Management of the therapeutic relationship in a patient with Complex PTSD and Personality Disorder

Individuals diagnosed with Complex PTSD (C-PTSD) have experienced repeated and often prolonged traumatic events. From a therapeutic perspective this can lead to difficulties in emotion regulation within-session, challenges with patient-therapist attunement, and impaired coregulation of emotions during therapeutic interactions. As a result, frequent therapeutic alliance ruptures can emerge, which in turn pose challenges for symptom-focused work. We describe a case study involving a 38-year-old woman presenting with C-PTSD, dissociation, anxiety and borderline and dependent personality disorder traits. We explore how difficulties in attunement and emotion regulation during therapy were mostly attributable to (i) maladaptive ideas regarding the self and others; and (ii) difficulties in recognizing both her own mental states and those of her therapist. For instance, the patient believed that the therapist was distant and critical; which she held to be fact rather than reflective of a mental state. We show how the therapist addressed these difficulties, incorporating repair of the therapeutic alliance, which enabled a return to symptom focused work. The case description offers guidance on how to maintain a dual focus on therapeutic alliance alongside symptoms when treating C-PTSD (with or without comorbidity).

Metacognitive Interpersonal Therapy for Misophonia: A Single-Case Study

BACKGROUND

Misophonia is a chronic condition in which the exposure to specific sounds increases the arousal and recurrence of specific intense negative emotions. We hypothesized that misophonia may be strongly related to maladaptive interpersonal schemas that create difficulties in interpersonal relationships. Subjects with maladaptive interpersonal schemas think that other people try to subjugate, criticize, dominate, exploit, deceive, disregard, and humiliate them. Furthermore, these patients typically endorse a representation of self as mistreated, constricted, harmed, damaged, humiliated, impotent, inadequate, or fragile.

METHODS

We describe the course of a treatment of Metacognitive Interpersonal Therapy (MIT) in a young man presenting misophonia and co-occurrent obsessive-compulsive personality disorder (OCPD) and avoidant personality disorder (AvPD), with narcissistic traits and normal hearing. We collected qualitative and quantitative data at the beginning of the intervention and at 2 years follow-up.

RESULTS

The therapy aimed at increasing awareness of maladaptive interpersonal schemas and promoting a healthy self. The results reported a significant decrease in misophonia; behavioural experiments were used to increase the quality of social relationships and tolerance to the trigger sounds.

CONCLUSIONS

MIT can be an effective therapy for the treatment of misophonia.

Group schema therapy versus group cognitive behavioral therapy for patients with social anxiety disorder and comorbid avoidant personality disorder: A randomized controlled trial

BACKGROUND

Patients with social anxiety (SAD) and comorbid avoidant personality disorder (AVPD) are severely impaired. Group cognitive behavioral therapy (GCBT) is considered an effective treatment for SAD. More knowledge on treatment of SAD with comorbid AVPD is needed. Schema therapy, developed for personality and chronic mental disorders, may be a promising treatment.

METHODS

We conducted a randomized controlled trial in an outpatient population (n = 154) with both SAD and AVPD. Group Schema Therapy (GST) and GCBT were compared on SAD symptoms (Liebowitz Social Anxiety Scale) and manifestations of AVPD (Avoidant Personality Disorder Severity Index).

RESULTS

Intention-to-treat analysis showed no significant differences between treatments at 3 months post-treatment and one-year follow-up. Both modalities led to significant and substantial improvements. No significant between-differences were found in depressive symptoms (Inventory of Depressive Symptoms) and quality of life (World Health Organization Quality of Life-BREF). Per-protocol analysis showed similar outcomes and no significant differences in recovery from SAD and AVPD. Significantly more patients completed GST.

CONCLUSION

GST and GCBT are valuable treatments for SAD with comorbid AVPD. The higher treatment retention in ST indicates ST is more acceptable than GCBT. Future studies should focus on enhancing treatment effects and improving retention to GCBT.

Agency in avoidant personality disorder: a narrative review

Objectives

Avoidant personality disorder (AvPD) is a highly prevalent personality disorder, especially in clinical settings, yet scarcely researched. People diagnosed with AvPD have severe impairments in functioning and suffer greatly, yet we still lack meta-analytic evidence for therapy and only a few RCTs are conducted. Patient factors are the most important for outcome in therapy, in general. Lack of agency might be a core deficit in people diagnosed with AvPD. Their conditions might be improved if we understand their agency better. We review previous research regarding psychological mechanisms and interpersonal relationships that facilitate or hinder agency in AvPD in daily life and psychotherapy.

Methods

Summarizing original literature in a narrative review with reflexive thematic analysis.

Results

People diagnosed with AvPD seem to have significant impairments in their sense of agency due to a lack of emotional awareness, an overweight of inhibiting vs. activating emotions, and difficulties regulating emotions. Difficulties also seem related to high levels of attachment avoidance and fear, creating strong ambivalence in social needs, in addition to a strong tendency to subordinate to others. A weak sense of self with a poor narrative, self-doubt, and harsh self-critique makes a reflexive and intentional stand increasingly difficult for these people.

Conclusion

This review gives a clinically meaningful understanding of core strengths and deficits in the personality functioning of AvPD that can help clinicians map out important therapeutic work, identify barriers to client-agency in therapy, and work through relational difficulties in the therapeutic alliance.

Automated facial expression analysis of participants self-criticising via the two-chair technique: exploring facial behavioral markers of self-criticism

Introduction

As self-rating scales are prone to many measurement distortions, there is a growing call for more objective measures based on physiological or behavioural indicators. Self-criticism is one of the major transdiagnostic factor of all mental disorders therefore it is important to be able to distinguish what are the characteristic facial features of self-criticizing. To the best of our knowledge, there has been no automated facial emotion expression analysis of participants self-criticising via the two-chair technique. The aim of this study was to detect which action units of facial expressions were significantly more often present in participants performing self-criticism using the two-chair technique. The broader goal was to contribute to the scientific knowledge on objective behavioural descriptions of self-criticism and to provide an additional diagnostic means to the existing self-rating scales by exploring facial behavioral markers of self-criticism.

Methods

The non-clinical sample consisted of 80 participants (20 men and 60 women) aged 19 years to 57 years (M = 23.86; SD = 5.98). In the analysis we used iMotions's Affectiva AFFDEX module (Version 8.1) to classify the participants' actions units from the self-criticising videos. For the statistical analysis we used a multilevel model to account for the repeated-measures design.

Results

Based on the significant results the self-critical facial expression may therefore comprise the following action units: Dimpler, Lip Press, Eye Closure, Jaw Drop, and Outer Brow Raise, which are related to contempt, fear, and embarrassment or shame; and Eye Closure and Eye Widen (in rapid sequence Blink), which are a sign that highly negative stimuli are being emotionally processed.

Discussion

The research study need to be further analysed using clinical samples to compare the results.

Perfectionism unbound: An integrated individual and group intervention for those hiding imperfections

The tendency to hide and mask suffering and one's perceived imperfections is one of the biggest obstacles in treating those with prominent perfectionistic traits. In this single case, we present an integrative form of psychotherapy for patients with recurrent strategies aimed at neither displaying nor disclosing their perfectionism. Emily was a 26-year-old woman diagnosed with Major Depressive Disorder and reported a personality pathology as diagnosed through the Alternative Model of Personality Disorders. The intervention comprised of a 4-month individual therapy and 2-month group therapy. The former is based on Metacognitive Interpersonal Therapy protocol for personality disorders. The latter is a protocol that integrates the Dynamic Relational Treatment for Perfectionism and Compassion Focused Therapy. At the end of this integrative treatment, Emily remitted from Major Depressive Disorder and personality pathology. Further studies should confirm our promising results in larger samples.

Case formulation in emotion-focused therapy

Case formulation in emotion-focused therapy aids therapists to both conceptualize core emotion schemes and follow markers across therapy that signify tasks aimed at emotional transformation. The case formulation process will be illustrated in the successful case of Jina, a woman with a history of childhood emotional abuse who sought therapy for depression. The three stages of case formulation are co-constructed between client and therapist. In stage one, the therapist assesses her initial emotion processing style and listens as the emotion-based narrative unfolds. In stage two, the core emotion scheme and formulation narrative organize around feelings of shame of inferiority and attachment-related feelings of being rejected and unloved. Attendant secondary emotions of powerlessness, and unmet needs for validation emerge. Stage three evolves as the therapist follows process markers, prompting chair work for both unfinished business and self-criticism, ultimately helping Jina access adaptive sadness and newly experienced self-compassion.

Treating intimate partner violence with metacognitive interpersonal therapy: The case of Aaron

Intimate partner violence (IPV) is responsible for loss of lives and significant psychological, financial, and social costs. Research into therapeutic effectiveness show inconsistent results irrespective of therapeutic orientation. The capacity to understand one's own mental states as subjective and distinct from others is an important factor in the regulation of mental states and physiological arousal associated with the perpetration of IPV. Metacognitive Interpersonal Therapy (MIT) offers an innovative approach in working with male perpetrators of IPV. The current paper outlines 14 sessions of MIT with a 45-year-old male perpetrator. A core aspect was helping the client resolve how his view of self and others were subjective experiences that were distinct from relational objectivity. The emergence of healthy self-narratives was fostered through experiential processes, involving guided imagery, rescripting and body focused interventions. Qualitative outcomes are summarized and implications for the use of MIT in treatment of perpetrators of IPV is discussed.

Transdiagnostic conceptualization of social avoidance through the lens of personality functioning and traits

This commentary seeks to highlight how social avoidance is portrayed in the six presented case-reports from the perspective of self- and interpersonal functioning as well as stylistic trait features of negative affectivity (e.g., anxiousness and shame) and detachment (e.g., social withdrawal and emotional restriction). This approach to avoidance and social isolation will subsequently be generalized to a range of mental disorders where such features play a significant role. We propose that self and interpersonal functioning along with traits of negative affectivity and detachment may serve as a transdiagnostic framework for describing features of avoidance and social isolation across different treatment models, traditions, and disorders. We specifically assume that future developments of the promising treatment approaches presented in the current collection of case reports may benefit from such a "shared" framework for conceptualizing and treating self- and interpersonal problems related to avoidance and social isolation.

Awakening to recognize the detrimental effects of social avoidance and the possibility of healing through reconnection

BACKGROUND

Loneliness and social avoidance are widespread and serious mental health problems. People experiencing loneliness or social avoidance have difficulties maintaining ordinary life activities and often experience profound suffering. How do we as clinicians deal with or help people out of loneliness and social avoidance?

AIMS

In this paper, we introduce the issue on loneliness and social avoidance. We do so by first defining loneliness and social avoidance and outlining the impact on mental health issues of these phenomena. Next, we introduce the six papers central to the special issue along with some thoughts on how to understand therapy and treatment of social avoidance.

DISCUSSION

We discuss new directions and how to move beyond more conventional therapeutic approaches to these problems.