Svrakic Dragan, Divac-Jovanovic Mirjana, Azhar Naazia
Department of Psychiatry, VA Medical Center St Louis, Washington University School of Medicine, St Louis, MO, USA,
Psychiatr Danub. 2019 Mar;31(1):2-17. doi: 10.24869/psyd.2019.2.
This paper presents an integrative model of personality and personality disorder which incorporates psychoanalytic concepts with modern neuroscience. In addition, a dynamic, personalized, and context - and time-sensitive diagnosis of personality disorder is introduced. The authors cogently argue that all clinical variants of personality disorder share the same common deficit: fragmented basic units of experience at the nonconscious core of the mind (aka "partial object relations"). The fragmentation propagates through mental faculties (thought, motivation, emotion), as they self-organize into subsystems of personality, e.g., one's sense of self, identity, character, moral values, rendering them polarized into extreme and thus adaptively suboptimal. The syndrome of personality disorder arises as a nonconscious compensatory maneuver of the fragmented mind to organize itself through a defensive but unrealistic self-image (e.g., narcissistic, schizoid, antisocial, etc.), giving rise to a host of unique symptoms. Symptomatic pharmacotherapy of personality disorder is best organized around four empirically derived domains of symptoms, shared by all variants to a variable degree: i) mood and anxiety dysregulation; ii) impulsivity, aggression, and behavior dyscontrol; iii) emotional disinterest and detachment; and iv) cognitive distortions and brief reactive psychoses. Pharmacotherapy targeting the above domains is nonspecific, as medications affect multiple domains simultaneously. Modest empirical evidence and considerable clinical benefits continue to support the use of medications in the overall symptomatic treatment of personality disorder.
本文提出了一种人格与人格障碍的综合模型，该模型将精神分析概念与现代神经科学相结合。此外，还引入了一种动态、个性化、对情境和时间敏感的人格障碍诊断方法。作者有力地论证了人格障碍的所有临床变体都存在相同的共同缺陷：在心灵的无意识核心处，经验的基本单位碎片化（即“部分客体关系”）。这种碎片化通过心理官能（思维、动机、情感）传播，因为它们自组织成人格的子系统，例如一个人的自我意识、身份认同、性格、道德价值观，使它们两极分化为极端状态，从而在适应性方面表现欠佳。人格障碍综合征是碎片化心灵通过一种防御性但不现实的自我形象（例如自恋型、分裂型、反社会型等）进行自我组织的无意识补偿策略，进而引发一系列独特症状。人格障碍的症状性药物治疗最好围绕四个基于实证得出的症状领域进行组织，所有变体在不同程度上都有这些症状：i）情绪和焦虑调节障碍；ii）冲动、攻击和行为失控；iii）情感冷漠和疏离；iv）认知扭曲和短暂的反应性精神病。针对上述领域的药物治疗是非特异性的，因为药物会同时影响多个领域。适度的实证证据和显著的临床益处继续支持在人格障碍的整体症状治疗中使用药物。
