety of forms, such as seductive behavior, threats of dangerous behavior such as overdosing on medication, and repeated unfavorable comparisons between current treatment and past treatment. The doctor must be alert to the first signs of such demands and establish a certain framework for the relationship, making it clear to what extent he intends to tolerate the patient's behavior. This must be done before the latter's demands increase excessively.
Obsessive personality disorder
Personality patients often express a greater willingness to please the doctor. However, with this type of personality disorder, psychotherapy, as a rule, does not have a positive effect, and its unskilled use can lead to excessive painful introspection, as a result of which the condition worsens rather than improves.
Schizoid personality disorder
The inherent desire of schizoids to avoid close personal contacts makes it difficult to use any type of psychotherapy. Often after several sessions the patient stops attending; if he continues treatment, he tends to intellectualize his problems and doubts arise about the scientific validity of the methods used in the clinic.
The doctor should try to gradually penetrate through these "intellectual barriers" and help the patient to become aware of his emotional problems. Only then can the doctor begin to look for ways to solve them. It is a slow process at best, and often ends in failure.
Borderline personality disorder
Patients with borderline personality disorder do not respond positively to exploratory psychotherapy, and attempts at such treatment may worsen their emotional control and increase their stress. It is usually best to use supportive treatment, focusing all efforts towards practical goals related to solving everyday problems.
Therapy for Personality Disorders with Dual Diagnosis
The term “dual diagnosis” refers specifically to individuals with personality disorders and an addictive problem. These types of people require therapeutic approaches that take into account two types of disorders, which greatly complicates the effectiveness of interventions. A number of studies have shown that individuals with mental disorders, including personality disorders, have an increased risk of developing addictive disorders.
There is evidence that eliminating or reducing substance abuse leads to improvement or elimination of mood and anxiety disorders, but less to a change in the core symptoms of the personality disorder itself. This fact in itself indicates that personality disorders are an independent nosological category and require additional therapeutic interventions.
A number of authors provide evidence that the coexistence of abuse of substances that alter the mental state and personality disorders is associated with an increase in psychiatric symptoms, and with a more destructive nature of the addictive implementations themselves.
P. Links and M. Target describe in such cases an increased risk of suicide, frequent hospitalizations, legal and labor problems of behavior.
Patients with a dual diagnosis are more susceptible to developing an uncontrollable craving for various forms of addictive activities, including the use of substances with addictive properties. They are more likely to experience emotional and somatic disorders. They are characterized by frequent interpersonal conflicts. In people with personality disorders, insufficiently intensive anti-addiction therapy rarely prevents relapse.
B. Thomas, T. Melchert and J. Banken point out in this context the following data: with standard in-hospital treatment after one year, 94% of patients with personality disorders relapsed while in addicts without personality disorders, relapse was diagnosed in 56% of cases.
At the same time, I. Nace and C. Davis note that the prognosis of addicts with borderline personality disorder (BPD) looked better (compared to antisocial disorder). The results of intensive in-hospital treatment for alcoholism were no worse than those of addicts without signs of PPD.
Despite the prevailing view that antisocial personality disorder (ALD) is “incurable,” K. Evans and J. Sullivan believe it is advisable to develop strategies and tactics that can be effective in some cases. This position is based on observations indicating that ALD is not uniform in severity, but represents a sequence (continuum) in which ALD of varying depths are represented: from very intense at one pole to conduct disorder and oppositional disorder at the other. For example, carriers of relatively mild forms of ALR are more susceptible to fear reactions and have a better chance of correcting them.
One of the important predictors of therapy success is age. Therapeutic interventions in childhood and early adolescence are more effective, which is explained by less fixation on antisocial behavior and greater control of children and adolescents by authority figures. Persons with ALD in middle life are motivated for therapy by the development of long-term affective disorders. I. Pinik et al. (E. Penick et al.) observed a positive effect of treatment with antidepressants in people with APD and alcoholism in a state of depression and anxiety disorder. The authors concluded that ALR does not necessarily block treatment of a comorbid disorder.
K. Evans and J. Sullivan emphasize that the goal of therapy for ALD is not to transform the patient into a highly sensitive, empathic person, since this is unattainable. The goal is to adapt the individual with ALD, to develop in him/her the belief that following social rules of behavior will allow them to achieve greater success, “look better” socially and reduce the number of troubles in life.
Therapy for people suffering from APD and having a dual diagnosis (plus alcohol addiction) has a number of specific features. K. Evans and J. Sullivan call them the “three Cs”: corral, confrontation and consequences. Fencing implies the need for patients to be in a closed system without the right to free movement. Otherwise, they will not systematically (or at all) attend sessions. Confrontation involves the removal of psychological defenses used in ALR. It is important, first of all, to break through the barrier of denial using cognitive approaches.
Individuals with ALD must understand that their false statements and explanations will be recognized by a specialist. At the same time, the latter should not act in a critical authoritarian role, but resort to conversation tactics in the form of “adult - adult” in the transactional analysis model. What matters is the specialist’s ability to understand the hidden motivations of people with APD, desires for certain places to spend time, contacts with specific people, alcoholics, drug addicts and other antisocial persons. The professional should also discuss what benefits the patient is trying to gain from the consultation and therapy. This could be, for example, a mitigation of punishment for convicted persons; the desire to preserve family life, especially in cases where it has created “most favored nation status” for the use of alcohol or other substances that alter the mental state. Thus, some points of mutual understanding can be found on the basis of demonstrating to the patient errors in their thinking, which objectively lead not to pleasure, but to a deterioration in their social position and a decrease in the possibilities of hedonistic realizations. Errors in thinking include the common minimization of negative aspects, rationalization, and ordinary lies. K. Evans and J. Sullivan find that in group therapy, discussion about specific errors in thinking has a strong impact on people with ALD.
The authors focus on alcohol abuse by persons with APD of the “royal child” syndrome, which consists of an inflated ego without truly high self-esteem. “I am unique/unique and I am above other people” - such a motto is associated with the opposite: “I am nothing/I am nothing.” This design provokes an attraction to alcohol. The consequences of behavior in the assessment of persons with ALD are limited to an antisocial attitude towards pleasure, buzz, excitement, and immediate gratification of desires. Long-term negative consequences are not taken into account and are not taken into account. There is no fear of negative consequences. Persons with ALD do not analyze the connection between the punishment they received and their antisocial behavior, although it would seem to be obvious. Although training individuals with ALD to understand the likelihood or inevitability of negative consequences of antisocial behavior is always difficult, it is an important element of therapy.
Alcohol addicts with APD have the peculiarity that they do not drink alcohol as systematically as ordinary alcohol addicts. However, in a state of alcohol intoxication, they cause, in general, more harm. Characteristic of them is a sharp increase in antisocial activities during intoxication.
Correction of codependency is included in the structure of therapy as an extremely important block. It is aimed at destroying the “enabling” situation - creating the most favored nation status for an addict with APD, which is sometimes metaphorically called a “hothouse environment”. Family members of an addict with APD are usually codependent individuals who use inappropriate strategies to keep patients from abusing substances. They include control, protection and competition and objectively lead only to negative consequences, stimulating an increased sense of impunity, irresponsibility, projective identification, and denial of the problem.
Educating family members in this context can be helpful, although the situation is more complicated if they themselves have ALD traits. Codependent family members usually show signs of anxiety and depression, which are aggravated by the inability to correct the addictive behavior of their loved ones. Family members of antisocial addicts literally use themselves, their emotions, activity, motivation, finances and health in fruitless attempts to correct the situation.
Addicts with APD show a clear tendency to blame codependent persons for their addictive problems, for which they use, depending on the situation, different formulations such as: “I am doing this as a sign of protest against your petty control”; “You are annoying me with constant surveillance”; “Your defense humiliates me in front of my relatives/neighbors, so I get drunk”; “I can’t stand these constant reproaches,” etc.
K. Evans and J. Sullivan believe that in the correction of antisocial addicts it is possible to use the twelve-step model, taking into account their personal characteristics. The importance of the “first step” is emphasized as a core element in therapy: “I admit my powerlessness over alcohol” (or other addictive agent). The recognition of powerlessness requires that addicts understand that they are unable to control both their use and its consequences. It is important to identify the loss of control over behavior while drinking alcohol, one’s powerlessness, as well as recognizing erroneous conclusions used to justify the use of addictive agents and other forms of antisocial behavior (manipulation, deception, irresponsibility, blaming others, etc.). It is necessary to focus the attention of antisocial addicts on their recognition of the negative consequences of antisocial behavior.
Individuals with borderline personality disorder (BPD) exhibit a tendency to periodically abuse mental state-altering substances, which negatively affects their professional development.
Maintaining sobriety is thus a major challenge for individuals with PPD who suffer from alcohol addiction or recurrent alcohol abuse, which also applies to the use of other addictive substances. K. Evans and J. Sullivan equate sobriety in these patients with safety. They believe that the 12-step model has a lot to offer borderline addicts, in particular helping to get rid of a negative self-image. Writing an autobiography and analyzing it, using a free story about one’s life (narrative), despite the presence of dramatic and traumatic events in the analysis, can have a positive impact.
Addictive tendencies in people with PPD manifest themselves, especially if they were raised in addictive families, where an alcoholic scenario was present in everyday life. Intensive alcohol consumption in people with PPD can be part of the structure of impulsive behavior, limited to the latter, but can also act as a way to eliminate unpleasant experiences and change the general background of dissatisfaction with oneself and the world around us. In the latter variant, there is often a change in compulsions with fixation on food (overeating), gambling, sex, etc.
P. Links et al. showed that the use of mental state-altering substances by persons with PPD leads to increased symptoms of the disorder, including self-injurious behavior. The risk of physical trauma, sexual violence, and accidents increases.
K. Evans and J. Sullivan offer some specifics in the application of the 12-step program for borderline addicts. They highlight the "terrible combination" that mixes PPD with chemical dependency. Among other things, in such cases the acquisition of new skills is delayed. According to the “first step,” from the authors’ point of view, it is important to focus attention on uncontrollability in relation to alcohol and other addictive substances. It is necessary to ensure that the patient/patient identifies situations where alcohol use was out of control and caused problems. The term “powerlessness” terrifies borderline addicts because they perceive it not as a metaphor, but as something very specific that relates to their ego.
The “Second Step” is essentially a declaration of faith. “We have come to believe that a Power greater than ourselves can restore us to health.” The problem is that for people with PPD, faith and connection with a higher power can be difficult to reflect. These people live in the moment; they have little ability to plan their future. Therefore, faith and hope for improvement in the future are difficult to achieve for them. Taking this feature into account, the “second step” is divided into small fragments. To do this, patients are asked to discuss how their drinking/substance abuse was abnormal; give several examples of positive experiences that occurred while not resorting to addictive drugs; describe even minor positive events in their life since abstinence.
The concept of a “Higher Power” requires special attention. It is necessary to find out the features of the individual manifestation of religious feeling, its projections in terms of faith in God, in Nature, in Something indefinable, but present, in Purposefulness, in the Meaning of life.
In working through the “third step” (“we have decided to entrust our will and our lives to the care of God, as we understand Him”), patients learn to get rid of obsessive thoughts and stop senseless attempts to super-control other people and events. Symbolic actions are used, such as writing on pieces of paper a list of problems that are most difficult to get rid of, burning notes and burying the ashes; tying such pieces of paper to a balloon and releasing it into the air. This takes into account the fact that many borderline patients believe in the power of symbolic rituals.
Individuals with a dual diagnosis (PDD + addiction) require consultation and treatment by highly trained professionals who have experience in quickly responding to the possibility of destructive impulsive actions. Knowledge of the family situation, significant intimate relationships, and risk areas that predispose to self-harm, suicide, and aggression is required.
Risk areas for borderline addicts (as well as for people with PPD in general) are experiences of abandonment, primarily related to intimate relationships, including the fear of abandonment itself, conflicts with a significant partner in a “tandem” relationship, and actual abandonment. Emotional support in such conditions is extremely important; it can prevent destructive reactions, including addictive implementations.
S. Ball in 2004 proposed a model of therapy called the “Dual Focus Therapy Design” (DTDF) in cases of personality disorders aggravated by addiction. It is based on the hypothesis that the core of pathology in personality disorders is the interaction of two broad cognitive-behavioral constructs: 1) early maladaptive schemas and 2) maladaptive styles of behavior that reflect these maladaptive schemas. The primary goal of therapy is interventions aimed at reducing the intensity of the influence of maladaptive patterns and developing more adaptive behaviors. The ideal goal of STDF involves achieving control over behavior and providing patients with the opportunity to satisfy significant human needs. Various methods are used to reduce disorders both on the first axis (addiction, short-term mental disorders) and on the second axis (symptoms of personality disorders).
As defined by A. Beck et al. and J. Young, early maladaptive schemas are persistent negative beliefs about oneself, other people and the environment. All core experiences and behavior are organized around these dysfunctional beliefs. Schemas are formed early in life, develop gradually, become increasingly complex and begin to influence ever wider areas of life. In persons with personality disorders, the dysfunction of these schemes is pronounced; they are extremely rigid and resistant to attempts to change them. J. Young, aka et al. gives the following characteristics of early maladaptive schemes. They:
1) develop in the interaction of temperament and repeated negative experiences in contacts with the closest people (parents, siblings, peers);
2) generate high levels of affect, have self-defeating consequences, or cause harm to others;
3) interfere with basic needs for autonomy, self-expression and interpersonal contact;
4) penetrate deeply into the psyche, becoming central to the “I”;
5) “triggered” (activated) by everyday events or mood states.
J. Young, S. Ball, R. Schottenfeld do not associate specific patterns with specific forms of personality disorder, but give 18 basic patterns. Every personality disorder has one or more of them.
Cluster "A":
1) abandonment/instability;
2) mistrust/violence;
3) emotional deprivation;
4) defectiveness/shame;
5) social isolation/alienation.
All these schemes are combined into the “Broken connections and repulsion” cluster.
Cluster "B":
6) dependence/incompetence;
7) hypersensitivity to danger;
8) confusion/underdeveloped “I”;
9) impossibility of achievement.
These patterns are grouped into the Autonomy and Execution Violation cluster.
Cluster "B":
10) privilege/dominance;
11) insufficient self-control/self-discipline.
The schemes are combined into the “Boundary Violation” cluster.
Cluster "G":
12) submission;
15) self-sacrifice;
16) seeking approval.
The cluster is called “Other Focus”.
Cluster "D":
17) hypersensitivity to mistakes, negativity;
18) overcontrol/emotional suppression.
The symptoms are grouped into the “Hypervigilance and Suppression” cluster.
On the basis of maladaptive schemes, maladaptive styles of behavior are formed, including long-term, unconsciously occurring cognitive and behavioral reactions. These reactions are self-defeating. J. Yang et al. behavioral styles are divided into: a) those that obey an early maladaptive scheme; b) avoiding the scheme and c) compensating the scheme.
The STDF identifies addiction as the primary disorder, but also considers dysfunctional schema activation and maladaptive avoidance (avoidance of people, situations, and moods that activate the schema) as factors that increase the risk of relapse in individuals with personality disorders. Within the framework of the model, addictive implementation can arise as a direct consequence of the activation of various maladaptive schemes and personal characteristics.
STDF is carried out over 24 weeks, it is strictly individual in nature, concentrating on establishing the main early maladaptive patterns with subsequent therapeutic effects on them. Prevention of relapses into dysfunctional forms of behavior caused by automatic switching to previous algorithms (dysfunctional patterns) is carried out.
STDF is an integrated correctional intervention with a dual focus - on addictive behavior and on personality disorder. Patients intensify self-analysis, search for independent solutions to problems and skills to prevent the realization of addictive desires and exacerbations of symptoms of a personality disorder.
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The persistence and depth of personality changes and the rejection of any help make personality disorders one of the most difficult medical problems.
Drug therapy may be useful for some patients at certain times. It is unlikely that drugs can cure a personality disorder, but there is growing evidence that drug treatment can reduce the severity and duration of some manifestations of personality disorders.
Impulsivity and aggressiveness are common in borderline and antisocial disorder. Since changes in the levels of GABA, serotonin, and dopamine in the brain were found in patients with aggressiveness and impulsivity, drugs that affect the level and ratio of mediators are used in treatment. Lithium salts (lithium carbonate), serotonergic drugs (fluoxetine, sertraline), antipsychotics (haloperidol in small doses, neuleptil, rispolept, etc.) are prescribed.
Emotional lability is especially characteristic of persons with borderline, histrionic, and narcissistic disorders. There is evidence that low doses of antipsychotics reduce emotional vulnerability; small doses of antidepressants, both tricyclics and MAO inhibitors, are also used. For dysphoria, carbamazepine is prescribed.
Anxiety is a very nonspecific symptom and can be observed in many personality disorders, but most often in dependent, avoidant, and obsessive-compulsive disorders. The drugs of choice are tranquilizers (clonazepam, alprazolam, etc.).
For short-term perception disorders and delusional ideas, which can occur during decompensation of schizotypal, schizoid, paranoid disorders, antipsychotics (stelazine, triftazine, haloperidol) are prescribed.
Drug treatment is usually chosen by those patients who expect immediate action from therapy and consider medications as a tangible means of self-control and suppression of unwanted behavior. When prescribing drug therapy, it is necessary to take into account the possibility of drug abuse, especially psychostimulants and tranquilizers. Drug treatment must be combined with other methods - psychotherapy (individual and group).
At planning psychotherapy It is often important to analyze the origin and development of a personality disorder, not just the type. A good psychotherapeutic alliance is essential for maximally successful therapy. It is necessary to discuss with patients those symptoms, those forms of behavior that are undesirable for them. They say that it is impossible for a person to change his nature; all he can do is change his circumstances. Treatment consists of helping a person choose a lifestyle that is less in conflict with his character. For example, it is important to find out the situations under which aggressive behavior most often occurs.
Psychotherapy must be structured, consistent and regular. Psychotherapy allows the patient to discuss both present difficulties and past experiences.
Group psychotherapy is an effective addition to individual therapy, allowing the patient to express their feelings without fear of consequences. This type of psychotherapy also provides social support and the opportunity to form meaningful connections with people both inside and outside the psychotherapy group.
Short-term hospitalization sometimes necessary during acute psychotic episodes or when there is a threat of destructive behavior. Hospitalization can also provide temporary removal from an external traumatic factor.
