When CBT is not enough: the challenges of personality pathology

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When CBT is not enough the challenges of
personality pathology

• PY6102 Advanced (D.PSYCH) Practicum
• Presented by Student E at JCU

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Summary of presentation

• A challenging case Ms X
• Alternative Formulations Solution Focused
  Therapy
• Therapeutic outcomes
• Summary of Journey
• Challenges for CBT the take home message

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A challenging case Ms X

• Referred for case-management of a potentially
  inflammatory company mistake
• Adopted 31 y.o. SWF, unkempt fair hair, casually
  groomed medium build. Nil
  deficits self-hygiene.
• Mood euthymic, demeanour towards intervention
  ambivalent. Became incensed talking about the
  welfare system, her family. Broke down when
  talking about traumatic events of the past.

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A challenging case(continued 1)

• Labile affect, but cautious of exposing emotions.
  Tight lipped and guarded. Maintained a seething,
  pervasive anger for the negative personal impact
  of others.
• Emotionally reactive to aspects of her past.
• Traumatic Hx CSA, sibling skullduggery, Stalking
  incidents (x2), physical assaults x2 .

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A challenging case(continued 2)

• Reported vague intrusions as sleep terrors
  (non-specific content). Avoided social
  interaction where possible.
• Hypervalent to the potential of others to harm
  her.
• Extremely severe reports on BDI-II, BAI, DASS,
  SCL scales (excluding SUI, ALC, DRG, PSY) - GSI
  gt80T. Not congruent with demeanour, presentation,
  narrative, or disclosure at interview.

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A challenging case(continued 3)

• Non-specificity per symptom cluster noted on PAI.
  NIM 2 SDsgtX, pattern of responses unreliable. Sx
  report considered functionally hyperinflated.
• PAI responses indicate low Rx motivation.
  Indicated provisional Dx of PTSD, PPYD.
• Clinical review of trauma-specific Sx indicated
  low frequency, non-specific intrusions, and no
  trauma-specific avoidance behaviour reported.

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DSM-IV considerations

• ?Posttraumatic Stress Disorder?
• Non-trauma specific intrusions. Affective
  arousal, but not directly related to specific
  traumatic event. Not hypervigilent, but wary.
• Sleep terrors w/out specific content. Intrusions
  only occurred in this context
• No acute cue reactivity to trauma-specific cues.
  Primary reaction to stalking incidents, was a
  sense of betrayal and anguish about not having
  been taken seriously, more than a devastating
  trail of emotional carnage

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DSM-IV considerations (Continued)

• Paranoid Personality Disorder
• Pervasive distrust and suspiciousness of others
  such that their motives are interpreted as
  malevolent- even when there no evidence for this.
• Suspects exploitation, anticipates harm from
  relatively benign interpersonal encounters
  harbors grudges litigates to right the wrong
  doings of others against her (eg., softball).
• No evidence of FTD

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DSM-IV Axial diagnosis

• Axis I Posttraumatic Stress Disorder
• (provisional only later removed)
• Axis II Paranoid Personality Disorder
• Axis III Endometriosis
• Axis IV Relationship problems (intimate,
  familial, social), money problems,
  Long-term unemployment (gt2yrs).
• Axis V GAF58 (April, 2002)

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Initial Rx strategy

• A CBT approach (initial PSTD Hypothesis)
• Anxiety inoculation strategies for between
  session arousal management (Meichenbaum, 1985)
• Re-processing most significant trauma
  (Foa, Keane, Friedman, 2000)
• Cognitive restructuring negative automatic
  thoughts, elucidating core beliefs
  (Beck, 1995 Greenberger Padesky, 1995 Leahy
  Holland, 2000)

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Initial Rx strategy (Continued)

• Record of social encounters for communication
  analysis (Kiesler, 1996 Leahy Holland, 2000)
• Behavioural experiments. towards benign social
  encounters (Leahy Holland, 2000)

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Challenges for treatment

• No specific primary problem!
• Non-specificity of intrusions (re-processing not
  possible)
• Poor homework compliance (Thought Records,
  reported problems determining what to write down
  - identifying ATs)

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Management of Engagement

• In session reviews of homework compliance
  (Bryant, Simons, Thase, 1999)
• Changed Thought record to better elicit ATs
  (Greenberger Padesky, 1995)
• Motivational Interviewing Technique Challenging
  Ltd commitment to Rx process (Miller
  Rollnick, 1991, 2000)

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Challenges for treatment (Continued)

• Presented regularly, but was not engaging in Rx
  process between sessions (maintenance)
• Reluctant to address emotionally weighted issues
  (family, interpersonal stance).
• Session content often derailed by daily
  trivialities (eg., character clashes _at_ TAFE).
• Interpersonal stance malignant aggression
• Unhelpful approach to therapy Why should she
  have to do this, when other people have caused
  her these problems?

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Characterological challenges for Cognitive
Behaviour Therapy

• Muddled issues no primary (Axis I) problem
• Adaptive inflexibility rigidity of thinking
  limiting here-and-now cog. restructuring.
• Avoidance of emotionally weighted issues
• Interpersonal interaction difficulties
• Poor homework compliance
• Low readiness to change (DH, TC, RE - DATOS, 1995)

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Alternative Formulations

• A Top-Down re-formulation of problem
• Psychoanalytic approach
• (Shapiro, 1965 Gabbard, 1994)
• Attachment Theory
• (Bowlby, 1988 Bartholomew Horowitz, 1990)
• Interpersonal Communication theory
• The Maladaptive Transaction Cycle (Kiesler,
  1996)
• Clinical Schema Theory (Segal, 1988 Young, 1999)

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Clinical Schema Theory

• Schemas (underlying cognitive structures) are
  acknowledged by cognitive theory (Beck Rush,
  1979 Freeman Leaf, 1989 Beck, Freeman
  Assoc., 1990 Safran Segal, 1990 Young, 1991,
  1994, 1999), and supported by cognitive science
  (Segal, 1988).
• Empirical evidence for deeper, underlying
  cognitive information processing filters found in
  studies of mood-congruent vs mood-incongruent
  response latencies (eg., Stroop studies), and
  studies of the S of A model (Anderson, 1981 in
  Segal, 1988)

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Clinical Schema Theory Schema Focused Therapy
(SFT)

• Exploratory FA evidence for validity of Early
  Maladaptive Schemas (Schmidt, Joiner, Young,
  Telch, 1995).
• Clinical Process outcome studies are underway,
  but no direct empirical evidence for efficacy
  of SFT.
• Initial indications suggest effectiveness of SFT
  process may be moderated by therapist optimism
  (Hoffart Sexton, 2002), client harmony with
  formulation, and therapist empathy (Hoffart,
  Versland, Sexton, 2002).

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Schema-Focused Therapy (continued)

• Anecdotal evidence of successful SFT outcomes is
  available (Flanagan, 1993).
• SFT enables Rx of characterological problems
  inline with the cognitive model, for which there
  is evidence.
• No treatment paradigm has been empirically
  validated in the Rx of PPYD (Turkat, 1990).

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Schema-Focused Therapy (SFT) Formulation for Ms
X.

• Schema Processes
• Maintenance MTC, Ltd Rx Commit., superficial
  communication w/others, isolated.
• Compensation haughty, arrogant, hypercritical
  interpersonal stance malignant aggression.
• Avoidance continual crises, derailment of
  session content

• Primary Schema domain
• Disconnection Rejection
• Early Maladaptive Schemas (EMS)
• Mistrust/Abuse (1)

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Schema-Focused TherapyInitial phase

• Administer Schema Questionnaire, review results
  in context of clinical history
• Feedback of primary Early Maladaptive Schema/s
  SFT formulation to client
• Build awareness of schema activation the
  empty chair technique.
• Explore schema process. Develop insight into
  antecedents of schema activation.
• Collaborate to address schema process.

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Therapeutic outcomes Ms X

• After 26 episodes of therapy
• More positive about future, no longer limited by
  trivial slights as before
• Fewer Nveg Sx, Sleep terrors to 2/7
• Enrolled at Univ.
• GAF 68 (13/12/02)

• Confounds to results
• Hyper-inflated and non-specific self-report on
  Mood Sx measures (PAI incl.).
• Medication
• (20mg Aropax mané)
• Limited Rx Commit.
• Preparation for handover (Sx)

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Summary of Journey

• A long-term therapy case, that challenged the
  utility of short-term CBT, and required
  alternative formulation upon review.
• A Schema-Focused Therapy approach enabled a
  transparent operational understanding of the
  characterological problems identified.
• Limited RTC, was re-conceptualised as schema
  avoidance bringing it into SFT context (avoiding
  MI confrontation).
• Fair prognosis, if commitment to Rx process
  improves.

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When CBT is not enough the take home message

• CBT is an efficacious and reliable short-term,
  method of intervention for affective conditions
  not exacerbated by personality pathology.
• Be aware of other formulations- dont become
  domain-bound to the CBT approach.
• As scientist-practitioners, report your success
  with alternative formulations, particularly
  process followed, and outcomes achieved.

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Acknowledgement

• Dr Ed Helmes
• a big thankyou to Ed for being a source of
  clinical challenge, and providing the stimulus
  for theoretical exploration of alternative
  perspectives for formulation of difficult cases.