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Sant Cugat Feb 2013 ORG
Sant Cugat Feb 2013 ORG
F. Lana y C. Snchez
www.parcsalutmar.cat
Cmo manejamos las emociones negativas durante las crisis en el proceso teraputico
Fernando Lana
Programa de trastorno lmite de la Personalidad Director del Master en Trastorno Mental Grave, IL3-UB Psiquiatra-Psicoanalista (CPM-IFPS) Centre Emili Mira-INAD Parc de Salut Mar de Barcelona
Carmen Snchez
Programa de trastorno lmite de la Personalidad Master en Trastorno Mental Grave, IL3-UB Psicloga Clnica-DBT Centre Emili Mira-INAD Parc de Salut Mar de Barcelona
OBJECTIVES: To review the evidence for the effectiveness of crisis interventions for adults with BPD in any setting. For the purposes of the review, we defined crisis intervention as 'an immediate response by one or more individuals to the acute distress experienced by another individual, which is designed to ensure safety and recovery and lasts no longer than one month.'
AUTHORS' CONCLUSIONS: There is no RCT-based evidence for the management of acute crises in people with BPD and therefore we could not reach any conclusions about the effectiveness of any single crisis intervention. High-quality, large-scale, adequately powered RCTs in this area are urgently needed.
Objectives
To evaluate the effects of psychological interventions for people with borderline personality disorder.
Search strategy
We searched the following databases: CENTRAL 2010(3), MEDLINE (1950 to October 2010), EMBASE (1980 to 2010, week 39), ASSIA (1987 to November 2010), BIOSIS (1985 to October 2010), CINAHL (1982 to October 2010), Dissertation Abstracts International (31 January 2011), National Criminal Justice Reference Service Abstracts (15 October 2010), PsycINFO (1872 to October Week 1 2010), Science Citation Index (1970 to 10 October 2010), Social Science Citation Index (1970 to 10 October 2010), Sociological Abstracts (1963 to October 2010), ZETOC (15 October 2010) and the metaRegister of Controlled Trials (15 October 2010). In addition, we searched Dissertation Abstracts International in January 2011 and ICTRP in August 2011..
Selection criteria
Randomised studies with samples of patients with BPD comparing a specific psychotherapeutic intervention against a control intervention without any specific mode of action or against a comparative specific psychotherapeutic intervention. Outcomes included overall BPD severity, BPD symptoms (DSM-IV criteria), psychopathology associated with but not specific to BPD, attrition and adverse effects..
Conclusions:
There are indications of beneficial effects for both comprehensive psychotherapies as well as non-comprehensive psychotherapeutic interventions for BPD core pathology and associated general psychopathology.
DBT has been studied most intensely, followed by MBT, TFP, SFT and STEPPS
However, none of the treatments has a very robust evidence base, and there are some concerns regarding the quality of individual studies.
Overall, the findings support a substantial role for psychotherapy in the treatment of people with BPD but clearly indicate a need for replicatory studies..
Diccionario de la Real Academia de la Espaola, significados: 1. Cambio brusco en el curso de una enfermedad, ya sea para mejorarse, ya para agravarse el paciente.
2. Mutacin importante en el desarrollo de otros procesos, ya de orden fsico, ya histricos o espirituales. 3. Situacin de un asunto o proceso cuando est en duda la continuacin, modificacin o cese. 4. Momento decisivo de un negocio grave y de consecuencias importantes. 5. Juicio que se hace de algo despus de haberlo examinado cuidadosamente.
TLP-DBT(m):
Activacin/excitacin de las emociones. Disfuncin del procesamiento cognitivo. Disfuncin regulacin de la atencin (cap para manejarla voluntariamente)
TLP-DBT:
Malestar insoportable (emocional). No puedo pensar en otra cosa. No habla de otra cosa
Amor Alegra/Gozo
According to Linehan's biosocial theory, individuals with BPD are emotionally sensitive from birth. This sensitivity leads to a propensity to experience negative affect across contexts and situations,
Following Linehan's biosocial model, we conceptualize emotion dysregulation in borderline personality disorder (BPD) as consisting of four components:
emotion sensitivity, heightened and labile negative affect, a deficit of appropriate regulation strategies, a surplus of maladaptive regulation strategies
Emotion sensitivity in BPD has primarily been associated with negative mood states (e.g., anger, fear, sadness) and not positive emotions
Given the complexity of the construct of emotion dysregulation there is a need for research that specifies: which components of emotion dysregulation are under study. the interplay amongst these emotion dysregulation components.
-La respuesta se ha ido formulando en torno a lo que NO-hacer. -La historia de la evolucin de la psicoterapia del TLP, se ha escrito muchas veces subrayando lo que no es recomendable: -NO utilizar divn (definicin TLP). -NO invalidar. -No actuar la contratransferencia, etc.
LO QUE NO HACER?
The therapeutic work is directed at: =>The devaluation: Youre afraid to want things from me which you cant control =>The manipulation: Youre trying exert control over me =>The projection: Youre mad at me for not always being available
C R I S I S
N O
NO accidente
LAS CRISIS SON MUY FRECUENTES EN EL TLP lo extrao sera que no las hubiese
Estar prevenidos
DBT
Terapia dialctico-conductual
MBT
Terapia basada en la mentalizacin
-Plan de crisis -Qu hacer cuando el T no est disponible? -El Tf, componente del tto -HH para disminuir la vulnerabilidad emocional
-T attends to AFFECT rather than content. -T explores the problem NOW. -T focuses on PROBLEM SOLVING. -T focuses on AFFECT TOLERANCE. -T helps P COMMIT herself to a plan of action. -T T assess Ps SUICIDE POTENCIAL. -T anticipates a RECURRENCE of the crisis. Muy IMP
=>Interventions should be: -AFFECT focused. -Refer to CURRENT/Immediate context. -Simple and Short. -Address CONSCIOUS content. -Non-judgemental.
-Clarify the feeling WITHOUT interpretation.
OJO
-ONLY address possible causes (current, IP ) as the emotional state subsides. -Link affect storm to therapy ONLY after it has receded.
Es fcil acercarse, contactar, comunicarse, ayudar... a una persona con un TLP en crisis?
Alright . . . what do you want me to say? Do you want me to say its funny, so you can contradict me and say its sad? Or do you want me to say its sad so you can turn around and say no, its funny!!!
From Whos Afraid of Virginia Woolf?, by Edward Albee
The Management of Affect Storms in the Psychoanalytic Psychotherapy of Borderline Patients Otto F. Kernberg
Columbia University Center for Psychoanalytic Research and Training, New York Presbyterian Hospital, Westchester Division, Joan and Sanford I. Weill Medical College, Cornell University, Okernber@med.cornell.edu Okernber@med.cornell.edu
Abstract
Affect storms are a frequent complication in the psychoanalytic approach to borderline patients. The descriptive, psychodynamic, and structural characteristics of these storms are explored, and the verbal, nonverbal, and countertransference manifestations that permit the formulation of interpretations under such conditions are described, as are the interventions required to maintain the treatment frame as a precondition for an analytic approach. The principal theoretical formulations regarding the affect pathology of borderline patients are reviewed and related to a proposed interpretive approach. An apparently opposite development, the utter absence of emotional developments in the sessions, is examined, and its defensive function of avoiding affect storms is explored. Clinical case material illustrates the proposed approach to these storms, and clinical evidence is given to support the approach, which centers on systematic analysis of the primitive internalized object relations of these patients in the transference, the use of countertransference analysis without countertransference communication to the patient, and the repeated restoration of technical neutrality in the service of protecting the treatment frame.
=>POR UN LADO: Estrategias potentes y bien definidas, sobre todo, las DBT.
=>POR OTRO LADO: lograr que el paciente las utilice durante la crisis.
HABITUALMENTE
NO las va a utilizar (sobre todo, al inicio) NO basta con recordrselas NO ser nada fcil, muchas veces, el primer acercamiento al paciente RIESGO de re-activacin emocional.
DBT
Terapia dialctico-conductual
MBT
Terapia basada en la mentalizacin
La funcin evolutiva principal del sistema de apego es mantener la proximidad del nio a su cuidador (Nolte et al, FBN 2011). Adulto: El apego es un sistema biolgico, fisiolgico-conductual, que facilita una respuesta dinmica al estrs provocado por diversas amenazas ambientales para que el individuo se adapte lo mejor posible al medio (Mikulincer and Shaver, 2007).
Sistema de apego
Respuesta biopsicosocial
(estrategias primarias de apego)
Estado de alerta
ADULTO
Sistema de apego
DES-ACTIVACION
Hipervigilancia
ADULTO
(neuro)sistemas cognicin social: activacin emocional +++ Sospecha +++ hipervigilancia +++ Anomalas en la capacidad de mentalizacin
Sistema de apego
RESPUESTA FINAL NO proporciona seguridad Re-acticacion Estrs +++ Activacin emocional +++
Nueva
Amenaza Miedo
Clinical evidence strongly implies that as the attachment bond between therapist and client intensifies, the quality of BPD patients mentalization will tend to deteriorate.
Psychotherapists of many orientations often attempt to provide understandings for issues that trigger intense emotional reactions (challenging interpersonal situations, issues of shame, guilt, feelings of inadequacy, etc.) at a time when the capacity for effective explicit mentalization is practically inaccessible.
LO QUE NO HACER?
The therapeutic work is directed at: =>The devaluation: Youre afraid to want things from me which you cant control =>The manipulation: Youre trying exert control over me =>The projection: Youre mad at me for not always being available
=>Es que no pones nada de tu parte =>Usted no quiere cambiar =>Llegas tarde, no tomas la medicacin para qu vienes?
=>Teoras que ayudan a comprender a los seres humanos: Ej. Las personas y los pacientes, primariamente, hacen todo lo que saben para sufrir menos (validacin). Contrarrestar mitos: el mito de la persona normal, madura.
El mito de la persona madura: Las persona normal (madura) es racional, estable, etc.
we used transcranial magnetic stimulation (TMS) to disrupt neural activity in the temporoparietal junction (RTPJ) transiently.
TMS vs control, provoca que los participantes juzguen los intentos de hacer dao... moralmente ms permisibles... TMS altera la capacidad para usar los estados mentales en el juicio moral.
http://www.ted.com/talks/lang/es/rebecca_saxe_how_brains_make_moral_judgments.html
Therapeutics