Table Of ContentTHE DYSREGULATED
ADULT
Integrated Treatment
Approaches
GEORGIA A. DEGANGI
ITS-PALSS, Kensington, MD, USA
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This book is dedicated to the memoryof Dr. Stanley I. Greenspan.
PREFACE
HOW TO USE THIS BOOK
TheDysregulatedAdult:IntegratedTreatmentApproachesisaskills-basedbookdesignedfor
use by mental health professionals and occupational therapists who work with adults
experiencing disorders of self-regulation. These are individuals who are intense, highly
sensitive to stimulation from the environment, emotionally reactive, and have difficulty
maintaininganorganizedandcalmlifestyle.Thisbookincorporatestreatmentstrategies
foradultswhostrugglewitheverydaydecisions,whomaybeimpulsiveintheiractions,
are easily frustrated, and react in extreme ways to everyday experiences. Some adults
with these problems crave intensity in interactions and in the environment. This may
resultinanoverwroughtandoverstimulatedstate,aquickangertrigger,andday-to-day
disorganization. In contrast, some adultswith these difficulties respondby withdrawing
from the world or becoming avoidant or socially isolated. They may battle with
depression and anxiety. Adults with these struggles often have difficulty adapting to
changing demands at home and work. They may be highly irritable or respond in
extreme or unpredictable ways. Their inconsistent responses to the important persons
in their life make interpersonal relationships very challenging.
The symptoms often vary for adults with disorders of self-regulation. These are
individualswhohaveacombinationofconstitutionalandemotional issues.Sometimes,
the person has a diagnosis that may include any of the following: bipolar or mood
disorder, borderline personality disorder, anxiety, depression, obsessiveecompulsive
disorder,Asperger’ssyndrome,eatingorsleepdisorder,and/orattentiondeficitdisorder.
Frequently, the person also has sensory integration problems that have never been
diagnosedandtreated.Theinterplayofsymptomatologyisdiscussedtohelpprofessionals
integratetreatmentstrategiesthataddresstheindividual’sregulatory,sensoryintegration,
and mental health problems. Chapters in the book are organized to address thevarying
waysinwhichtheproblemsmanifestforadults.Oneofthepremisesofthisbookisthat
peoplemayhaveaphysiologicalpredispositionthatmakesitextremelydifficultforthem
to control their behavioral responses. Their nervous systems often do not give them
accurate internal feedback to help them mediate their world.
BOOK FORMAT
Chapter1providesanoverviewofproblemsofself-regulationinadults.Itdescribesthe
different types of regulatory problems in adults, emphasizing how these difficulties
impact relationships with others, work performance, and everyday functioning. Two
xi
xii Preface
checklists appear at the end of this chapterdone to define the symptoms and type of
regulatorydisorderandtheothertoevaluatehowthepersoninteractsdynamicallyusing
a developmental framework. These checklists should help guide the diagnostic and
therapeutic process.
The chapters that follow focus on specific types of dysregulation. Each chapter
includes background information that emphasizes the developmental and neurobio-
logicalunderpinningsoftheproblem.Clinicalobservationsandchecklistsappearatthe
endofeachchapterthatmaybeusedfordiagnosisandtreatmentplanningtohelpclients
learn more about themselves and their problems. The treatment strategies described in
each chapter integrate three main approaches from the fields of mental health and
occupational therapy: dialectical behavioral therapy, mindebody therapies and sensory
integrationtechniques,andinterpersonaltherapy.Dialecticalbehavioralapproacheshelp
the client to understand what his or her behavior means, to learn how to reframe
problems in a more positiveway, and to take charge of hisor her problems in proactive
ways. Because many individuals with regulatory difficulties have sensory integration
problemsandexperiencebodilyreactionsduring interpersonalinteractionsandstressful
life experiences, principles from sensory integration therapy and other mindebody
techniques are described to help clients to self-calm and organize their bodies. Finally,
emphasis is placed on the relational dynamics between the adult and significant persons
in his or her life, including spouse, friends, children, and colleagues. Therapeutic
techniquesareprovidedonhowtofosterengagementwithothersinpositivewaysandto
improveattachmentswhileattendingtotheimportanceofprovidingphysiologicalsafety
and reducing averse bodily responses that interfere with interactions with others. The
importance of building resilience, developing support systems, and nurturing oneself
within the context of a balanced, well-structured family life is discussed.
Each chapter presents detailed therapeutic strategies to help professionals evaluate
what might work in addressing common problems related to eating, sleep, mood
regulation, anxiety, attention, and behavioral control. These treatment strategies are
integrated into clinical case examples of adults who experience specific problems of
dysregulation.Theseclinicalexamplesarebasedonactualcasesbuthavebeenchangedto
protecttheidentitiesofclientswhilepreservingtheclinicaldecision-makingprocessand
the dynamics of the therapeutic process. Manyof these case examples incorporate how
the clients’ problems of dysregulation impact their relationships with others and their
ability to function in everyday life.
Twentyskillsheetsappearintheappendixofthisbook.Theseareintendedtobeused
during the treatment process to help clients learn and apply the strategies described in
this book. Each chapter references specific skill sheets that apply to the treatment
approaches described for particular problems of dysregulation.
ACKNOWLEDGMENTS
Many people helped me in writing this book. First, I thank the many children, adults,
and families with whom I have worked throughout the years. They have been my best
teachers in discovering the most effective ways to help persons with dysregulation.
Without them, this book would not have been possible.
Several superb mentors and collaborators have been instrumental in helping me to
discover new ways of working with and understanding individuals with dysregulation.
I had the honor to be guided by Dr. Stanley Greenspan, child psychiatrist, who helped
me in integrating sensorimotor, emotional, and developmental frameworks into
a holistic model of working with children and adults. This book is dedicated to his
memory. Dr. Stephen Porges, developmental psychologist, collaborated with me in
researching disorders of self-regulation in children and taught me the importance of
linkingtheoriesandresearchwithclinicalapproaches.BothDrs.GreenspanandPorges
helped me to understand the profound effect that constitutional problems have on the
person’s developmental course and the impact on relationships. I am indebted to
Dr. Polly Craft, who offered me the gift of discovering the special meaning that each
child and parent have for one another. She helped me to learn parenteinfant psycho-
therapy, which was the basis for the affective-attuned experiential therapy described in
this book.
I amdeeplyappreciativeof Dr.Anne Kendall, who contributedherknowledge and
expertise to manyof the skill sheets that appear in this book. Dr. Kendall helped me to
applyconceptsofdialecticbehavior therapy(DBT)to difficultclients.Theemphasisin
DBTon skills development has been an inspiration for the tool-centered orientation of
this book.
Ihavehadthegoodfortuneofworking inavarietyofsettingsthathaveallowedme
to grow as a professional. I thank all of my colleagues at Integrated Therapy Services:
Psychological and Learning Support Services, Inc., in Kensington, Maryland, and the
Reginald S. Lourie Center for Infants and Children in Rockville, Maryland. These
colleagues have provided ongoing support and insight that have allowed me to blend
my knowledge of occupational therapy with clinical and developmental psychology
and to integrate different therapeutic perspectives including cognitiveebehavioral
therapy with psychodynamic approaches. It was at the Lourie Center that I learned
the importance of fostering emotional health and development through the parente
child relationship and the value of early intervention and prevention in treating
multiproblem families.
xiii
xiv Acknowledgments
The case vignettes and examples that are described in this book are based on real
clinicalexamples.Thenamesandpertinentidentifying informationoftheseindividuals
and their families have been disguised to protect their identities.
Finally, I thank my loving husband, Robert Dickey, who endured many hours of
listeningtomeasIformulatedideasforthisbook.Iamsogratefulforhisunconditional
support and encouragement for my professional endeavors.
11
CHAPTER
Problems of Self-Regulation in Adults
Problems of self-regulation are common among adults with a range of psychiatric
diagnoses. These problems may include difficulties with self-consoling, sleep, eating,
attention, sensory hypersensitivities, and/or mood regulation (i.e., irritability, anxiety,
and depression). The common diagnoses of individuals who have poor self-regulation
include bipolar or mood disorder, anxiety, obsessiveecompulsive disorder, Asperger’s
syndrome, eating or sleep disorder, attention deficit disorder, borderline personality
disorder, and post-traumatic stress disorder.
Poorself-regulationisaprocessdeficitthatimpactstheperson’severydayfunctioning
and interpersonal relationships. Often, problems of self-regulation are lifelong and have
roots in the person’s early childhood development. As problems with self-regulation
become entrenched, the person struggles with self-soothing and mood regulation.
TheDysregulatedAdult (cid:1)2012ElsevierInc.
ISBN978-0-12-385011-9,Doi:10.1016/B978-0-12-385011-9.00001-8 Allrightsreserved. 1
2 TheConceptofSelf-RegulationanditsDevelopment
It impacts the capacity to modulate arousal for sustained attention, to be motivated for
purposeful activities, to process and tolerate a range of sensory stimulation, and to
toleratechangeandhandleeverydaystress.Frequently,thepersonstruggleswithcoping
skills,impulsivity,andself-control.Asaresultoftheregulatorydisorder,thepersonisapt
to have difficulty developing a clear sense of identity, purpose in life, and self-efficacy.
Most of the research on regulatory problems is on infants and young children
(DeGangi, 2000; Greenspan, 1992); however, the diagnosis of regulatory disorder as
defined by Zero to Three (1994) has wide application to adults experiencing similar
symptoms. Because adults with these behaviors are commonly observed in clinical
practice, it is important to understand how self-regulation develops; the symptoms
underlyingvariousregulatoryproblems;andhowdifficultieswithself-regulationimpact
adaptive behavior, everyday functioning, and interpersonal relationships.
In this chapter, an overview of regulatory processes in adults is presented and
a conceptual model of self-regulation is proposed. The symptoms that constitute
a regulatory disorder in adults are described. The different types of regulatory disorders
thathavebeenproposedbytheDiagnosticClassification:0e3aremodifiedanddescribed
in relation to current research on adults with emotional problems. Case examples are
presentedtodepictthesymptomatologyofthedifferentsubtypes.Checklistsareprovided
to assist the clinician in diagnosing adults with problems of self-regulation. The Adult
Symptom Checklist can be used in helping clients understand their own regulatory
profile. In addition, the Adult Emotional Observation Scale is presented for use by
therapists to better understand the client’s capacity for self-regulation and to serve as
a guide for treatment.
1. THE CONCEPT OF SELF-REGULATION AND ITS DEVELOPMENT
1.1 Overview
Inthedevelopingperson,theearlyregulationofarousalandphysiologicalstateiscritical
for successful adaptation to the environment. The development of homeostasis is
importantinthemodulationofphysiologicalstatesincludingsleepewakecycles,hunger
andsatiety,bodytemperature,andstatesofarousalandalertness.Itisneededfor mastery
of sensory functions, self-calming, and emotional responsivity. It is also important for
regulation of attentional capacities (Als, Lester, Tronick, & Brazelton, 1982; Brazelton,
Koslowski,&Main,1974;Field,1981;Sroufe,1979,2005;Sroufe,Coffino,&Carlson,
2010; Tronick, 1989, Tronick & Beeghly, 2011).
Self-regulatorymechanismsdevelopandrefineearlyintheperson’slife.Someofthe
important milestones include the formation of affective relationships and attachments,
reciprocal communication and language, the use of self and others to control internal
states,anunderstandingofcausalrelationshipsinhumanbehavior,andthedevelopment
of self-initiated organized behaviors. It is generally recognized that self-regulatory
ProblemsofSelf-RegulationinAdults 3
mechanisms are complex and develop as a result of physiological maturation, caregiver
responsivity, and the person’s adaptation to environmental demands (Lyons-Ruth &
Zeanah,1993;Rothbart&Derryberry,1981).Iftheseessentialprocessesarenotinplace
early in life, it impacts the person lifelong, compromising his or her ability to develop
self-control and mindful behavior.
1.2 Fundamental Skills Needed for Self-Regulation
1.2.1 Level 1: Homeostasis
Reading and Interpreting One’s Body Signals
The foundations of self-regulation lie in the person’s capacity to develop homeostasis
early in life. This is especially important for self-soothing and the ability to read one’s
own physiological responses and bodily rhythms (e.g., body temperature, sleepewake
cycles, and hungeresatiety). In a normally developing individual, the person regulates
internal arousal states and attentional focus for learning and processing information. To
accuratelyreadbodilystates,thepersonneedsclear internalfeedbackfromthebody,the
abilitytodifferentiateandinterpretbodystates(e.g.,“I’mhungryandit’stimetoeat”),
andthe abilityof the mind to control the bodyunderdifferent environmental demands
or situations (e.g., “I’m tired but it’s not time to sleep” and “I need to find a way to
increase my arousal to stay awake and alert”).
A complex interplay between the person’s psychological experience and internal
physiological state makes self-regulation possible (Porges, 2003, 2009). A dynamic
bidirectional communication occurs between the peripheral nervous system and the
brain, providing a feedback loop between the vagal system and the brain. For example,
increasedchangesinheartratehelpsupportfight-or-flightbehaviors,whereasdecreased
heartratesupportssocialinteractionsandaffectiveandcommunicativesignaling.Specific
cues in the environment elicit physiological states associated with safetyor danger (e.g.,
high,piercingscream).Internalfeedbackbetweenthevagusnerve,aprimarycomponent
of the autonomic nervous system, and the brain helps the person with breath control,
physiologicalrelaxation,andtoachieveanoverallstateofcalmnesswhenself-regulationis
needed.Thisisaccomplishedthroughthevagusnerve’sinfluencesontheheartandbreath
control.Thepolyvagalsystemalsoprovidesfeedbacktothebodytoprepareitforflightor
fight when physical threat is imminent.In the polyvagaltheory, the autonomic nervous
system responds tosocial interactions, environmentaldemands, and sensory stimulation.
Italsoprovidesfeedbacktothebraintomodulatehowthenervoussystemshouldreactto
real-world challenges.
Processing Sensory Stimulation
Self-regulation depends on the person’s capacity to observe and process sensory stimu-
lation from the outside world (DeGangi, 2000; Greenspan, 1989, 1992; Lachmann &
Beebe,1997).Thisincludestheperson’sabilitytoprocessandtoleratearangeofsensory
