UNDERSTANDING PERSONALITY DISORDERSPresented by Catherine R. Barber, Ph.D.

catherine.romero.barber@gmail.comSponsored by Institute for Brain Potential

OBJECTIVES

Primary Objectivesa. List key brain regions influencing social reasoning and conduct.b. Identify features of and effective treatments for paranoid, schizoid, schizotypal,

antisocial, borderline, histrionic, narcissistic, dependent, avoidant, obsessive-compulsive, passive-aggressive, and depressive personality disorders.

c. Describe personality disorders that may underlie hypochondriasis, body dysmorphic disorder, selected eating disorders, and substance abuse.

d. Review principles that facilitate the transformation of personality.

Secondary ObjectivesA. Differentiate categorical and dimensional models of personality pathology.B. Describe basic theoretical models of personality disorder etiology. C. Identify practical strategies for working with personality-disordered clients.D. Recognize and learn to cope with counter-transference.

AGENDA

9:00 – 10:00 AM OrientationIntroduction to Personality DisordersTheories of Personality Disorders

10:00 – 10:30 AM Cluster A: Odd/Eccentric

10:30 – 10:45 AM Morning break

10:45 – 11:30 PM Cluster B: Dramatic/Emotional

11:30 – 12:00 PM Cluster C: Anxious/Avoidant

12:00 – 1:00 PM Lunch break (presenter available for questions at 12:30 – 1:00)

1:00 – 1:30 PM Common Co-morbid Conditions

1:30 – 2:30 PM Practical interventions

2:30 – 2:45 PM Afternoon break

2:45 – 4:00 PM Specific treatment approachesConclusions and Evaluations

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PRESENTATION OUTLINE

I. Introduction to Personality Disorders

A. Differentiating personality style from personality disorder

1. Personality style: The way in which a person relates to oneself, others, and the world. Comprises various traits or tendencies as well as habits or behaviors.

2. Personality disorder: An enduring and pervasive pattern of perception, thought, and behavior that falls outside of social norms, is usually inflexible and maladaptive, and thus causes impairment or distress.

3. We all have a personality style. Our style may even include traits or habits that are represented in one or more of the personality diagnoses. However, if these do not cause impairment or distress to oneself and/or others, we would not consider them pathological. Some behaviors that we will discuss in the context of personality disorders may actually be adaptive, depending on the context. Example: attention-seeking (performing arts); extreme concern with order and detail (research, school, clerical tasks, etc.); suspiciousness (investigational or intelligence agencies).

4. Sometimes the line is not clear! Example: Eccentric or quirky behavior may bother others but not the individual who is eccentric.

B. Models of personality pathology

1. Various models of personality pathology exist. These typically conceptualize personality disorders as either categorical/prototypical or dimensional constructs. Examples:

a. Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text Revision (DSM-IV-TR; APA, 2000): The most commonly used diagnostic system in the U.S. Uses a prototypical model of diagnosis, in which a person is said to have a personality disorder if he or she has a minimum number of features that are considered prototypical for the disorder. This model facilitates communication, but important information may be missed and category might not fully represent a “real life” construct. Also, most contemporary research does not support the distinctness of the DSM-IV-TR categories (i.e., there is a lot of overlap across disorders, and the criteria within each category are highly heterogeneous). Similarly, research does not generally support the construct or predictive validity of these categories (Depue & Lenzenweger, 2005). The risk of “reifying” diagnoses is substantial.

b. Five-factor model/the “Big Five” (e.g., McCrae & Costa, 1996): One of the most common dimensional systems, this model suggests that personality (and thus personality pathology) can be defined in terms of 30 dimensional facets organized into 5 higher-order dimensions: Openness to experience, conscientiousness, agreeableness, extraversion, and emotional stability. There is substantial evidence to support these 5 factors or traits,

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which are strongly heritable (i.e., genetically based). The model is useful because it contains more information and looks at personality strengths and weaknesses as falling on a spectrum. However, downsides include the lack of built-in information about what point on the continuum a “disorder” begins and the lack of user-friendliness of this system due to its lack of context for each trait (Rottman et al., 2009).

c. Shedler-Westen Assessment Procedure (SWAP: e.g., Westen, Shedler, & Bradley, 2006): This method combines prototypical and dimensional information to provide a profile of how much or how little an individual is similar to each cluster of descriptors.

2. Assessment: Multiple tools exist to assess the presence and type of personality disorder. Among the most common:

a. Structured Clinical Interview for DSM-IV Personality Disorders (SCID-II; First et al., 1997)

b. Minnesota Multiphasic Personality Inventory – 2 (MMPI-2; Butcher et al., 1989)

c. Personality Assessment Inventory (PAI; Morey, 1991)d. Millon Clinical Multiaxial Inventory – III (MCMI-III; Millon et al., 2006).

3. Bottom line: Although we will review the DSM-IV-TR personality disorder prototypes, keep in mind that traits and all other aspects of personality can be described as falling somewhere along a continuum. For the purposes of treatment, it is far more useful to identify, understand, and address the problematic thoughts, behaviors, emotions, etc., than simply to assign a specific personality disorder diagnostic category.

C. A few more caveats about diagnosing

1. Although we will discuss what constitutes a “disorder,” and visual illustrations will be used to highlight various aspects of the personality disorders, it is critical that sufficient information be gathered before actually making a diagnosis or otherwise drawing a conclusion that a person has a personality disorder. It is rarely acceptable to conclude that someone has a personality disorder on the basis of a single conversation or other limited observation.

2. It is also not useful to engage in “distance diagnosing,” that is, drawing conclusions about someone’s personality without actually having met them or spent some time with them.

3. A common misconception is that all patients who are “difficult” have personality disorders. “Difficult” patients may be difficult for a variety of reasons, including but not limited to the presence of a personality disorder. We will discuss how to manage difficult patients in general, but keep in mind that separate techniques may be necessary to manage personality-driven difficult behavior.

D. The scope of personality disorders and current thought regarding treatment

1. American Psychiatric Association (2000) prevalence estimates range from 0.5% to 2.5% in the general population. However, a recent study of a community (non-

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clinical) sample (Lenzenweger et al., 2007) suggests that about 10% of all adults may meet criteria for a personality disorder.

2. These numbers are even higher in clinical settings (about 2-10% in psychiatric outpatient settings and 10-30% in psychiatric inpatient settings; APA, 2000).

3. Just as personality traits are fairly well-set by mid-childhood, personality disorders emerge in childhood and crystallize by adolescence. However, clinicians do not diagnose personality disorders until a person is 18 or older

4. Because personality disorders involve every aspect of a person’s experience—perception, thought, emotion, behavior—they are notoriously challenging to treat. However, they are not completely intractable. Unfortunately, many clinicians are insufficiently equipped to treat personality disorders, and there continues to be considerable stigma associated with these conditions.

5. Most clinicians do not think of personality disorders in medical terms, where the disorder is an “illness” to be “cured.” Rather, the disorders comprise “patterns” or “tendencies” to be “modified” and/or “coped with.”

6. As with all other psychiatric disorders, personality disorders have biological bases that are beginning to be better understood. Yet there are few psychiatric disorders in which the environment plays so large a role in their development. As we discuss etiology, keep in mind that aspects of nature and nurture contribute to the development of personality disorders.

II. Theories of Personality Disorders

A. Psychodynamic/Psychoanalytic

1. This category comprises many theories, not just one. However, these theories generally share common features, such as an emphasis on early experiences in the development of personality, the role of the unconscious, and the function of defense mechanisms.

2. One of the most commonly used theories in contemporary psychodynamic practice is object relations theory (e.g., Kernberg, 1993). This suggests that the ways in which people experience and respond to themselves, others, and the world are heavily influenced by emotions linked to early experiences with significant others. These experiences become internalized as “object relations” and provide a template for future interactions.

3. Object relations theory has much utility for the understanding of the different personality disorders. Various authors (e.g., McWilliams, 1994; Van Denburg, 1994) have described characteristic object relational patterns for the main personality disorders, which will be highlighted as we discuss each disorder.

B. Cognitive-behavioral

1. This category also comprises several theories. However, all accept the cognitive model: An individual’s perceptions and assumptions shape his or her emotional and behavioral responses. Events trigger interpretations, which in turn influence emotions and behaviors. Emotions and behaviors, in turn, influence thoughts.

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2. Cognitive theorists have identified three levels of cognitive processes that shape people’s emotions and behavior:

a. Automatic thoughts: spontaneous thoughts that are influenced by one’s unique learning history and that may or may not be true.

b. Schemas: organizing beliefs about the self, others, and the world.c. Cognitive distortions: interpretive heuristics or biases that contribute to

dysfunctional thinking when overused.Beck and other clinical researchers (e.g., Beck et al., 2004; Young et al., 2003) have, in turn, described and researched common schemas associated with various personality disorder, which we will also examine.

3. Principles of reinforcement are involved in learning (and extinguishing) the thoughts and behaviors that make up personality. Reinforcement and punishment are responsible for the frequency and strength of most behaviors. Behaviors that are followed by something pleasant or by the removal of something unpleasant will strengthen and occur more often. Behaviors followed by something unpleasant or the removal of something pleasant will weaken and occur less often.

4. We also learn through observation and modeling. What we see others (e.g., parents, siblings, peers) do in turn influences what we do.

C. Biological

1. Thinking of disorders in terms of “biological” versus “psychological” or “environmental” is a misunderstanding. Every behavior, thought, feeling, and experience is biologically based, as all of these originate in the brain, a biological organ. However, the brain responds to something—it is constantly receiving and processing information that comes from the environment.

2. Therefore, it is much more useful to focus on what areas of the brain and which brain processes go awry in psychological disorders, and how both physical factors (e.g., genetics, head injuries, medical diseases) and environmental factors (e.g., learning history, trauma) affect brain chemistry. We can hypothesize about the origin of specific personality deficits by examining individuals who have known damage to a specific structure of the brain and observing their behavior. Examples:

a. Temporal lobe epilepsy and personality (e.g., Lanteaume et al., 2009; Monaco et al., 2005).

b. Frontal lobe damage and psychopathy (e.g., deOliveira-Souza, 2008)3. Personality disorders, like most disorders, involve nearly all aspects of brain

functioning: perception, memory, speech, executive functioning, and social reasoning, among others. Thus, many brain areas may be malfunctioning in someone with a personality disorder. However, key regions implicated in personality disorders include the prefrontal cortex and the limbic system (Barlow & Durand, 2009; Coccaro & Siever, 2005).

a. Prefrontal cortex: Responsible for executive functioning, which comprises planning, decision making, behavioral activation and inhibition, and reasoning. This region selects and implements behaviors based on internal goals.

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b. Limbic system: A complex system of cortical and sub-cortical structures (including the amygdala) that supports and regulates emotion, long-term memory, autonomic functions (e.g., heart rate, sleep/wake cycle, hunger, thirst, sexual arousal, etc.), and the reward center.

c. These regions interact, forming circuits that underlie complex phenomena such as social reasoning, self-image, motivation, and impulsivity.

4. Within each brain region, chemical messengers or “neurotransmitters” facilitate or inhibit the firing of neurons, which causes communication between neurons. Key neurotransmitter systems implicated in personality pathology include serotonin (5-HT), norepinephrine, and dopamine. Examples of specific relationships that have been observed among neurotransmitter activity and behavior include:

a. Serotonin and mood, impulsivity, and appetitive behaviors.b. Norepinephrine, arousal, and risk-taking behaviors.c. Dopamine/opiods, pleasure, and reinforcement.d. Dopamine and psychotic symptoms (delusions and hallucinations).

5. Given the role of neurotransmitters in brain functioning, it stands to reason that psychopharmacological interventions (i.e, medications) may benefit individuals with personality disorders. To some extent, this is true, particularly when it comes to helping people with emotion dysregulation, impulsivity, and thought disturbance. However, medication is rarely (if ever) enough to change personality, given that most behaviors are highly complex and the result of years of learning and practice! Thus, most clinicians strongly recommend psychotherapy to address the unique interplay of traits and learned behaviors that make up a personality disorder.

a. Benefits of pharmacotherapy for personality disorder symptoms.b. Common side effects of medications used in the treatment of personality

disorders.

D. An integrative approach: Many clinicians and researchers conceptualize personality disorders in terms of biological components, internal psychological processes, and environmental and social factors. This “biopsychosocial” model will be used as we discuss each personality disorder.

1. We will review 12 personality disorders, 10 of which are listed in the DSM-IV-TR and two of which are commonly accepted personality disorders in clinical literature (and are listed in DSM-IV-TR “for further study”). In addition to examining DSM-IV-TR criteria, we will examine the following for each personality disorder:

a. Characteristics of the disorder and DSM-IV-TR Diagnostic criteria (from APA, 2000)

b. General population prevalence estimates (from Lenzenweger et al., 2007; Torgerson et al., 2001)

c. Common defense mechanisms (from Gabbard, 2005; McWilliams, 1994; PDM Task Force, 2006)

d. Object relational patterns (from McWilliams, 1994; Van Denburg, 1995)e. Cognitive schemas (from Beck et al., 2004; Young et al., 2003)

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f. Key neurobiological mechanisms (from Coccaro & Siever, 2005)2. A few words about DSM-IV-TR clusters: Grouping or “clustering” personality

disorders by the surface characteristics that they hold in common is a common clinical approach taken by the DSM to facilitate communication. However, there is scant research suggesting that disorders within a given cluster are etiologically or fundamentally related. Remember not to fall into the “reification” trap!

III. The Personality Disorders

A. Cluster A: Odd/Eccentric

1. Paranoid Personalitya. Characterized by suspiciousness, distrust, guardedness, grudges, hostility,

and covert vengefulness.b. Occurs in approximately 0.5-2.5% of the general population.c. Common defenses: projection, projective identification, reaction

formation.d. Object relations: Others are dangerous and/or “users.”e. Common self schema: “I’m vulnerable.”f. Key neurobiological findings: scant evidence about specific pathology;

disorder may be more common in relatives of people with schizophrenia.

2. Schizoid Personalitya. Characterized by detachment, restricted emotional expression, isolation,

minimal interest in sexual or social experiences, lack of pleasure, and indifference.

b. Occurs in approximately 1.7- 4.9% of the general population.c. Common defenses: withdrawal, intellectualization.d. Object relations: The social world is engulfing.e. Common self schemas: “I’m a misfit.”f. Key neurobiological findings: largely unknown. The disorder may be

more prevalent in relatives of people with schizophrenia.

3. Schizotypal Personalitya. Characterized by discomfort with relationships, eccentric behavior,

psychotic-like symptoms.b. Occurs in approximately 0.6-3.3% of the general population.c. Common defenses: withdrawal, fantasy.d. Object relations: Others are experienced as piecemeal and incoherent.e. Common schemas: “I am defective.”f. Key neurobiological findings: Substantial evidence for the role of

dopamine (excess – psychotic symptoms; deficit – cognitive symptoms). Ventricular enlargement is often seen, though frontal lobes are relatively well-preserved (which may serve as a buffer to the development of full-blown schizophrenia).

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B. Cluster B: Dramatic/Emotional

1. Antisocial (Sociopathic) Personalitya. Characterized by disregard for and violation of the rights of others, lack of

remorse, and manipulation. May include a component characteristic of psychopathy that entails an interpersonal style that is cunning and charming.

b. Occurs in approximately 0.7-1.0% of the general population.c. Common defenses: omnipotent control.d. Object relations: Others are selfish, manipulative, and not worthy of

respect.e. Common schemas: “I’m vulnerable.”f. Key neurobiological findings: Serotonin plays a strong role in impulse

control and aggression (insufficient serotonin poor impulse regulation and increased aggression). Decreased autonomic arousal also is common (i.e., reduced “fight or flight” response when facing risks). Pleasure center (fueled by dopamine) may also be overactive. Increased amygdala activity is associated with aggression (e.g., Siever, 2008).

2. Borderline Personalitya. Characterized by instability in affect regulation, interpersonal

relationships, self-image, and behavior. Often involves chronic suicidal ideation and behavior, as well as self-injury.

b. Occurs in approximately 0.7-1.6% of the general population.c. Common defenses: splitting, projective identification.d. Object relations: Others are unpredictable and inconstant.e. Common schemas: “I’m defective.” “I’m vulnerable.” “I’m helpless.”

“I’m bad.”f. Key neurobiological findings: Serotonin is implicated in impulse control

and emotion regulation. Imaging studies demonstrated reduced anterior insula response (King-Casas et al., 2008). There is a possible role of peptide (e.g., opioids, oxytocin) dysfunction (Stanley & Siever, 2010).

3. Histrionic Personalitya. Characterized by excessive emotionality and attention-seeking behavior.b. Occurs in approximately <1.0-2.0% of the general population.c. Common defenses: repression, regression, conversion, sexualizing, acting

out.d. Object relations: Same-sex others are of little value; those of the opposite

sex are powerful, exciting, e. Common schemas: “I’m nothing.”f. Key neurobiological findings: Unknown.

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4. Narcissistic Personalitya. Characterized by grandiosity, need for admiration, and lack of empathy.

Two subtypes are often identified: malignant/oblivious and fragile/shy/hypervigilant.

b. Occurs in approximately <1.0% of the general population.c. Common defenses: idealization, devaluation.d. Object relations: Others are better than I am; I must be better than they are

to feel good.e. Common schemas: “I’m inferior.”f. Key neurobiological findings: Unknown.

C. Cluster C: Anxious/Avoidant

1. Avoidant Personalitya. Characterized by social inhibition, feelings of inadequacy, and

hypersensitivity to criticism.b. Occurs in approximately 5.0-5.2% of the general population.c. Common defenses: symbolization, displacement, projection,

rationalization, avoidance.d. Object relations: Others who are more powerful can provide safety.e. Common schemas: “I’m undesirable.”f. Key neurobiological findings: Most closely related to social phobia, which

is marked by dopamine deficiencies.

2. Dependent Personalitya. Characterized by an excessive need to be taken care of, submissiveness

and clinginess, and fears of separation.b. Occurs in approximately 0.6-1.5% of the general population.c. Common defenses: regression, reversal, avoidance.d. Object relations: Others are powerful and their care is essential.e. Common schemas: “I’m helpless.”f. Key neurobiological findings: Unknown.

3. Obsessive-Compulsive Personalitya. Characterized by a preoccupation with orderliness, perfectionism, and

mental and interpersonal control, to the detriment of flexibility, openness, and efficiency.

b. Occurs in approximately 2.0-2.4% of the general population.c. Common defenses: isolation of affect, reaction formation,

intellectualizing, moralizing, undoing.d. Object relations: Others try to exert control, which must be resisted.e. Common schemas: “My world can go out of control.”f. Key neurobiological findings: Unknown.

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D. Other problematic personality styles under review

1. Passive-aggressive (Negativistic)a. Characterized by the tendency to deny negative emotions (e.g., anger)

while acting them out in a covert or indirect way (e.g., by withholding affection, giving the “silent treatment,” etc.)

b. Prevalence estimates vary too widely (e.g., 1% to 10% of the general population; 20% of adolescents!) to be reliable.

c. Common defenses: projection, externalization, rationalization, denial.d. Object relations: Others require conforming to their rules.e. Common schemas: “I should only have to do what I want; others’ needs

are not as important.”f. Key neurobiological findings: Unknown.

2. Depressivea. Characterized by self-criticism, judgment, intense guilt, dejection.b. Reliable prevalence estimates are not available.c. Common defenses: introjection, reversal, idealization of others,

devaluation of the self.d. Object relations: Others will criticize, reject, or abandon.e. Common schemas: “I am fundamentally bad.”f. Key neurobiological findings: Unknown.

E. DSM-5 Proposed Classification System (from www.dsm5.org). Changes to the way personality disorders are diagnosed have been proposed by the Personality Disorders Task Force. Some of the changes include:

1. A new general definition of personality disorder based on severe or extreme deficits in core components of personality functioning and elevated pathological traits.

a. “Personality disorders represent the failure to develop a sense of self-identity and the capacity for interpersonal functioning that are adaptive in the context of the individual’s cultural norms and expectations.” (from dsm5.org) 

2. 5 identified severity levels of personality functioning ranging from 0 (No impairment) to 4 (Extreme impairment).

3. 5 personality disorder (PD) types (Antisocial/Psychopathic, Avoidant, Borderline, Obsessive-Compulsive, and Schizotypal have been proposed, pending empirical validation), each defined by core PD components and a subset of:

4. 6 broad, higher order personality trait domains , with 4-10 lower-order, more specific trait facets comprising each, for a total of 37 specific trait facets (proposed, pending empirical validation). Trait domains include Negative Emotionality, Introversion, Antagonism, Disinhibition, Compulsivity, and Schizotypy.

Note that this system would incorporate both dimensional and prototypical elements.

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IV. Common Co-morbid Conditions and the Role of Personality

A. Hypochondriasis and other Somatoform Disorders

1. Somatic/physical expression of emotions is common in individuals with histrionic, dependent, and obsessive-compulsive personality disorders. This may represent an effort to obtain attention, to keep others close, or to express emotions.

2. Hypochondriacal fears are usually not assuaged by reassurance by a physician, repeated medical tests, and other forms of “proof” that no illness exists.

3. Cognitive-behavioral treatment has the most empirical support, although there is a role for SSRI’s to address the anxiety component of this disorder.

4. If hypochondriasis occurs within the context of a personality disorder, the interpersonal functions of hypochondriasis must be addressed.

5. Emotional disclosure via expressive writing may be a useful approach for individuals with hypochrondriasis or other pain syndromes of unknown origin.

B. Body Dysmorphic Disorder (BDD)

1. BDD involves severe distortion in perception of one’s appearance, resulting in obsession over the “flawed” body part(s) and, at times, extreme efforts to change the body part(s).

2. BDD is often comorbid with Borderline Personality Disorder and Avoidant Personality Disorder, likely for different reasons.

3. Treatment general focuses on modifying cognitive distortions and exposing the individual to the “flawed” body part(s) while preventing typical problematic responses. Note that plastic surgery is rarely effective in changing the individual’s perception of himself/herself.

4. Pharmacological agents (e.g., SSRI’s such as Citalopram) may also be effective.

C. Eating Disorders

1. The eating disorder category comprises several distinct and overlapping diagnoses, including anorexia nervosa, bulimia nervosa, and binge-eating disorder (the latter of which is included in DSM-IV-TR as a category for further study). All involve some disturbance of eating; however, significant emotional concerns generally underlie the problematic behavior pattern(s).

2. Eating disorders (especially bulimia and binge-eating) are common in individuals with Borderline Personality Disorder and may represent different aspects of the diagnosis (e.g., impulsivity, self-destructiveness, dichotomous thinking, identity diffusion). Interestingly, DBT has shown effectiveness in the treatment of bulimia.

3. Obsessive-compulsive personality disorder may be involved in anorexia.

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4. The presence of a personality disorder in the context of an eating disorder may make the eating disorder particularly hard to treat, especially if personality traits strongly support the eating disorder.

D. Substance Abuse

1. A large percentage of individuals with personality disorders also have a substance use disorder (abuse or dependence). This is especially true for antisocial and borderline personalities, as these are marked by impulsivity and stimulus-seeking.

2. The presence of a personality disorder makes substance use treatment significantly more difficult. Dual diagnosis-focused programs may be most appropriate.

V. Pathways to Transforming Personality

A. Practical interventions for helping people with personality disorders

Numerous simple strategies can target global problems. These are useful for therapists, health professionals, other service providers, family members, co-workers, etc.

1. Problem: Lack of social awareness. Intervention: Most people with personality disorders either lack awareness of their interpersonal behavior or cannot generate skillful interpersonal behaviors on command. Social awareness can be developed through self-monitoring, modeling, and feedback/self-disclosure.

2. Problem: Disabling thoughts. Intervention: Most intense emotions don’t just “happen.” They are usually a response to a thought, assumption, interpretation, or belief. Pervasive, negative thinking patterns (e.g., schemas) can be overcome through cognitive strategies. Examples include identification and monitoring of automatic thoughts, examining and weighing evidence for and against thoughts, and generating alternative, balanced thoughts.

3. Problem: Perpetual pessimism. Intervention: Pessimism is an acquired (learned) explanatory style in which the worst is assumed. At extreme levels, pessimism can lead to hopelessness; both characteristics are associated with negative health outcomes (e.g., Smith & MacKenzie, 2006). Fortunately, optimism can be increased through many of the strategies that are useful for modifying disabling thoughts. Modeling optimistic/benign attributions and encouraging behavioral experiments to test beliefs can change explanatory style over time.

4. Problem: Lack of gratitude, empathy, and/or forgiveness. Intervention: Numerous aspects of positive psychology are critical for transforming personality, particularly in light of their benefits on emotional and relational health. Strategies for increasing these factors include benefit-finding, mentalizing, and expressive writing.

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5. Problem: Lack of self-care. Intervention: Self-care (including religious and spiritual practices, when relevant) is the foundation for mental health and runs through several models of therapy. Strategies include attending to nutrition, exercise, and sleep; increasing mastery; and finding meaning and purpose.

B. Managing counter-transference

1. Keep theory in mind; it will help you empathize with the patient.2. Remember that it’s (usually) not you; don’t take behavior too personally.3. On the other hand, be open to the possibility that you could be contributing to the

situation; Stay attuned to your own treatment-interfering behavior.4. Consult with colleagues—a consultation team is an excellent option for mental

health professionals working with numerous personality-disordered patients.

C. Examples of difficult behavior in individuals with personality disorders, and methods for addressing each:

1. Help-rejection and other resistance: This cuts across personality disorder categories. Assess and modify readiness to change using MI techniques.

2. “The button radar”: This is particularly common in Antisocial PD and Borderline PD. Practice acceptance and maintain confident stance.

3. Lack of trust: This is particularly common in Paranoid PD. Provide objective information and address concerns directly.

4. Decreased attachment capacity: This is particularly common in Schizoid and Schizotypal PD’s. Stay solution-focused while providing a safe environment and engaging in usual rapport-building activities.

5. “Attention-seeking”: This is particularly common in Histrionic PD, Narcissistic PD, and Borderline PD. Use non-pejorative language, refrain from reinforcing undesired behavior, and determine the motivation for the behavior.

6. Aggression: This is particularly common in Antisocial PD. Conduct risk assessment, create a safety plan, link behavior with consequences and desired goals.

D. General strategies for working with individuals with personality disorders

1. Set boundaries and observe limits; use a treatment contract that explicitly sets out the terms and parameters of treatment.

2. Self-monitor your own reactions and practice self-disclosure judiciously.3. Provide rationales for treatment strategies; answer questions thoroughly and non-

defensively.4. Balance validation with change.5. Highlight consequences of treatment-interfering behaviors, including

consequences to the treatment relationship.6. Encourage mentalizing.7. Use an empirical approach – measure change quantitatively, and shift course as

necessary.

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E. State-of-the-art treatment models

1. Dialectical Behavior Therapy (Linehan, 1993a; 1993b; Lynch et al., 2007)a. Biosocial model of BPDb. Functions and modes of therapyc. Levels of disorder, stages of treatment, and target hierarchyd. Skills training: Core mindfulness skills, Distress Tolerance, Emotion

Regulation, Interpersonal Effectiveness

2. Schema Therapy (Young et al., 2003)a. Maladaptive coping styles: overcompensation, avoidance, and surrenderb. Strategies for change: cognitive, behavioral, and experiential

3. Mentalization-based Therapy (Bateman & Fonagy, 2006, 2009)1. “Keeping mind in mind”2. Mirroring and empathy

4. Motivational Interviewing (Miller & Rollnick, 2002)1. Stages of change2. Resistance as a relationship variable3. Eliciting and strengthening “change talk”

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Recommended Websites

www.behavioraltech.comwww.borderlinedisorders.comwww.borderlinepersonalitydisorder.comwww.bpdcentral.comwww.dsm5.org www.motivationalinterview.orgwww.mclean.harvard.edu/research/clinicalunit/psychosocial.phpwww.menningerclinic.comwww.schematherapy.com

Please contact Catherine Barber if you would like a copy of the slides: catherine.romero.barber@gmail.com

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