Personality Disorders

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Personality Disorders
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Neurotic-Borderline-Psychotic

• Cluster A- Psychotic- odd/eccentric
• Paranoid, Schizoid, Schizotypal
• Cluster B- Borderline- dramatic/emotional
• Antisocial, Borderline, Histrionic, Narcissistic
• Cluster C- Neurotic- anxious/fearful
• Avoidant, Dependent, OCPD

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Personality Disorders ARE

• Chronic- dating back to childhood or adolescence
• Enduring Patterns across situations
• (2) cog, affective, interpersonal, or impulse
  control
• Often ego-syntonic
• Coded on Axis II

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Paranoid PD

• Pervasive distrust/suspiciousness or others as
  malevolent (exploit, harm, deceive)
• Difficult to get along with/difficulties having
  close relationships due to argumentativeness,
  hostile aloofness, or complaining
• Hypervigilent, guarded, defensive- appear cold-
  but internally labile
• Elicits hostility in others-thus confirming
  expectations
• Need to be self- sufficient and Autonomous
• Need to control those around them
• PROJECTION
• Seek to confirm negative beliefs
• BE CAREFUL TO ASSESS CULTURAL ISSUES (ex.
  Refugees)

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Cognitions of the Paranoid PD

• Cog Others can not be trusted and will try and
  hurt you, but do not confront directly because
  it will be seen as a personal attack, so.
• If overestimates threat of underestimates- help
  form more realistic appraisal of coping
• If coping lacks, help build it
• Cognitive errors
• Over Generalizations
• Dichotomous thinking
• Reason backward from beliefs to evidence to
  reinforce beliefs
• INTRODUCE an element of doubt, NOT challenging
  beliefs

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How to interact with the Paranoid PD

• If you get the client to trust you- youre done ?
• Allow interpersonal space, time between sessions,
  due to high anxiety provoked in sessions
• Never directly confront about delusions-help cl
  explore and support them
• Explain every move made and be straightforward
  and clear, allowing cl to control moves
• Move slow, show a quiet formal genuine respect
• Limit reflections, simple nods suffice-
  reflections may cause fear in the patient
• Educate about assertion vs aggression
• Determine triggers and help to avoid when unable
  to tolerate adequately. Help remove env.
  Irritants
• Therapist must not fall into Transference and CT

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Issues in treating the Paranoid PD

• OVERARCHING GOAL Loosen up the extreme
  constriction and inflexibility that pervades all
  domains
• Help identify the possible rewards from
  relationships
• PROJECTION- increase self-efficacy
• When they withdraw in self-protective
  way-encourage them to gather further information
  before reevaluating assumptions about others
• Help to be other focused
• Communication skills training, role playing,
  immediate feedback to help diminish
  hypersensitivity to social evaluation and
  eliminating behaviors that invite criticism
• Help change from identification with the
  aggressor to differentiation from the aggressor
• Explore benefits of being alone vs relationships
• Increase empathy
• Turn blame on others to self-examination
• Teach frustrations are a normal part of life
  (they ruminate about past wrongs done to them)
• As defenses loosen up, vulnerability, inferiority
  and worthlessness will rise and depression may
  result. Here a shift in tx is necessary
• Meds

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Schizoid PD

• Detachment from social relationships and
  restricted range of expressed emotions in
  interpersonal settings
• Do not want or enjoy close social interactions as
  opposed to Avoidant PD- who want social
  interaction, but are afraid
• Indifferent to praise or criticism
• Intellectualization is used
• Passively detached from environment
• Appear to lack capacity to experience emotional
  pleasure or pain
• Do not tend to obtain gratification from self or
  others
• FLAT and COLORLESS

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Interacting with Schizoid PD in Therapy

• Reliable, stable therapeutic relationship that
  mirrors the client
• Therapist must be more active at first
• CT-frustration, helplessness, boredom
• Cls may not value therapy

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Goals in treating the Schizoid PD

• GOALS
• Therapist must assess level of tolerance for
  social relatedness and desire of client
• Enhancing Pleasure, expressive abilities, and
  energy level
• Helping them be minimally active (Prevent total
  isolation that may lead to reality break, but
  dont push for too much activity-they cant
  tolerate it)
• Increasing affect, perceptual awareness, and
  responsiveness to environment (so they dont
  withdraw into themselves)
• Help clarify thought process

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Treating the Schizoid

• Behavior Therapy may be used to teach,
  reinforce, role play, in vivo exposure, audio
  videotaping of social skills (careful assessment
  of reinforcers is necessary as they dont respond
  to much
• DTR- to clarify and attend to vague cognitions
  and emotional experiences
• Explore functional and dysfunctional aspects of
  isolation
• Educate family and sig other on acceptance of
  Schizoid lifestyle while helping them set up mild
  socialization opportunities

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Schizotypal PD

• Acute discomfort with close relationships
• Difficulty with social cues and interactions
• Anxious around others
• Cognitive and perceptual distortions
• Ideas of reference (benign event has special
  meaning)
• Believe they have special powers to sense events,
  mind read, magical thinking
• Often suspicious of others
• Eccentric behavior

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Cognitions of the Schizotypal PD

• Cognitions
• Ideas of reference-unrelated events are related
  to him
• Paranoid ideation
• Magical thinking-I can read your mind or control
  events, you can do this too.
• Experience of illusions sees people in shadows
• Emotional reasoning- emotions are facts
• Personalization- responsible for external events

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Assessment and how to interact with the
Schizotypal PD

• Assess are they more avoidant or Schizoid in
  nature
• Therapy should be well structured, supportive and
  move at the clients pace so as not to cause
  undue anxiety and regression. Due to cls beliefs
  they can read minds or telepathically cause
  events, checking in on their experience of
  therapy is important
• SUPPORTIVE THERAPY!!! After establishing rapport,
  continue to support, but help reframe gently
• You are the cls reality testing observing ego,
  your goal is to increase cls pleasure in living
  and reduce anxiety (building up better defenses)
• Give Advice about social interactions, dress,
  speech, mannerisms.
• They project, so watch transference and CT
• DO not analyze dreams, free associations, use
  neutral stance etc. This will cause regression
  and worsen the disorder

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Goals in treating the Schizotypal PD

• GOALS
• Enhance self-worth and help to recognize
  positive attributes
• Teach more adaptive functioning (repeatedly- as
  they have trouble generalizing)
• Reduce social isolation (therapy itself is a
  reality testing function reducing some effects of
  the reality distorting isolation)

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TX SCHIZOTYPAL PD

• USE ideas of reference, magical thinking, and
  daydreaming along with lack of human contact and
  feedback which impede on accurately interpreting
  their environment
• Social skills training and environmental
  management. Help to do as much as they can for
  themselves.
• Teach to evaluate thoughts by environmental
  evidence vs feelings
• Help pt to disregard thoughts that wont
  disappear w/ cognitive coping There I go again,
  even though I am thinking this thought- it does
  not mean its true
• Track and test predications
• Find practical ways to help cl improve life
• Medications can help with some symptoms

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Antisocial PD

• Disregard for and violation of others rights
• Deceitful and Manipulative-enjoy getting over
  on others and POWER
• Must have symptoms of conduct disorder prior to
  age 15
• Tend to be impulsive and are irresponsible
• Little to no remorse
• Said to burn out in middle age, but may be due
  to deaths, imprisonment, and learning to channel
  personality style in less public and flagrant
  ways
• Consequences rarely play a part in their decision
  making, and acting out is a regulatory mechanism,
  impulses are directly expressed
• Usually in tx due to ultimatum

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Cognitions of APD

• COG Distortions
• Wanting something or wanting to avoid something
  justifies my actions-Justification
• My thoughts and feelings are completely accurate
  just because they occur to me-thinking is
  believing
• I always make good choices-personal infallibility
• I know I am right because I feel right about what
  I do- feelings make facts
• Others are irrelevant unless it affects
  me-Importance of others

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How to interact therapeutically with APD

• Avoid power struggles at all costs
• Openly acknowledge the vulnerability of therapy
  to manipulation by the anti social to reduce
  opposition. Remove self from evaluator role
• Best if th is self-assured, reliable, relaxed and
  nondefensive, clear personal limits, strong sense
  of humor, NOT wishy washy or touchy feely MORE
  FIRM and NURTURNING
• CT- fear, charmed, coldness/hatred of client
• Will try to enlist therapist as ally against
  others or con therapist into being impressed by
  cls insights and reform

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TX APD

• GOAL Help cl see how his/her behaviors hurt him
  (are a disadvantage to him) in the long run
• Identify APD behaviors as a disorder causing long
  term consequences to the afflicted individual.
  Therapy framed as an initial experimental trial
  to look at situations that might be interfering
  with the cls independence and success in getting
  what he or she wants
• Use choice review exercises Problem sit is
  listed and possible behavioral responses listed
  and rated in relation to their consequenses
• Behavioral techniques may work in the setting,
  but dont generalize
• Cooperative activities with other antisocials
  with severe consequences may help (Wilderness
  camps)
• Cognitive work to help move cl from concrete
  operational thinking to more formal thought
• Prognosis of APD developing concern for others is
  slim

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Borderline PD

• Instability in personal relationships,
  self-image, affects, and impulsivity
• Do WHATEVER to avoid perceived or real
  abandonment
• Often fear engulfment as well (push/pull)
• Idealize and devalue
• Splitting
• Borderline, while difficult, are probably more
  amenable to change and reorganization than many
  other PDs
• Desire gratifying relationships, and flexibility
  of personality are strengths that work toward Tx

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Goals for BPD

• Goal balancing polarities They are both
  passive and active, self and other focusedjust
  one at a time (not integrated) And when one is
  not working they shift to the other, thus feeling
  like they dont know who they are, ruining
  relationships and feeling empty and confused

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How to interact with BPD

• START therapy with clear explicit boundaries,
  clear goal of helping the client to be more
  independent and that limits will help in this
  goal. Therapist should then be responsive and
  supportive WITH IN THOSE LIMITS (Frame)
• Make clear that getting better does not equal
  being thrown out of tx
• Remember A real alliance (not just an idealized
  one) takes time
• Begin supportive and then move to supportive
  confrontation of splitting, poor choices, etc.
• BE CONSISTENT

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TX BPD

• Remember that BPD will have several other
  symptoms of other disorders and PDs. Underneath
  is a dichotomous thinking, unstable sense of
  self, and frantic need to avoid abandonment and
  engulfment. Keep this in mind to focus on
  undercurrents and not get lost in symptoms
• Make a few concrete goals that can be followed
  week to week (due to cls lack of stable self and
  difficulty staying focuses or having consistency)
• Help build compassion for self, help in self
  soothing and self-protection skills
• Help cl see counter productive nature of
  behaviors
• Help cl tolerate anxiety that causes the
  switching from one extreme behavior to another.
  If they can contain the anxiety, they can choose
  a better response
• Help cl define self and form a more solid
  identity
• Reducing vacillations between extremes helps cl
  to form stable identity
• Confront all good/ all badagain helping cl to
  integrate splits
• Help connect behavior to early history,
  psychodynamic work can be very helpful, validate
  cls experience, predict regressions when cl
  succeeds as normal
• DBT- see book, Use peer Group work
• Psychopharmacology

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Histrionic PD

• Excessive emotionality and attention seeking
  behavior
• Feel uncomfortable and unappreciated when they
  are not the center of attention-Demand the center
  of attention
• Shallow and rapidly shifting emotions, often
  sexually provocative, speech is impressionistic
  and global (do not focus on facts or details)
• Highly suggestible
• Often play a role in interpersonal
  relationships
• Move quickly away from conflict, to new
  relationships-thus not forming deep supportive
  networks
• Feel incapable of handling a large number of
  lifes demands and need someone truly competent
  and powerful to do so for them
• Use REPRESSION and FANTASIES OF FUSION WITH A
  POWERFUL OTHER and DISTRACTION to avoid
  dysphoria/anxiety
• Use DISSOCIATION and CHANGING PERSONAS when one
  fails to avoid stress- MIRROR THEM TO PROMOTE
  COHESION
• Histrionics often marry compulsives

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How to interact with HPD

• Join with the clients observing ego against self
  defeating part of client (build up super ego)
• Start with Skills training, CBT, DTR, exploratory
  therapy, behavioral experiments (they obsess
  about external events-help them turn inward)
  cognitively first as it may be less threatening
• Help client focus more on details (ask for
  details)
• Actively recommend alternative behaviors
• Actively address transference
• Use clients need for approval to reinforce
  self-exploration

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Goals for the Histrionic PD

• Establish SPECIFIC tx goals to keep patient
  motivated
• OVERARCHING GOAL- correct the tendency of Cl to
  fulfill all their needs by focusing on others to
  exclusion of self (done to ensure powerful other
  is always available and admiring them) which
  leaves no energy to focus on internal states

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How to reach the goal for HPD(notice they all
promote a focus inward to meet needs)

• Help them to give up active control over others
  actions and reactions (increasing passivity to
  experience and enjoy whatever occurs)
• Help them to slowly explore and focus on thoughts
  and feelings
• Help them to tolerate and cope with less
  satisfying aspects of relationships and tolerate
  not being center stage in order to gain long
  term intimacy
• Help see long term gains of keeping seduction and
  flirtation to appropriate relationships
• Teach more appropriate skills to meet needs
  communication and assertiveness
• Help them differentiate when their theatrical
  drama can be appropriate and when to contain it
• Help them tolerate BOREDOM ANXIETY
• Help develop a personal identity, since they are
  defined by others. May seem fragmented- help
  integrate with consistent feedback and pulling
  together of events and history
• Reinforce all independent and assertive behavior
  by the client (thus promoting active vs reactive
  behavior, reducing manipulation and a focus
  inward on detemining needs)
• Relaxation/physical activity to reduce anxiety
• Encourage them to take emotional risks
• Confronting dependency with and acceptance that
  it can not be satisfactorily fulfilled is a sign
  of huge progress

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More Specific Techniques for HPD (and other
disorders that increase focus inward)

• Have cl make list of everything they know about
  self (basics too- favorite color, food)
• Address fear of rejection by having cl focus on
  previous lost relationships and how they have
  survived
• Talk about need to have ALL needs met by
  significant powerful other and if this occurred
  one would lose all of self
• Do not use playful banter- this increases cls
  belief they must entertain and be on display
• DO NOT BECOME A SAVIOR

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Narcissistic PD

• Grandiosity, need for admiration, lack of
  empathy, unique/special (may feel uniquely
  inadequate as well)
• FRAGILE self-esteem
• Attach to idealized others
• Sense of entitlement
• Perceived or real criticism will plummet them
  into despair or rage
• Tend to marry other Narcissists, dependents, or
  masochistics

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How to interact with NPD

• Always begin with good supportive working
  alliance
• Apologize for Narcissistic injuries and process
• Reach them thru their pain
• Point out lacks of empathy in client and work to
  improve empathy and behaviors
• Psychodynamic restructuring- confront conscious
  and unconscious anger, process neg/pos
  transference toward therapist, address use of
  splitting, projection, and projective
  identification (Kernberg) or adopt a sympathetic
  and accepting stance, while addressing need for
  patient to accept personal limitations (Kohut)
• If feelings of emptiness and sensitivity to
  rejection are interfering with therapy consider
  medications to reduce

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Cognitions of NPD

• COGNITIVELY tendency to overvalue self is due
  to faulty comparisons with others, whose
  differences from self are overestimated. Will
  also do this in opposite direction and experience
  depression if defenses dont kick in (all or
  nothing thinking).
• Help to think in more middle ground.
• Help to make comparisons intrapersonally.
• Help to find similarities with others
• COG Cl comes up w/ evidence for alt beliefs
  (DTR)
• Everyone has flaws
• One can be human like everyone else and still be
  unique
• collegues can be resources, not just competitors
• limiting focus on evaluation by others and better
  management of affective reactions to evaluation
• enhanced awareness of feelings of others
• increase empathy
• eliminating exploitive behavior

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TX of NPD-Once a patient accepts that
unattainable ambitions and maladaptive behaviors
must be given up in favor of more realistic
cognitive and interpersonal behaviors- a huge
part of the work is done

• Overarching goals Help cl accept their
  weaknesses and deficiencies and increase
  other-orientedness
• Help to connect to early interactions to free
  them up to modify them. Im angry, I deserved
  that award How might your parents react to your
  not receiving the award? INTERNALIZATIONS
• Responses focus on cls disappointment vs blaming
  of others (cls externalize)
• Youve tried so hard, and your wife still
  complains VS
• Youve tried so hard, and you feel devastated
  when things dont work as perfectly as you
  thought they would

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TX NPD

• Adjustment of grandiose fantasies to more
  realistic ones (Tend to fantasize a lot, do not
  try to stop this, just readjust it) Help to
  focus on pleasure from activity in fantasy vs.
  audience evaluation -this becomes a rehearsal for
  life
• Help to evaluate when evaluation is not
  important, how to request specific feedback from
  others, thought stopping
• Group can be used, but not always the best option
  due to narcissistic wounding

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Avoidant PD

• Socially inhibited, feel inadequate,
  hypersensitive to negative evaluations and
  hides/withdraws (vs Narcissist who splits)
• People are experienced as critical and
  disapproving unless tons of nurturing, acceptance
  and support are shown
• Want relationships and belonging DESPERATELY, but
  are too fearful to engage (vs Schizoid who has no
  interest in relationships)

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Interaction with Avoidant PD

• Therapeutic relationship is very important
  because avoidant client will only report what
  will keep the therapist from thinking poorly of
  them
• High empathy and support from therapist is
  needed, as well as a SAFE HAVEN
• Start supportive, but then more
  confrontive/interpretive/uncovering (Insight
  oriented work on anxiety provoking fantasies and
  childhood)
• Remember Insight is not progressbehavioral
  change is!

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Tx of APD

• Help establish internal reference points for
  sense of self
• Skills Training Social skills, assertiveness,
  increased social contact, Self-monitoring of own
  withdrawal behavior, DTR, hierarchy of
  activities, anxiety reduction skills, giving up
  triangular relationships, risk taking.
• Help them learn Anxiety is a signal to check
  maladaptive thoughts
• Increase Cls active focus on pleasurable stimuli,
  decrease avoidance of potentially painful stimuli
• Help them understand the amount of energy they
  spend avoiding and processing nonexistent
  personal assaults or stupid behavior on their
  part
• Help differentiate between real, imagined, and
  incidental threats in normal living
• Medication to reduce anxiety
• Group, family and couples therapy

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Dependent PD

• Need to be taken care of, tend to be
  submissive/clingy and have fears of separation
• Feel unable to function without the help of
  others
• Require high advise and reassurance from others
• Difficulty expressing opinions and needs due to
  fears of losing the other
• Conflicted about obtaining autonomy because this
  will lead to abandonment/ and they dont know how
  to connect to others as autonomous
• Hate to be alone- others define self

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Interactions with DPD Helping to build a self

• Use therapeutic relationship to explore dependent
  dynamics (help client to self-activate sessions,
  ask for needs to be met)
• Start with more structure and provision of
  dependency needs in therapy and move cl slowly
  toward more autonomy in session
• More severe clients may need to transition from
  parental dependency to less severe marital
  dependency w/ therapist being a transitional
  object
• Help cl see parents more realistically
• Address fears that autonomy/assertiveness will
  cause them to lose others (resistance in therapy)

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Treatment of Dependent PD Interdependence (not
total independence) is the goal with the
flexibility to more between self-reliance and
mutual dependence

• Countering their belief that their fate is
  dependent on others
• Help cl develop active involvement in need
  satisfaction, without excessive support from
  others
• Increase self-perceptions of adequacy and
  competence/trust in/caring for self
• Promote self-control, independent thinking,
  independent personality (replacing internalized
  representations of others with a more mature,
  realistic one of their own) Reducing
  Identification
• Teach not to wait passively for needs to be met
• Explore how when short term gain of comfort come
  from clingy behaviors/ long term relational
  problems are likely
• Teach anxiety reducing techniques since
  autonomous behavior will temporarily increase
  anxiety
• Role play, model, or conduct anxiety hierarchy of
  ind/assertive behavior
• Explore gradiations between dependency and
  independency
• DTR to help with catastrophying and self-critical
  thoughts
• Problem solving and conflict management
  techniques, Assertiveness training, communication
  skills, role playing, self-management

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OCPD Conflict Rage at being controlled
(passively acts out emotions) vs fear of being
punished (compliance)

• Preoccupied with orderliness, perfectionism, and
  mental and interpersonal control at the expense
  of openness, flexibility and efficiency
• Attend to rules, details, lists so that the
  overarching goal is lost
• Poor time management (due to detail
  orientation-think thesis)
• Perfectionist and self-imposed HIGH standards
• Dont want to waste time and may be overly
  devoted to work or tasks
• Self-critical
• May hoard
• Reluctant to delegate tasks, RIGID, stubborn,
  there is a correct way to do things (Shoulds)
• Appear to have resolved conflicts thru obedience,
  but are struggling at a deeper level to restrain
  their defiance thus they
• Force ambivalence and anxiety out of
  consciousness and express passively (thus
  reactive to E) or impose strict rules

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Cog Distortions of OCPD

• Cog distortions-OCPDs like CBT
• There are right and wrong behaviors, decisions,
  emotions
• Failure is intolerable
• I must be perfectly in control of my environment
  and myself
• making mistakes leads to punishment
• self-criticism is helpful in preventing others
  disapproval and motivating myself
• Explore fear of giving up worry and
  self-criticism, as they believe this motivates
  and keeps them doing what they are supposed to
  do confront how it actually does the opposite
  (sometimes resulting in numbing out and
  procrastination)

43
Interactions with OCPD

• Cl will want structure, but sessions should be
  open with spontaneous communication. This is
  likely to cause T and CT, including rage and
  anger toward self, therapist and process. If cl
  believes anger to be not ok they may become
  busy at work and begin missing sessions. Th
  should use cls intellectual curiosity to explore
  behavior in a trusting E
• Remain warm and kind, as they are used to people
  becoming frustrated with them
• Know that unfamiliar situations are more
  difficult for them and this includes therapy
• Address vulnerability to shame
• Ask over and over how do you feel? and when
  they reply with a thought, say That helps me
  understand what you think, but how do you feel

44
TX OCPD See self and other at the same time

• You want to shake up their structure and help
  them be more flexible. Help see how they may
  have internalized critical and demanding parents,
  thus developing empathy for self as a child.
  Psychodynamic exploratory work of childhood,
  dreams and fantasies can help cl access repressed
  aspects of self and loosen up self
• Help client give up desire for harmonious
  understanding with caregivers
• Help them establish an identity that that
  differentiates their feelings and desires from
  those they perceive as expected of them
• Help them bring repressed anger and fear of
  disapproval to surface
• Help them realize expectations of others and
  needs of self are both valid
• Help decrease concerns with outcomes and help to
  make decisions based on personal needs and
  desires
• Help desensitization to avoided situations,
  highly structured behaviors and rituals
• RELAXATION TECHNIQUES- convince them they are not
  a waste of time by trying it out
• Warn of relapse, as cls will want to do therapy
  perfectly
• Explore sexuality-issues here due to control and
  rejection (reframe as differences in desire)
• Acknowledge benefits of OCPD, but also note the
  creativity blocking and inefficient aspects of it
• Once wishes are acknowledged as acceptable, then
  perfectionism is left to content with
• Medications to reduce anxiety can be helpful
• Group therapy is not a good option (due to
  others frustrations with them)