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Clinical Guidelines for Psychotherapy of Patients with Borderline Personality Disorders

PSYCHOANALYTICAL NEWSLETTER
№ 8, 1990

Michael H. Stone

Michael X. Stone (M. Stone) - American psychoanalyst, MD, professor of clinical psychology at Columbia College of Physicians and Surgeons in New York, attending psychiatrist at the Mid-Hudson Forensic Psychiatric Hospital, visited St. Petersburg as a guest in 1999 Professor of the Eastern European Institute of Psychoanalysis. Text of a lecture given at the East European Institute of Psychoanalysis in 1999.

Translation from English by S. Pankov

The concept of “borderline state” has existed in psychiatric terminology for more than a hundred years. In one of my works, I tried to trace all the stages of evolution that this term has experienced over such a long period of its existence.
It took many years for this once rather rough concept, originally used to describe a state balancing “between neurosis and psychosis,” to acquire its modern meaning as a definition of a disorder characterized by pronounced tendencies towards emotional lability, impulsivity, irritability and self-destructiveness (Stone, 1980, 1986). For sixty years, from the 1920s until 1980, when the third edition of the Diagnostic and Statistical Manual (DSM-III) was published, the term “borderline” was widely used in psychoanalytic circles rather than among adherents of traditional psychiatry. . The basis for the new definition was extensive excerpts from the work of Adolph Stern (A. Stern, 1938), indicating the possibility of successfully overcoming emotional collapse caused by stress. This was followed by the more precise, although at the same time rather broad, criteria of Kernberg (1967), and later by the succinctly formulated and practical criteria proposed by Gunderson and Singer (1975).

When was the concept of borderline personality disorder first introduced? new section("Axis-II") of the third edition of the Diagnostic and Statistical Manual, the eight-paragraph article was a fusion of the formulations of Kernberg and Gunderson. The current definition in the fourth edition of the Diagnostic and Statistical Manual (DSM-IV) is identical to the first, with the exception of one additional paragraph, based on Gunderson's research, regarding “brief psychotic episodes.”

Due to the fact that the Diagnostic and Statistical Manual is widely used in clinical practice, diagnostic criteria have now become more stringent (compared to the Kernberg criteria). According to modern “standards”, a more severe degree of pathology is considered a convincing basis for making a diagnosis of borderline personality disorder. This is explained primarily by the fact that borderline personality disorder, in essence, is not characteristic of all patients whose condition meets Kernberg’s criteria, among which, along with the blurring of identity and a decrease in the ability to adequately assess reality, Kernberg calls impulsivity, increased sensitivity to stress and the inability to overcome the consequences of serious stress through health procedures. This condition Kernberg himself calls it the “borderline personality organization.”

Currently, the Diagnostic and Statistical Manual definition of borderline personality disorder is considered the standard definition within general psychiatry, although many psychoanalysts still use the broader criteria proposed by Kernberg. Most patients with borderline personality disorder are characterized by increased aggressiveness, a tendency to demonstrate suicidal actions, as well as impulsiveness in communicating with others, especially with loved ones. However, even in the absence of these signs, the patient's condition may meet the diagnostic criteria for borderline personality organization, although most patients are characterized by the full range of these signs. This difference has special meaning for clinical practice.
Therapeutic methods recommended in psychoanalytic literature and promoted by clinicians such as Helene Deutsch (1942), Melitta Schmideberg (1947), Robert Knight (1953), John Frosch (1960), Otto Kernberg (Otto Kernberg, 1967; 1975), Robert Wallerstein (1986), and others (Clarkin, Yeomans, & Kernberg, 1999), are generally intended for patients who exhibit more moderate self-destructiveness and irritability than those with borderline personality disorder. The patients described in the psychoanalytic literature on this issue fit more or less into the clinical picture that Kernberg, in his 1967 article, calls borderline personality organization, and only a small proportion of such patients show a tendency to self-mutilate ( opening veins, burning the skin with cigarettes, etc.) or committing demonstrative suicidal acts. In addition, psychoanalytic works usually involve patients who have received a good education and occupying a stable social and financial position, although not all patients suffering from borderline personality disorder meet these criteria. Issues related to these important differences will be addressed below when we discuss the variety of modern therapeutic methods, each of which has proven itself better in working with a specific group of patients suffering from borderline personality disorder.

Various manifestations of borderline personality disorder

Before considering special therapeutic methods, which are now widely used, we turn to the problems associated with heterogeneity among patients with borderline personality disorders. Even if we limit ourselves to cases of borderline personality disorder, not to mention borderline personality organization, we cannot fail to note the diversity of etiological and social factors, as well as clinical subtypes, which largely determine the treatment strategy. Thus, the clinical approach must take into account the individual characteristics of each borderline patient.

Concerning etiological factors, then borderline personality disorder usually affects those patients whose impulsivity and increased irritability were a reaction to trauma suffered in childhood, in particular to incest. Women are victims of incest more often than men, and therefore the number of women suffering from borderline personality disorder exceeds the number of men with the same disorder by two to one, and in some cases by 5-6 times (Stone, 1989; Zanarini, 1990 ; Paris, 1993). Another factor contributing to the gender disparity among patients with borderline personality disorder is the greater predisposition of women to depression. Influenced depressive states in combination with increased irritability can also occur clinical picture borderline personality disorder. For example, according to the results of a long-term follow-up study conducted at the New York State Psychiatric Institute, many patients with borderline personality disorder who were not victims of incest had severe depression, and depression was consistently inherited in their families. various diseases manic-depressive (Stone, 1990). In other groups of patients with borderline personality disorder, the main factors influencing the formation of pathology were a predisposition to attention disorder combined with hyperactivity, a tendency to “episodically” lose control over oneself, which was more often observed in young men (Andrulonis et al., 1981), or affective disorders, including manic depression (Akiskal, 1981; Stone, 1990).

The task of choosing the optimal type of treatment is complicated by the various comorbidities and “admixtures” of other disorders that are characteristic of almost all patients whose condition, in accordance with the criteria proposed in the fourth edition of the Diagnostic and Statistical Manual, allows a diagnosis of borderline personality disorder. The most common among concomitant diseases or complications, is a pronounced affective disorder, which may take the form of severe or manic depression. The disorder ranks second among comorbidities eating behavior, more common among women. It's about, first of all, about anorexia nervosa and bulimia nervosa. In some cases, attacks of anorexia and bulimia alternate. Women with borderline personality disorder often experience increased symptoms (depression and irritability) during the premenstrual period (Stone, 1982). Among pathological conditions arising against the background of borderline personality disorder can also be called panic disorder, obsessive-compulsive disorder and dissociative disorder, although symptoms of these diseases are less common. In addition, it has been noted that many patients with borderline personality disorder tend to abuse either alcohol or marijuana, but often do not limit themselves to a specific stimulant and use a range of drugs (cocaine, LSD, angel dust, PSP, heroin, etc. .). In each of the above cases, it is necessary to use special treatment methods. A similar approach would be ideal in the treatment of patients with latent borderline personality disorder.

Many of these symptomatic disorders are associated with unhealthy “cravings” for food, drugs, etc. The optimal type of treatment for such disorders is special 12-step treatment programs: the Alcoholics Anonymous program (in the case of alcoholism) and Narcotics Anonymous (in the case of heroin and cocaine addiction), as well as an anonymous program for people prone to overeating (in the case of bulimia), etc. Currently, special treatment programs have been created even for people who exhibit an unhealthy addiction to gambling and sex (for example, the Sexaholics Anonymous program). In other cases, the clinician usually has the option of turning to drug therapy. When treating patients with borderline personality disorder combined with a mood disorder, antidepressants and tranquilizers, alone or in combination, are often used successfully. The use of serotonin blockers is advisable in the treatment of patients suffering from borderline personality disorder in combination with post-traumatic stress disorder, as well as patients suffering from obsessive disorders or depression (Markowitz et al., 1991). Patients with borderline personality disorder often exhibit “impulsive aggression,” which is an indication for the use of serotonin blockers (Coccaro & Kavoussi, 1997). A variety of medications (including antidepressants, anxiolytics, and bromocriptine) can be used to mitigate the symptomatic reaction during the premenstrual period and should be selected empirically based on the individual susceptibility of each patient.

It should be noted that cases of “pure” borderline personality disorder (and even more so borderline personality disorder) are extremely rare. Based on data presented by Oldham and colleagues (Oldham et al., 1992), borderline personality disorder may co-occur with more than three other personality disorders listed in the Diagnostic and Statistical Manual. Borderline personality disorder is “dramatic” in nature, so it seems quite natural that the accompanying personality disorders are mostly included in the so-called Dramatic Section of the Diagnostic and Statistical Manual (Dramatic Cluster, Cluster B), where, along with “borderline state”, they appear narcissistic, histrionic and antisocial personality disorders (Zanarini, Frankenberg, et al., 1998). However, patients with borderline personality disorder may exhibit other tendencies, in particular, addiction, avoidance, obsessiveness and paranoia. Kernberg pointed out this characterological diversity back in 1967. In an article he published, he listed some common subtypes within the borderline personality organization, in particular, “infantile” (or histrionic, in the terminology of the Diagnostic and Statistical Manual), hypomanic, paranoid and depressive-masochistic . When treating patients belonging to the depressive-masochistic subtype, the prognosis is usually more favorable than when treating patients exhibiting hypomanic or histrionic tendencies, regardless of whether the criteria proposed in the Diagnostic and Statistical Manual are used when making a diagnosis, or Kernberg criteria. Roy Grinker and his colleagues (Roy Grinker et al., 1968) also noted the presence wide range types of borderline disorder in his scheme, mentioning, among others, the “as if” subtype and the anaclitic-depressive type, which is closest in a functional sense to neurotic disorders. In the case of borderline anaclitic-depressive disorder, the prognosis seemed to be the most favorable. In my long-term follow-up study of 299 patients with borderline personality disorder, of whom 206 patients met the criteria specified in the third edition of the Diagnostic and Statistical Manual, the least success in comparison with other types of disorder, with the exception of antisocial, for which treatment results quite naturally were the most insignificant, it was possible to achieve in the treatment of individuals who exhibited increased irritability and excitability. In general, patients with borderline personality disorder, who are characterized by anger and hostility, regardless of the type of disorder, respond less well to treatment, if only because they are sometimes negatively affected by the very fact of being forced to separate from those on whom they depend, whether either relatives, close friends or therapists.

In addition, clinicians should take into account that the results of therapy and, to some extent, the choice of therapeutic methods are influenced by some other factors associated with the patient, but not related to the characteristics of his personality. For example, according to the results of a study conducted by McGlashan (1986, Chestnut Lodge), and my own long-term follow-up study of the P.I. 500, positive indicators for therapeutic prognosis are high intellectual level, visual attractiveness, artistic talent and the ability to self-discipline. When patients suffering from borderline personality disorder combined with alcoholism joined Alcoholics Anonymous and found the strength to follow the recommendations to the end, the results of therapy were successful. Obviously, in this case we should talk not only about high degree motivation to overcome the disorder, in which the presence of the disease is not denied, but is recognized, but also about the ability to self-discipline. Self-discipline and motivation can be seen as positive personal factors along with being talented and good looking. However, all these features should be perceived only as auxiliary therapeutic agents, regardless of the type of therapy.

Therapeutic approaches to treating borderline personality disorder

Currently, a variety of approaches have been developed within the framework of conversational psychotherapy, which are widely used in the treatment of patients suffering from borderline personality disorder. Therapists do not have a universal treatment method. However, some basic methods prove to be the best side exclusively or predominantly in the treatment of certain patients. Therefore, in the process of treating other patients, the therapist can rely on one therapeutic approach (especially since during training, therapists master one specific method of treatment), from time to time, if necessary, additionally involving other therapeutic methods. The combination of various therapeutic methods is of particular importance in the treatment of inpatients with borderline personality disorder, when the clinical picture is complex: multiple symptomatic disorders, frequent suicide attempts, obvious impulsivity, drug addiction. In such cases, it is necessary not only to carry out complex treatment, but also to correctly outline the sequence of application various methods.
The main therapeutic approaches can be divided into three broad categories:
1. Supportive psychotherapy.
2. Psychotherapy of psychoanalytic orientation.
3. Cognitive/ behavioral psychotherapy.
Each of the above categories lends itself to further subdivision. For example, psychoanalytically oriented psychotherapy includes a number of therapeutic approaches, notably Gunderson's exploratory therapy, Kernberg's transference-focused therapy, Kohut's (1971) therapy, which draws on the principles of self psychology, and therapeutic methods developed earlier by Edith Zetzel. Zetzel, 1971), Melitta Schmiedeberg (1947) and others. Due to the fact that one of the essential features of borderline psychopathology is impulsivity, which is mentioned in all definitions of the “borderline state” (Stone 1980, p. 273) and the “cure” for which is the setting of restriction, the importance of this aspect of therapy is noted in within any approach. In his book entitled Supportive Psychotherapy: A Dynamic Approach, Rockland (1992) mentions limit setting among other essential interventions designed to support the patient. Kernberg (1993) emphasizes the importance of a limiting mindset in the context of transference-focused psychotherapy, while Gunderson (1984) makes a similar point when talking about psychoanalytically oriented psychotherapy. In a monograph devoted to the problems of dialectical behavior therapy, Linehan (1993) also points out the importance of regulation and necessary restrictions. Despite the fact that, from a tactical point of view, such an attitude is essentially part of behavioral therapy, the importance of this method in the treatment of patients with borderline personality disorders is so great that it can hardly be considered an element of only one of the above therapeutic approaches.

Supportive psychotherapy

In the context of psychotherapy with patients with borderline personality disorder, Rockland (1989) mentions a number of support techniques along with the limit mindset. In general, supportive psychotherapy is aimed at specific goal V to a greater extent than psychoanalytic therapy. Meanwhile, the therapeutic alliance plays a key role in all types of psychotherapy, and within the framework of supportive psychotherapy, the therapist is already initial stage treatment to create such an environment directly indicates that the patient and therapist will make a joint effort to solve the patient's problems, emphasizing to the latter that the therapist is “here” for the patient and is therefore extremely interested in helping and collaborating with him. Thanks to this, the patient begins to feel less lonely and helpless.

Support methods that have proven themselves in the treatment of patients with borderline personality disorders include an agreement on the procedure of therapy, which is concluded between the therapist and the patient before starting treatment, encouragement, the ability to reassure and encourage, providing advice and recommendations, creating a kind of “container” " (as Winnicott put it) for the patient's powerful emotional outbursts, indirect intervention (for example, involving the patient's relatives in emergency cases), revising the patient's statements from a more realistic point of view (similar to the explanation within psychoanalytic therapy), willingness to praise the patient for real achievements, strengthening its defense, providing intellectual interpretations (which help shed light on the causes of some conflicts without the need for “deep” analysis, the inertia of which can be irresistible), and the use of “approximate interpretations” (Glover, 1931) in the event that Such interpretations, despite their inaccuracy, help relieve anxiety. Another important element of supportive care is education, which is not always limited to advice and recommendations. Quite often, patients with borderline personality disorder do not comply with the rules of behavior (they are late for sessions, react inappropriately to various situations, forget to pay for treatment, etc.). Additionally, patients with borderline personality disorder may ignore the risk of infection venereal diseases and not being aware of what behavior is dangerous. In such cases, training becomes especially important.

Typically, maintenance psychotherapy for patients with borderline personality disorder involves one therapy session per week, ranging in length from half an hour to an hour, although sometimes two sessions per week are performed during the initial phase of treatment. Given the fact that many patients suffering from borderline personality disorder have suffered childhood trauma, as well as the vulnerability of such individuals and the complete turmoil in their current lives, it must be recognized that a “quick fix” is unlikely to be possible. IN ideal conditions therapy, which takes several years (from five to ten), leads to complete stabilization of the patient’s condition, regardless of therapeutic approach.

Cognitive and behavioral psychotherapy

In the context of treating patients with borderline personality disorder, cognitive and behavioral therapy uses a number of fundamental strategies that have no analogues in supportive psychotherapy or psychoanalytically oriented psychotherapy. The general “philosophy” and special methodology of cognitive and behavioral therapy are described in detail by Aaron Beck and Arthur Freeman in a book devoted to the problems of treating personality disorders (A. Beck & A. Freeman, 1990). Behavioral therapy and psychoanalytic psychotherapy practitioners alike emphasize the need to “identify and address core issues” (p. 4), but approach this task differently. From a psychoanalytic perspective, core issues and conflicts are unconscious (and therefore difficult to access). Specialists who practice cognitive therapy assume that such problems are mostly conscious in nature. Therefore, the goal of cognitive therapy is to increase the level of conscious awareness of hidden problems. As Beck and Freeman note, the cognitive therapist's work "occurs simultaneously at the level of the symptomatic structure (overt problems) and at the level of the 'underlying schema' (implicit structure)" (p. 4). It is believed that the behavior of an individual, including the inappropriate behavior of patients suffering from personality disorders, is structured in accordance with these patterns.
Patients suffering from borderline personality disorder are characterized by certain patterns of insufficient adaptation, formed under the influence of childhood experiences. Beck and Friedman note nine such schemes with the characteristics inherent in each of them: 1) alienation and loss (the specific expression of which is subjective feelings associated with loneliness and lack of support from others); 2) inability to love (as a result of which the individual is convinced that not a single person from those who knows him well will want to get close to him); 3) excessive dependence; 4) subordination; 5) lack of trust (combined with fears that others are always ready to take advantage of them and offend this individual); 6) lack of self-discipline (which is expressed in impulsiveness and inability to control oneself); 7) fear associated with the risk of losing control over emotions; 8) a feeling of guilt (which is expressed in the fact that the individual condemns himself as a “bad” person); 9) emotional deprivation (the individual’s conviction that no one can understand him).

Patients with borderline personality disorder are more likely than others to experience what Beck (1976) calls dichotomous thinking. The latter is a special case of cognitive deviation, due to which events Everyday life perceived by the individual as either unconditionally good or unconditionally bad. Due to the lack of ability to capture the halftones of black and white flowers Patients with borderline personality disorder tend to show increased sensitivity to the most insignificant remarks from relatives and lovers, dramatically changing their perception of the “offender”, who immediately turns into a disgusting and hostile person for them. Meanwhile, pleasant episodes associated with a long-term relationship between the patient and his partner are forgotten due to momentary disappointment. Of course, this tendency also manifests itself in the course of psychotherapy. At the moment of positive experiences, patients adhere to no less extreme positions. At the same time, the idealization of a partner seems as unrealistic as the hatred that arises in connection with negative experiences. Extremes in reactions result in equally exaggerated emotions and extremes in behavior (impulsiveness, destructive behavior: promiscuity, drunkenness, aggressiveness), which is characteristic symptom"borderline state". The goal of cognitive and behavioral therapy is to help the patient distinguish between the tones of black and white and learn to respond more calmly to unpleasant events in everyday, professional and intimate life.

In recent years, one of the most prominent representatives of this therapeutic trend has been Marsha Linehan. She proposed a detailed methodology for treating patients with borderline personality disorder who (like most such patients) engage in self-harm and suicidal behavior. The proposed technique is designed to enable patients to gradually get rid of destructive tendencies and make a choice in favor of more acceptable ways of interacting with others. The principles of such therapeutic intervention are outlined in Linehan's book Dialectical Behavior Therapy (DBT, 1993). In addition, a practice manual for dialectical behavior therapy has now been released. In practice, dialectical behavior therapy is a treatment program that is typically delivered at a frequency of one individual session per week and one group session per week. In this case, the patient gets the opportunity to call the therapist by phone if he is close to committing one or another self-destructive action. Telephone contacts are allowed provided that such an act has not yet been committed, since the purpose of these contacts is to help the patient find a more acceptable solution to a particular problem. (In parentheses, we note that women are more likely to open their veins than men.) At the very beginning of therapy, during the preliminary session, the patient is informed of the terms of the mutual agreement, according to which he has no right to call the therapist if the act has already been committed. This pattern of relationships serves as a kind of conditioning mechanism: self-control is encouraged by permission to telephone contact with the therapist, and impulsivity entails a ban on such contact. Based on reports from Linehan and her colleagues, the methods they practice have proven to be effective. Patients receiving dialectical behavior therapy showed greater reductions in self-destructive behavior and suicide attempts than a control group of patients with borderline personality disorder who received “traditional therapy” (usually supportive therapy).
It should be noted that Linehan, mentioned in the report, “ traditional therapy” included significantly fewer individual sessions throughout the week. The question therefore arises, is the superiority of dialectical behavior therapy due to the effectiveness of the new technique or the frequency of individual sessions with a therapist who could achieve equally impressive results if he practiced supportive therapy or psychoanalytic psychotherapy with the same frequency? In addition, we do not have data on stability therapeutic effect, achieved by Linehan and her colleagues, since no long-term follow-up studies (over 10 years or more) focusing on such a technique have yet been reported.

If we consider the restriction mindset as a method of “support”, then it should be recognized that dialectical behavior therapy (as well as any form of effective therapy patients with borderline personality disorder) borrowed tactics from supportive therapy. Typically, cognitive and behavioral therapy (including dialectical behavior therapy) takes little account of transference and countertransference experiences. However, Linehan uses countertransference interpretations to great effect.

An illustration is provided by a case study described by Linehan. We are talking about a patient who repeatedly expressed a desire to commit suicide due to severe professional stress, along the way hinting that Dr. Linehan could not even imagine the full horror of the situation, since she had achieved success in her professional activities and was already “out of reach” for similar stressful experiences. After listening to this patient, Dr. Linehan countered, “Believe me, I can understand. I myself constantly have to deal with stress. You can’t imagine how difficult it is to deal with people who constantly threaten to commit suicide” (p. 395). This phrase by Linehan belongs to the category of paradoxical reactions that are included in the arsenal of dialectical behavior therapy, along with other strategies described in the same work (p. 296). A practitioner of dialectical behavior therapy may use metaphors, play the role of “devil’s advocate”, advocate compromises (when communicating with patients suffering from typical borderline personality disorder and prone to extremes), and make generalizations (similar to interpretations within the framework of psychoanalytically oriented psychotherapy) etc.

From a theoretical point of view, the goals of dialectical behavior therapy are dictated by clinical observations, which lead to the conclusion that, in general, the problems characteristic of patients suffering from borderline personality disorder fall into two main categories: problem behavior and limitations. Problematic behavior is often associated with increased irritability, which complicates close relationships, and also takes the form of self-destructive actions, be it demonstrative and genuine suicide attempts or self-harm, such as cuts and burns. Limitation is expressed in the form of insufficient emotional regulation, distorted ideas about sex life and interpersonal relationships, awkwardness in communicating with friends and colleagues. Individual sessions, which are an integral part of the course of dialectical behavior therapy, are focused primarily on changing problem behavior, while training in communication skills is designed to eliminate limitations. Individual therapy focuses on a thorough analysis of maladaptive behavior. The therapist invites the patient to analyze certain difficult situations after the fact and choose a more effective way to solve the problems associated with them, or gives the patient relevant advice, recognizing that finding a way out of the current situation was not easy, but at the same time pointing out the need for changes and the development of a more constructive approach . During the therapeutic process, in connection with the discussion of issues related to a “more constructive approach” and learning more effective ways solving various problems, the patient gradually (partly thanks to group therapy) begins to learn new communication skills, which can be judged by changes in his behavior.

Psychotherapy of psychoanalytic orientation

The development of a psychoanalytic approach to the treatment of patients with borderline personality disorder has a long history, which is reflected in the relevant scientific literature. In one of my papers (Stone, 1980), I listed the various names that have been given to this approach since the 1920s. The terms exploratory psychotherapy (Gunderson, 1984), expressive psychotherapy (Kernberg, 1975), and transference-focused psychotherapy (Clarkin, Yeomans, & Kernberg, 1999) are now widely used.

It should be noted that there are much more similarities between the listed approaches than differences. This applies to all therapeutic techniques that do not correspond to the classical model of psychoanalysis: during the session the patient is in a sitting position and not lying on the couch; the therapist is much more actively involved in the dialogue with the patient and often allows himself to interrupt the patient’s long pauses with remarks at the first session; explanations and interpretations focus on the here and now rather than on childhood experiences; the therapist is more willing to intervene in the event of signs of danger and alarming symptoms; in general, the therapist takes a more active position than is customary when working with patients who are characterized by a relatively stable state (corresponding, according to Kernberg’s definition, to a neurotic rather than a borderline level of personality organization).

Other approaches to the treatment of patients with borderline personality disorder include the interpersonal method developed by Harry Sullivan3 (Harry Stack Sullivan, 1953) and his followers, among whom Harold Searls (1986) deserves special mention, as well as the Heinz method of self psychology Kohut (Heinz Kohut, 1971). When defining a “borderline state,” the above-mentioned authors use less strict criteria than Kernberg and the authors of the corresponding section of the Diagnostic and Statistical Manual, although in general their criteria are closer to Kernberg’s lengthy definition. Essentially, Kohut stated a “borderline state” not based on the results of the initial interview (as is customary when making a diagnosis), but rather due to the lack of an adequate response on the part of the patient after several months of therapy in a traditional psychoanalytic setting using the couch. Searles pays special attention to countertransference, considering the latter as an indicator of repressed emotions redirected to the therapist (through the defense mechanism of projective identification).

For example, a young woman with borderline personality disorder, consumed by jealousy of her older sister, who is more attractive and well-adjusted, refuses to acknowledge her jealousy and talks incessantly about the incomparable qualities of her former boyfriend, without allowing the therapist to say a word. As a result, the therapist begins to feel jealous of this example of masculinity, in comparison with which the therapist looks much more modest in the eyes of the patient. Having finally noticed his jealousy, the therapist understands that we are talking about a “foreign emotion” that the patient intentionally aroused in him. This observation, in turn, allows him to bring up the topic of jealousy in conversation (for example, as follows: “Do you think there is any connection between the jealousy I feel when you praise your friend and your personal life?” ). And only after this the patient begins to talk for the first time about the fact that she experiences jealousy towards her more successful sister, which she hid for a long time and refused to admit.

Transference-focused psychotherapy

As expressive therapy was refined by Otto Kernberg and his colleagues (Kernberg, 1975, 1984; Kernberg, Selzer, et al., 1989), practices were developed for this therapeutic approach, now referred to as transference-focused psychotherapy (Clarkin, Yeomans, & Kernberg, 1999).
From a theoretical point of view, the basis for transference-focused psychotherapy was object relations theory, the principles of which were outlined by Kernberg in many articles published beginning in the mid-1960s (Kernberg, 1967, 1975, 1980). According to Kernberg's theory, patients in a borderline state (which is viewed through the prism of a more extensive category of borderline personality organization or its subtype - borderline personality disorder), unlike people suffering from psychosis, are able to distinguish themselves from another person, but cannot combine your perception of positive and negative aspects of your own personality or the personality of an important participant in the relationship. Due to the fact that the individual uses the primitive defense mechanism of “splitting,” the ability to realistically and holistically perceive one’s own personality and the personality of another person is reduced.
Clinicians observe this defense mechanism in action when a patient with borderline personality disorder evaluates others, including the therapist, as exclusively positive (“idealized”) or exclusively bad people, without distinguishing the nuances of interpersonal relationships. In addition, patients with borderline personality disorder often dramatically change their opinion about this or that person, and can throw mud at someone whom they idolized a moment ago, and vice versa. The patient may completely deny unwanted and unacceptable feelings (without being aware of them), disown such feelings (that is, be aware of them but not acknowledge them), or project these feelings onto another person, such as the therapist, like the jealous patient mentioned above.

According to Kernberg, patients with borderline personality disorder tend to exhibit abnormalities related to impulsivity, affect, and identity, individually or in various combinations. Despite the fact that impulsivity can manifest itself in different ways, its characteristic feature is the rapid transition from thought to action (which leads to what is called “passer a l’act” in French psychiatry). In such cases, the action is usually thoughtless and inappropriate. Affective disorder is expressed, as a rule, in the form of emotional lability and a tendency to sudden changes in mood and opinion about the people around them (“idealization” is replaced by contempt, and exaggerated tenderness by unjustified hatred).

Dysfunction of emotional regulation often plays a key role in the process of blurring identity: the emotional life of patients suffering from borderline personality disorder consists of many successive short and contrasting episodes, each of which is dictated by the last, positive or negative, experience in communication with a loved one. At the same time, the cause of hatred towards a loved one can also be a completely trivial event. For example, a woman suffering from borderline personality disorder may suddenly change her opinion of her husband if he did not notice that she styled her hair differently. The patient, who is vaguely aware of his tendency to rapid mood swings, faces difficulties in determining his “true” attitude towards this or that person and asks the questions: “Do I love him or hate him?” “Am I a good person or a scoundrel?” The main task facing transference-focused psychotherapy is to eliminate such “splitting” and help the patient develop a more holistic view of himself and others, which, in turn, leads to desired changes in his behavior.

Understanding the features of operation defense mechanisms characteristic of patients suffering from borderline personality disorder, allows you to choose the right direction for therapy. In order for the patient to be able to form a more complete picture of himself and those around him, it is necessary to eliminate the “splitting”. Thanks to this, relationships between the patient and people close to him - relatives, sexual partners, spouse, friends, work colleagues - become more harmonious. The tendency to extremes and sudden changes in mood soon manifests itself in a transference situation. Constant fluctuations between idealization and contempt, love and hatred, self-deprecation and arrogance become a characteristic feature of the attitude towards the therapist. Patients with borderline personality disorder rely on “actualizing the transference” rather than understanding it. In other words, they try to turn the therapeutic relationship into a friendship or love affair, or into real hostility, from which they can only escape. In order to eliminate such tendencies, the patient should be helped to refuse actions and learn to express in words those emotions that push him to unacceptable actions.

As mentioned, some of the most common unacceptable behaviors experienced by patients with borderline personality disorder include suicide attempts and self-harm. In addition, such patients often exhibit risky sexual behavior (eg, casual sex with strangers), alcoholism, drug use, anorexia, or bulimia. Often, patients with borderline personality disorder create a tense environment in communication with the therapist, refusing to leave the office after the end of the session, threatening the therapist, throwing various objects at him, skipping sessions without warning, not paying bills, making overt attempts to seduce the therapist, or refusing to complete the course. therapy.

Under ideal conditions, transference-focused psychotherapy occurs at a frequency of 2-3 sessions per week. Before starting treatment, the therapist and the patient enter into a mutual agreement, which stipulates the procedure for conducting therapy: frequency of sessions, conditions for telephone contacts, etc. The therapist informs the patient about the primary tasks that will be solved during the course of treatment. Attention is paid primarily to those problems that cause the patient the greatest concern and seem potentially dangerous. During each session, the degree of impact of such affects on the patient is assessed through the use of three communication channels: verbal communication, non-verbal communication (gestures, facial expressions of the patient, etc.) and countertransference.

When choosing priority tasks, the therapist can rely on practical recommendations Linehan and Kernberg, which represent a kind of algorithm for this technique. Essentially, the proposed algorithms form the basis of any effective therapy and therefore cannot be considered specific feature transference-focused psychotherapy or dialectical behavior therapy. According to Linehan, threats or behavior related to suicidal tendencies should be taken into account first, since ignoring these problems can have dire consequences. Secondly, the therapist must remember that such patients can interrupt the course of therapy at any moment, because they are impulsive and lack patience. Thirdly, attention should be paid to symptomatic conditions that threaten the patient’s health: drug addiction, anorexia, severe depression. Fourthly, it is necessary, as far as possible, to eliminate or mitigate symptoms that do not pose an immediate threat to the patient’s life: dysthymia, increased irritability during the premenstrual period, bulimia, social phobia. Fifthly, you should pay attention to characteristics patient's personality, associated with a lack of adaptive abilities and interfering with optimal functioning. Sixth, it is necessary to analyze the patient's ambitions, hopes and aspirations (determining the degree to which they are realistic).

In transference-focused psychotherapy, addressing issues related to suicidal (or aggressive) tendencies is also considered a priority. Second priority is given to eliminating the obvious threat of premature cessation of therapy. Then, in descending order of importance, are problems related to deception or concealment (in which any intervention by the therapist fails) and violation of the contract between patient and therapist (for example, non-compliance with prescribed medications). The next point is symptomatic behavior in sessions, for example, refusal to leave the room after the session time has expired, being late, attempts to seduce the therapist, etc. In addition, some importance is attached to issues related to acting out between sessions and the desire to reduce minimize the content of sessions through conversations on random and superficial topics. Latest questions associated rather with the psychoanalytic aspects of transference-focused psychotherapy. However, as noted above, in connection with the dialectical behavior therapy algorithm, specialists practicing transference-focused psychotherapy also pay attention to the serious and less serious symptoms observed in patients with borderline personality disorder.

According to leading theorists of transference-based psychotherapy (Clarkin, Yeomans, & Kernberg, p. 9-10), this type of therapy is characterized by features characteristic of most forms of psychodynamic psychotherapy, namely a strict framework of therapy, more active participation of the therapist than with analysis of patients suffering from neuroses, restraining the patient’s hostile feelings and aggressive emotions, the desire to eradicate the tendency to self-destructive behavior through confrontation, the use of interpretations that allow establishing a connection between feelings and actions, focusing on what is happening “here and now,” setting limits and close attention to countertransference experiences (Waldinger, 1987).

Unlike Kohut's methods, transference-focused psychotherapy does not involve counseling or other supportive interventions. In addition, transference-based psychotherapy places greater emphasis on negative transference. Along with explanatory and interpretive methods, confrontational methods play a key role in transference-focused psychotherapy (with obvious contradictions in the patient's statements, with inconsistent statements regarding certain participants in the relationship, with the threat of self-destructive behavior or behavior that is dangerous to therapy). That's why this type therapy differs from other forms of therapy for patients with borderline personality disorder.

Of course, confrontation in practice has nothing to do with the use of torture during cross-examination. The point is that the therapist invites the patient to reconsider his own contradictory statements, the paradoxical nature of which the patient might not have been aware of. For example, the therapist might say: “I noticed that at first you claimed that with the death of your father you lost your dear person on the ground, but the next moment you stated that your father sexually abused you when you were still a teenager. It seems strange to me that, remembering your father, you only called him a “dear” person.”

As Clarkin and his colleagues note (Clarkin et al., p. 2), important strategies for transference-focused psychotherapy include: analysis of the underlying principles of the patient's object relations as they assert themselves in the transference situation; analysis of “role reversal” during therapy; a combination of strictly separated positive and negative ideas about oneself and others. Patients with borderline personality disorder tend to change roles periodically during therapy. At one session, the patient, with all his appearance and behavior, tries to emphasize a respectful attitude towards the therapist, and at the next session, he strives to humiliate the therapist with insulting remarks, as if the patient had turned into a “grumpy parent”, and the therapist plays the role of the “pupil” that the patient himself was in the past. childhood. In order to help the patient free himself from the tendency to rapidly change roles, to understand the nature and causes of this phenomenon, the therapist encourages the development of integrative processes on which the success of therapy depends. In this way, the therapist prepares the ground for more constructive and harmonious relationships, which are an important stage in the healing process of patients with borderline personality disorder, taking into account their inherent feelings of loneliness.

Group psychotherapy

Treatment programs for patients with borderline personality disorder commonly include different kinds group psychotherapy. The opinion is often expressed that group psychotherapy is an important additional element of individual psychotherapy (based, as a rule, on one of the approaches described above) and has proven itself well, in particular, at the initial stage of pharmacotherapy, when symptoms corresponding to the “second axis” predominate ( "Axis-II").

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 especially typical for persons with borderline, histrionic, narcissistic disorder. 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 disturbances of perception and crazy ideas, which may 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, consider medications as a tangible means of self-control and suppression of unwanted actions. 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.

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).

At individual treatment Personality disorders have 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) did interesting message about 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 regarding drug treatment, frequent requests for assurances of constant readiness to provide assistance, telephone calls at the most inopportune times and attempts to impose unrealistic treatment conditions. Indirect requirements are expressed in various forms ah, for example, in seductive behavior, threats to commit dangerous actions such as taking an excessive dose of medication, repeated unfavorable comparisons of current treatment with those in the past. 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 physician should try to gradually penetrate through these “intellectual barriers” and help the patient become aware of his emotional problems. Only then can the doctor begin to look for ways to solve them. IN best case scenario it is a slow process and often ends in failure.

Borderline personality disorder

Patients with borderline personality disorder do not give positive reaction for exploratory psychotherapy, moreover, attempts at such treatment can worsen their emotional control and strengthen. It is usually best to use supportive treatment, focusing all efforts towards practical goals related to solving everyday problems.

Personality disorders are a range of mental disorders that involve disturbances in consciousness, feelings, thoughts and actions. Previously, this deviation was called constitutional psychopathy.

general information

A person with a personality disorder completely changes their behavior. In social circles, behavior may differ from what is generally accepted and “normal.” This type of psychopathy is accompanied by destruction of consciousness. Each person experiences the disorder differently. “Lighter” forms only distort the idea of ​​the world around us and people, while the severe course of psychopathy leads to antisocial behavior and lack of control over one’s actions. The symptoms of the disorder are as follows:

Causes

Personality disorder most often manifests itself in adolescents. In this case, the disease progresses and worsens the person’s condition in adulthood.

According to WHO (World Health Organization, labeling F60-F69), every 20th person suffers from constitutional psychopathy.

As a rule, chronic and severe forms appear quite rarely.

The following aspects influence the development of the disorder:

Are personality disorders treatable?

It is impossible to answer this question unambiguously. To do this, you need to study 3 types of personality disorders. Their treatment is prescribed individually, based on the degree and type of disease:

Personality disorder can be treated if mental disorder was discovered at an early stage. As a rule, many are embarrassed or afraid to visit a psychotherapist who would help fight their internal “demons.”

In 80% of cases, psychopathy ends in serious complications, which are accompanied by inappropriate behavior and communication problems. It all depends on the type and type of disorder. If there genetic predisposition, then treatment will be difficult, long and ineffective. If psychopathy is acquired, then with the help of regular psychological assistance, attending trainings and using medications, a person will be able to lead a full life.

What is avoidant personality disorder?

In clinical psychology, this type of psychopathy is called anxious or avoidant. It most often occurs in adolescents and young adults aged 16 to 25 years. The reason is indifference, aggression, violence from parents, guardians and peers.

Manifestation of anxiety disorder:

This type of psychopathy is serious disorder, which is examined and treated in rare cases. Deviation can only be detected in a clinical setting.

Diagnosis of psychopathy

Only a psychiatrist can make a clinical diagnosis and prescribe treatment. If the cause of the personality disorder is head injuries or tumors on the soft tissues, then the patient is referred to a neurologist and surgeon, as well as for anamnesis collection: X-ray examination, MRI and CT.

The cases in which diagnostics are needed are listed below:

Before making a diagnosis, a psychiatrist conducts dozens of tests and observes the patient. At this moment, it is very important to be open and not hide your past, especially if the issues affect relationships with parents and peers.

Treatment of personality disorder

Two techniques are used to treat personality disorder. Treatment methods consist of medications and psychotherapy.

Treatment with medications is prescribed if psychological help Does not help. Indications for use: depression, anxiety and paranoia. Typically, selective serotonin reuptake inhibitors (SSRI label), anticonvulsants and sedatives are used. For example, the most effective antidepressant- This is Amitriptyline. It not only reduces anxiety, but also affects the central nervous system as an antiserotonin drug. Antipsychotics include Haloperidol, Aminazine, Olanzapine and Rispolept.

Neuroleptics are psychotropic drugs, which help with hallucinatory, paranoid and delusional disorders. Neuroleptics are prescribed for treatment severe forms personality disorders, which are accompanied by depression, manic agitation. The most powerful drugs are determined by the amount of chlorpromazine and its antipsychotic effect. The weakest ones are estimated at 1.0 coefficient, the strongest ones reach 75.0.

It is a proven fact that medical supplies They do not cure the root cause, but only muffle and calm the emotional state.

Also, medications are intended to relieve painful symptoms (anxiety, apathy, anger). The job of a psychiatrist is to analyze the patient and create an overall picture.

In order for treatment to be effective, rules are introduced. For example, control aggression or anger, change your thinking and attitude towards life. With a personality disorder, individual therapy is recommended first so that the specialist gains confidence in the patient. Then group classes are introduced. On average, psychotherapy takes 2-4 years.

If you ignore problems mental health, this can lead to the development of new mental illnesses. Against the background of constitutional psychopathy, schizophrenia appears, paranoid, expansive and fanatical personalities develop, as well as psychosis, delusional disorder and Asperger's syndrome. It is important to remember that if you have a personality disorder, you should not self-medicate or ignore warning signs and avoid the help of specialists.

Sexual disorders in men and women can be caused by for various reasons. In some cases, they are in a clear cause-and-effect relationship with various mental and somatic diseases, in others, a visible connection between these disorders and any other pathology is not established. At the same time, in both cases, the individual’s reaction to his inferiority undoubtedly has a secondary pathogenic effect on sexual function according to neurotic mechanisms. Prerequisites arise for the formation of a “vicious circle” that determines the relative persistence and therapeutic inertia of disorders of sexual function.

These factors indicate the need for a corrective influence on the patient’s personality in order to stop his personal reaction and restore broken interpersonal relationships in the family. Considering that different neurotic disorders can be not only accompanying and complicating factors, but also the cause of sexual dysfunction, then the advisability of using psychotherapy in the treatment of these disorders becomes obvious.

Despite the recognition of the great role of psychotherapy in the complex treatment of patients with sexual disorders, the methodologically correct foundations of its construction and implementation have not yet been sufficiently developed.

Naturally, the use of psychotherapy for all forms of sexual disorders in men and women must be combined with other adequate therapeutic measures, and the construction of effective psychotherapy should be based on the correct methodological positions, providing for the indispensable adherence to a number of general principles discussed below.

Psychotherapy as a system of therapeutic interventions.

Psychotherapeutic measures in the treatment of various forms of sexual disorders in men and women should be aimed at correcting their constitutional and personal reactions to existing sexual pathology, which is most often hyperactualized by patients due to the emergence of an inferiority complex. The use of psychotherapy in such cases should not be of an episodic nature, but of a system therapeutic effects, the beginning of which is already initial examination sick. A thorough clinical examination of the patient should be carried out subject to strict adherence to the rules of deontology and medical ethics. At the same time, the doctor should constantly remember the possibility of iatrogenic effects that aggravate the clinical manifestations of sexual disorders and complicate the prognosis of the disease (Smirnov G.V., Smirnova T.G., 1987). The system of psychotherapy should have the character of a continuous chain of therapeutic effects on the patient’s personality, which various stages Treatments are implemented using various forms, methods and techniques of psychotherapy.

If, in the case of pseudo-impotence and pseudo-frigidity, in a number of cases it is sufficient to conduct one or several explanatory instructive conversations, then in the treatment of real-life sexual disorders, a system of psychotherapeutic influences on the patient’s personality, and through it on the psychosomatic correlation, turns out to be necessary. This is especially true for patients with primary sexual disorders.

Sequence of psychotherapeutic activities.

The next principle of psychotherapy for patients with sexual disorders is adherence to stages and consistency in its implementation, so that each treatment session is a logical continuation of the previous one and a prerequisite for the next one. This determines not only immediate effectiveness, but also durability therapeutic effect psychotherapy (Smirnov G.V., Smirnova T.G., 1983, 1985: Smirnov G.V., Ageeva T.S.. 1982).

Solving the problems underlying each stage of psychotherapy requires taking into account and matching its methods, forms and content of the therapeutic orientation of other applied methods of therapeutic intervention ( medications, physiotherapy, regimen recommendations).

The construction of effective psychotherapy for sexual disorders involves the implementation of three stages:

The first stage is the formation of healthy psychological attitudes. It involves conducting a series of psychotherapeutic conversations aimed at eliminating patients’ misconceptions about the norm and pathology of sexual function, pessimistic assessments of their disease and prospects, as well as corresponding behavioral tendencies. Conducting psychotherapy also involves the implementation of general therapeutic effects.

This stage includes active discussion with patients about the following topics:

1) anatomy of the genital organs, physiology of sexual function, psychophysiology and psychology sex life person. When discussing this topic, it is necessary to cover questions about the norm and physiological fluctuations of sexual function, as well as the influence personal characteristics people on their sex life;

2) causes of sexual disorders and methods of their prevention;

3) efficiency complex treatment sexual disorders and types of recovery from painful conditions;

4) hygiene and mental hygiene of sexual life. The presentation and discussion of these topics is carried out in one or several conversations, the number of which is determined by the doctor depending on the contingent and number of people making up the treatment group, as well as other specific conditions. It is necessary to remember the obligatory psychotherapeutic orientation of the presentation of each of the mentioned topics and the optimism of conclusions and conclusions.

Interviews should begin after a preliminary assessment of patients included in the treatment group. Knowledge of the causes and conditions for the development of sexual weakness or frigidity in them and taking into account their personal characteristics allows the use of educational medical conversation, the so-called rebound psychotherapy (Velvovsky I.3., 1968).

The second stage of psychotherapy must be aimed at overcoming neurotic reactions, which represent the personal reaction of patients to their sexual inferiority. These reactions according to the mechanism of “true” neuroses as a result of disorders of the functional relationships between the cerebral cortex and the subcortical region, as well as in connection with a violation of personality relationships (Myasishchev V.N., 1960) can lead to a secondary breakdown of sexual function, thus closing image of a “vicious circle” of factors that predetermined the development of sexual disorders. It is necessary to take into account the characterological, typological characteristics of patients, socio-psychological maladjustment of spouses, indicators of auto- and hetero-suggestibility, as well as the variant of clinical manifestations, the severity and nature of the course of sexual disorder and secondary neurotic reaction.

The final stage of psychotherapy is aimed directly at restoring and activating sexual function.

When implementing this stage of psychotherapy, it must be borne in mind that sexual dysfunction in primary potency disorder and primary frigidity is caused not only by the formation of a pathological conditioned reflex (in the pathoreflex form), a violation nervous regulation sexual function (in the dysregulatory form), or weakness of the morpho-functional structures that form the basis of the sexual instinct (in the constitutional-genetic form), but also the extinction of conditioned sexual reflexes, due to a violation of the physiological rhythm of sexual activity of patients. The last factor, which is the pathogenetic basis of the withdrawal form, is involved in the pathogenesis of all clinical forms both primary and secondary sexual disorders. All of the above factors contribute to the strengthening of the pathological dominant that arises in patients, associated with the hyperactualization of sexual inferiority.

Carrying out final stage psychotherapy involves a purely individualized selection of treatment methods from the arsenal of known methods of psychotherapy and their differentiated use in the form of individual and collective-group sessions.