Personality Disorders

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

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

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)

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

How to interact with the Paranoid PD If you get the client to trust you- you’re 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

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

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

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

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 don’t push for too much activity-they can’t tolerate it)

Increasing affect, perceptual awareness, and responsiveness to environment (so they don’t withdraw into themselves)

Help clarify thought process

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 don’t 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

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

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

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

client’s 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 cl’s 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

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)

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 won’t disappear w/ cognitive coping “There I go again, even though I am thinking this thought- it does not mean it’s true”

Track and test predications Find practical ways to help cl improve life Medications can help with some symptoms

Antisocial PD Disregard for and violation of other’s 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

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

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 cl’s insights and reform

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 don’t 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

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

Goals for BPD

Goal: balancing polarities: They are both passive and active, self and other focused…just one at a time (not integrated) And when one is not working they shift to the other, thus feeling like they don’t know who they are, ruining relationships and feeling empty and confused

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

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 bad…again 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

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 life’s 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

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 client’s need for approval to reinforce self-

exploration

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

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

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 cl’s belief they must entertain and be on display

DO NOT BECOME A SAVIOR

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

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

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 don’t 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

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. “I’m angry, I deserved that award” “How might your parents react to your not receiving the award?” INTERNALIZATIONS

Responses focus on cl’s disappointment vs blaming of others (cls externalize):

You’ve tried so hard, and your wife still complains VS You’ve tried so hard, and you feel devastated when

things don’t work as perfectly as you thought they would

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

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)

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 progress…behavioral change is!

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

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 don’t know how to connect to others as autonomous

Hate to be alone- others define self

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)

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

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 Don’t 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

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 other’s

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)

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”

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 other’s frustrations with them)