Personality Disorders: Advanced Treatment and Management

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1 Personality Disorders: Advanced Treatment and Management Registration Number:

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3 Personality Disorders: Advanced Treatment and Management Written and Presented by: Gregory W. Lester, Ph.D Any opinions, findings, recommendations or conclusions expressed by the author(s)or speaker(s) do not necessarily reflect the views of Cross Country Education, Inc. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold with the understanding that the publisher is not engaged in rendering legal, accounting or other professional service. If legal advise or other expert assistance is required, the services of a competent professional person should be sought. Copyright 2011 Greg Lester & Cross Country Education, LLC. No part of this workbook may be reproduced in any manner without the expressed written consent of Greg Lester & Cross Country Education, Inc. From a Declaration of Principles jointly adopted by a Committee of the American Bar Association and a committee of Publishers. 6045

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5 Vq"eqorn{"ykvj"rtqhguukqpcn"dqctfu1cuuqekcvkqpu"uvcpfctfu< I declare that I or my family (do, or do not) have any financial relationship in any amount, occurring in the last 12 months with a commercial interest whose products or services are discussed in my presentation. Additionally all Planner s involved do not have any financial relationship. Requirements for successful completion is attendance for the full day seminar, if not, amended CE will be granted accordingly based on your boards/associations requirements (rules) along with a completed evaluation form. Cross Country Education and all current accreditation statuses does not imply endorsement of any commercial products displayed in conjunction with this activity. Personality Disorders: Advanced Treatment and Management Gregory W. Lester, Ph.D Cross Country Education Leading the Way in Continuing Education and Professional Development.

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7 Table of Contents Part I: Fundamental Distinctions of Personality Disorder Differentiating Axis I from Axis II 1 Differentiating Normal from Disordered Personality 2 Research on the Effects of Personality Disorders 4 Research on the Cause of Personality Disorders 5 Part II: Advanced Diagnostic Information Cluster A 6 Cluster B 14 Cluster C 27 Deleted and Appended Personality Disorders 36 Part III: Advanced Interventions Interventions I: Guiding Principles 38 Interventions II: What You Are Intervening In 39 Interventions III: The Options for Intervention 41 Management 41 Treatment 42 Interventions IV: How to Choose an Approach 43 Interventions V: How to Manage 46 Fundamental Management Principles 46 Fundamental Management Techniques 46 Interventions VI: How to Treat 54 Fundamental Treatment Principles 54 Fundamental Treatment Techniques 55 The Types and Order of Treatment 55 The Moment-to-Moment Fluid Process of Treatment 56 Interventions VII: How to Proceed Assessment 57 Attachment 57 Motivation 57 Treatment Frame 58 Part IV: Initiating the Treatment Procedures Choosing Treatment Targets 60 Constrain the Drama 60 Increase Problem-Solving 65 Enhance Observing Ego 70 Install Traits 72 i

8 Target of Deficits by Diagnosis 74 Extinguish 80 Modify 80 Replace 80 Create 80 Part V: Personality Disorders in Children Overview 99 Diagnosis - General 100 Cluster A Paranoid 103 Schizoid 104 Schizotypal 105 Cluster B Antisocial 106 Borderline 108 Histrionic 112 Narcissistic 113 Cluster C Avoidant 116 Dependent 118 Obsessive-Compulsive 119 Additional Information on Children Parent Training Programs 120 Alterations in Treatment for Children 121 Play Therapy 121 Part VI: Personality Disorders in Couples Why Couples Therapy is Uniquely Difficult 122 Relevant Diagnostic Distinctions 123 Treatment Assumptions 125 Treatment Process 126 Part VII: Personality Disorders in Families Research Conclusion 129 Parent Pathologies Possibly Produce 129 The Fundamental Diagnostic Issue with Families 132 Family Treatment - Personality Disorder in a Family 133 How to Explain a Personality Disorder to a Significant Other 134 Family Treatment - A Personality Disordered Family 146 ii

9 Part VIII: Group Treatment of Personality Disorders Evidence of Effectiveness for Group Treatment 147 Advantages of Group Treatment 147 Disadvantages of Group Treatment 147 Characteristics Specific to Group with Personality Disorders 148 Part IX: Medications Important Notice 150 Overview 150 Data on Specific Classes of Drugs 151 The Prescription Process 153 Other Medication Information 154 Part X: Crises Rule # 1 of Crisis Management 156 Techniques 157 Part XI: Prevention Prevention 158 Part XII: Safety Issues Suicide 159 Part XIII: Violence Against Others Violence Against Others 161 Part XIV: Liability Issues Liability in Suicide 162 Part XV: Self-Care Self-Care 163 Part XVI: References References 165 iii

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11 Part I: Fundamental Distinctions of Personality Disorder

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13 Part I: Fundamental Distinctions of Personality Disorder Differentiating Axis I from Axis II Axis I: Malfunctioning psychological or neurological system resulting in symptoms that are impairing or distressing to the person with the symptoms Axis II: Deficient psychological resources resulting in characteristics that cause bad consequences for the person with the characteristics and/or other people Bottom line: Axis I conditions are symptoms that are problematic due to their presence Axis II conditions are characteristics that are problematic due to their effects 1

14 Differentiating Normal from Disordered Personality Normal Personality 1. Sufficient flexibility and adaptability as to be able to achieve more positive than negative consequences 2. Productive awareness of one s own tendencies and biases in a way that enables the ability to self-correct Bottom Line: Normal personality means that an individual s self-induced consequences are generally more positive than negative due to adequate cognitive, behavioral, and affective flexibility combined with adequate and productive self-awareness and self-corrective capacity. Disordered Personality 1. Deficient personality resources ( Missing Traits ) Seems to possess only one fundamental, pervasive, and rigid trait or theme in life Other personality traits seem to be missing including one major, central, impairing deficiency 2. Deficient self-corrective capacity ( Missing Observing Ego ) Pervasive inability to see oneself and others objectively, realistically, and productively Pervasive inability to self-correct 2

15 3. Unproductive escalations ( Drama ) Worsens or unnecessarily prolongs problems due to inappropriate responses Consistent escalated responses (upset, aggressiveness, fear, etc.) that are unproductive 4. Deficient problem-solving Persistently avoidant, passive, helpless, or hostile in the face of problems Persistently dismissive, derisive, or despondent regarding possible solutions Bottom Line: Personality Disorder means that an individual s self-induced consequences are generally problematic and negative due to a rigid and constricted set of cognitive, behavioral, and affective responses combined with inadequate selfawareness and self-corrective capacity. 3

16 Research on the Effects of a Personality Disorder 1. A personality disorder diagnosis is more strongly related to quality of life than any Axis I Disorder or any somatic, health, socioeconomic, demographic, or life situation variable. 2. There is a perfect linear correlation between the overall number of personality disorder criteria met and an individual s quality of life and level of dysfunction. 3. Quality of life varies by diagnosis; from highest to lowest: Obsessive-Compulsive Narcissistic Histrionic Antisocial Dependent Schizoid Paranoid Borderline Schizotypal Avoidant 4. People who fit the diagnosis personality disorder do not differ from the general population in education level, but tend to be more often separated, divorced, never married, more commonly unemployed, to have more frequent job changes, and to have longer periods of disability. 4

17 Research on the Cause of Personality Disorders 1. Genetic Loading 28%-80% depending on diagnosis 56% overall genetic variance 2. Environmental Elements 20%-72% depending on diagnosis 44% overall environmental variance Bottom line: Personality disorders are an interaction effect between genetics and environment, with the genetic and environmental causes largely unidentified. 5

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19 Part II: Advanced Diagnostic Information

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21 Part II: Advanced Diagnostic Information Cluster A Paranoid Personality Disorder I m paid to be suspicious when there s nothing to be suspicious of. Wilford Brimley s character in the film The Firm Pervasively: Suspicious or mistrustful Primary Deficiency: Trust Diagnostic Threshold: At least 4 of 7 DSM IV Criteria Most Notable behavioral aspects: 1. Hypersensitivity to criticism 2. Hypervigilance 3. Constantly finding fault with everyone but themselves Typically Comes Across as: Bitter, resentful, suspicious, blaming, hostile, aggressive, grandiose, oversensitive, hypervigilant, argumentative, unreasonable, offensive Most Important Differential Diagnoses: 1. Paranoia Difference is lack of clear-cut delusions or hallucinations Typical Axis I Comorbidity: 1. Agoraphobia with panic 6

22 2. Bulimia Empirical Data: 1. No long-term outcome studies 2. No controlled psychotherapy studies Possible Biological Underpinnings: 1. Low threshhold for limbic system stimulation 2. Deficiencies in inhibitory centers 3. Anhedonia 4. General neurological irritability 5. Data suggest about 40% of the traits are inherited Possible Developmental Risk Factors: 1. Indulgence or aggrandizing experiences 2. Harsh experiences 3. Rigid or overcontrolling environment Themes: No one likes me because I m better than they are. Life is harsh and unfair and if people can screw you they will. The best defense is a good offense. Major cognitive errors: Selective Abstraction Overgeneralization Prognosis: Guarded Biggest Danger: Retaliatory behavior Most Reliable Indicator: Hypersensitivity to criticism 7

23 Interesting Tidbits: 1. Fewer than 1/4 are free of another Axis II diagnosis 2. Millon Subtypes Malignant - Belligerent, intimidating, vengeful, callous, tyrannical, hostile fantasies, persecutory, delusional Obdurate - Assertive, unyielding, steely, stubborn, unrelenting, peevish, cranky, self-righteous Querulous - Contentious, argumentative, fault-finding, resentful, unaccommodating, jealous, sullen, whiny Fanatic - Pretentious, contemptuous, arrogant Insular - Reclusive, hermit-like, self-protectively seclusional, hypervigilant Bottom Line: A person who constantly blames others, finds fault in others, fears or feels that others are mistreating them or excluding them, feels that others may have malevolent motives, and never finds fault or blame in themselves. Schizoid Personality Disorder I am the midnight watchman down at Miller Tool and Die; I watch the metal rusting, and I watch the time go by. A Better Place to Be by Harry Chapin Pervasively: Indifferent Primary Deficiency: Attachment Diagnostic Threshold: At least 4 of 7 DSM IV Criteria 8

24 Most Notable behavioral aspects: 1. Lack of desire for closeness 2. Affective blankness Typically Comes Across as: Aloof Most Important Differential Diagnoses: 1. Autism 2. Major Depressive Episode 3. Social Phobia 4. Avoidant Personality Disorder 5. Schizotypal Personality Disorder 6. Dependent Personality Disorder Typical Axis I Comorbidity: 1. OCD 2. Hypochondriasis 3. Catatonia Empirical Data: 1. No long-term outcome studies 2. No controlled psychotherapy studies Possible Biological Underpinnings: 1. Passive, anhedonic temperament 2. Increased dopaminergic postsynaptic limbic and frontal lobe receptor activity Possible Developmental Risk Factors: 1. Indifferent parenting style 2. Fragmented communication style with emotional unresponsiveness 9

25 Themes: I don t need anyone. Relationships are messy and undesirable. I m a misfit. Major cognitive errors: Overgeneralization Prognosis: Poor Biggest Danger: Lack of motivation to change Most Reliable Indicator: Lack of desire for or enjoyment of close relationships. Interesting Tidbits: 1. Oldest name on Axis II, coined in 1924 by Bleuler 2. Clinical reports of compulsive or perverse sexuality Despite typical lack of heterosexual interest 3. Millon subtypes: Affectless - Passionless, unresponsive, chilly, uncaring, lackluster, unexcitable Languid - High inertia, lethargic, weary, leaden, lackadaisical, exhausted Depersonalized - Disengaged, distant, disconnected, dissociated Remote - Distant, removed, inaccessible, solitary, isolated, homeless, drifting Bottom Line: A person who, even though not depressed, is a consistent loner, does not seem to enjoy people at all, and finds very little pleasure in life. 10

26 Schizotypal Personality Disorder Giddyup! Kramer s answering machine message in Seinfeld Pervasively: Odd or Eccentric Primary Deficiency: Ability to Conform or Fit Diagnostic Threshold: 5 of 6 DSM IV criteria Most Notable behavioral aspects: 1. Behavioral and appearance oddities 2. Strange or inappropriate affect 3. Poor social judgment 4. Odd use of language Typically Comes Across as: Strange, odd, peculiar, confusing, disconnected, anxious Most Important Differential Diagnoses: 1. Schizoid Personality Disorder 2. Psychosis 3. Autism 4. Borderine Personality Disorder Typical Axis I Comorbidity: 1. Major Depressive Disorder 2. Generalized Anxiety Disorder Empirical Data: Poor affect-labeling skills Inappropriate social behavior Fifteen Year Followup Study: Lower overall functioning than Borderline Personality Disorder 11

27 Low suicide rate - only one suicide in the study Poor global functioning at followup ½ unemployed Few relationships Low rate of psychosis - only one psychotic diagnosis in the study Possible Biological Underpinnings: 1. Passive infantile reaction pattern 2. Genetic link to schizophrenia Possible Developmental Risk Factors: 1. Impoverished early stimulation 2. Parental indifference Themes: I m on a different wavelength from most people. Life is odd and strange and magical. Beware of magic and strange abilities in other people. Major cognitive errors: Magical thinking Low base-rate interpretations Prognosis: Guarded Biggest Danger: Socioeconomic impoverishment Most Reliable Indicator: Pervasively odd appearance or behavior Interesting Tidbits: 1. Most predictive factor is a first-degree biological relative with a psychotic or schizophrenic diagnosis 12

28 2. The only personality disorder with a primary response to medication - neuroleptics are said to be helpful 3. The most-studied and most common of Cluster A personality disorders 4. Millon Subtypes: Insipid - Drab, sluggish, inexpressive, bland, barren, indifferent, vague, tangential Timorous - Warily apprehensive, suspicious, guarded, alienated Bottom Line: A person who does not fit well in life due to strange thinking and behaving that is pervasive and stable but does not rise to the level of delusions or hallucinations. 13

29 Cluster B Antisocial Personality Disorder And don t give me any of that right-and-wrong stuff, because I just don t care. Edward Norton s character in the film The Italian Job Pervasively: Exploitive Primary Deficiency: Honor or Integrity Diagnostic Threshold: At least 3 of 9 DSM IV criteria Most Notable behavioral aspects: 1. Failure to keep agreements 2. Denial of culpability Typically Comes Across as: Charming, engaging, appealing, untrustworthy, lying, callous, dangerous Most Important Differential Diagnoses: 1. Narcissistic Personality Disorder 2. Paranoid Personality Disorder 3. Borderline Personality Disorder Typical Axis I Comorbidity: 1. Substance use and dependence 2. ADHD 3. Malingering 4. Intermittent Explosive Disorder 5. Acute anxiety state (when caught) 14

30 6. Malingering 7. Factitious Disorders Empirical Data: 94% have a history of trouble with unemployment and jobs 85% have a history of violence 72% have multiple moving violations 67% have severe marital problems 47% have a significant arrest record Long term followup study shows: A grim outcome and a malignant course Famous study by Black, et. al, year followup of 45 subjects: 1. All had married 2. 39% had married more than once 3. 91% had produced children 4. Few were actually raising their children 5. 1/3 of their offspring showed psychiatric problems 6. ½ were irregularly employed 7. 1/4 were unemployed at the time of the followup of 45 were completely unimproved showed some improvement no longer met the criteria 11. They were a highly problematic group to study: 30% denied all past difficulties (!) A few were drunk during the interview One subject threatened the interviewer One subject made sexually suggesting remarks All improvement was solely the result of reduced impulsivity Even those who were improved had severe interpersonal problems Best predictor of outcome was recovery from substance abuse Psychotherapy outcome studies: 1. Skills training does not generalize 15

31 2. Psychotherapy fails 3. The only subjects who could respond were those who were made to feel guilty Possible Biological Underpinnings: 1. Low levels of serotonin 2. Difficult infantile temperament 3. Low threshold for limbic system stimulation 4. Autonomically hyperactive 5. Low baseline anxiety Possible Developmental Risk Factors: 1. Parental hostility and deficiency 2. Abuse or mistreatment 3. Poor models and authority figures Themes: No one will look out for you, so you have to get what you want any way you can. What I want is right and any interference with me is wrong. I am alone and must be strong and dominant. The ends justify the means. People are suckers. Major cognitive errors: Mind reading Minimizing Excuse-making Blaming Extreme optimism Intellectualizing Justifying Rationalizing 16

32 Prognosis: Extremely poor Biggest Danger: Violence against others Crimes Most Reliable Indicator: Repetitive agreement violation Interesting Tidbits: 1. Aging seems to be the only factor that makes some less problematic 2. No psychotherapy works 3. No medication works 4. Current standard is to manage their behavior through confinement 5. Kernberg: Our job as mental health professionals is to protect the world from them. 6. Original Cleckley summary: Superficial charm, unreliability, poor judgment, lack of social responsibility, absence of guilt or remorse 7. Researchers referred to the course of Antisocial being malignant and its outcome grim 8. Millon subtypes: Nomadic - Feels jinxed, ill-fated, cast aside, peripheral drifter, gypsy-like roamer, vagrant, dropout and misfit, vagabond, impulsive Covetous - Feels intentionally deprived and denied, begrudging, envious, seeks retribution, avariciously greedy, please from taking rather than having Malevolent - Belligerent, vicious, malignant, brutal, resentful, anticipates betrayal, desires revenge, callous, fearless, guiltless (typical of those still called psychopath ) 17

33 Risk-Taking - Dauntless, intrepid, bold, audacious, daring, reckless, foolhardy, impulsive Reputation-Defending - Needs to be thought of as perfect, invincible, indomitable, formidable, inviolable, overreacts to slights Bottom Line: A person who does do not care what is right or wrong, has no regard for consequence, does not learn from experience, is indifferent to what happens to other people, and is willing to do anything in order to get what they want and to punish those who interfere with them. Borderline Personality Disorder One day she s satisfied, and the next I find her crying, and it s nothing she can explain. If She Knew What She Wants by the Bangles Pervasively: Unstable and extreme in psychological functioning Primary Deficiency: Consistency and Proportionality Diagnostic Threshold: At least 5 of 9 DSM IV criteria Most Notable behavioral aspects: Erratic, chaotic, and extreme reactions and behaviors Dysregulated responses Dichotomous Typically Comes Across as: Intense, passionate, impulsive, excessive, angry, unreasonable 18

34 Most Important Differential Diagnoses: 1. Narcissistic Personality Disorder 2. Dependent Personality Disorder 3. Schizoaffective Disorder 4. Bipolar Disorder Typical Axis I Comorbidity: 1. Major Depressive Disorder 2. Dysthymia 3. Eating disorders 4. Substance abuse and dependence 5. Intermittent explosive disorder Empirical Data: 1. Empirically validated as a distinct entity based in: 1. Dysregulated Affect 2. Dysregulated Behavior 3. Disturbed Relatedness 2. Psychotherapy has been shown to generally be helpful: 1. Psychodynamic (viz. Transference Focused, Mentalization-Based) 2. Cognitive-Behavioral (viz. DBT, Schema Therapy) 3. Supportive (viz. Rockland, Dawson) 4. Biggest danger is dropout: nearly 2/3 drop out of treatment within the first few months 3. Mediation useful for targeted effects year followup study: 18.2% rate of early mortality Most no longer met criteria, but still had significant deficits and impairment 5% still showed evidence of major depression or substance abuse Possible Biological Underpinnings: 1. High autonomic reactivity 2. Hyperresponsiveness to stimuli 19

35 3. Difficult infantile temperament 4. Failure of executive functions of brain (self-regulation) Possible Developmental Risk Factors: 1. Childhood mistreatment or invalidating environment 2. Erratic parenting, family functioning, and treatment Themes: Beck: I am powerless and vulnerable. I am inherently unacceptable. The world is dangerous and malevolent. Young: I ll be alone forever because no one would want me if they got to know me. No one is ever there to meet my needs, to be strong, or care for me. Major cognitive errors: Dichotomizing Absolutism Blaming (self and others) Overgeneralization Prognosis: From poor to good Biggest Danger: Self-damaging impulsive acts Suicidal behavior Most Reliable Indicator: Shifting dichotmizing Interesting Tidbits: 1. The more structured the treatment, the lower the dropout rate 20

36 2. Most do not have trauma outside of normal limits 3. Nearly half are men 4. The best predictor of outcome is severity of pattern when in 20's 5. Observable to preschool in some 6. The most studied and researched of any personality disorder 7. DSM III criteria had a 50% comorbidity with Histrionic, DSM IIIR reduced this to 23%, DSM IV criteria good differentiation 8. Millon subtypes: Discouraged - Pliant, submissive, humble, feels vulnerable and in constant danger, hopeless, depressed, helpless and powerless Impulsive - Capricious, flighty, distractable, frenetic, agitated, potentially suicidal Self-Destructive - Intropunitive, angry, conforming, highstrung, moody Petulant - Negative, impatient, restless, stubborn, defiant, resentful Bottom Line: An individual who is erratic and unpredictable, and shifts between extreme states of mood and thought without a clear sense of self or who they are. Histrionic Personality Disorder Oh my God, oh, my God, it s the, it s the, it s the, uh, the raw intelligence stuff! Brad Pitt s character in the film Burn After Reading Pervasively: Expressive Primary Deficiency: Shame 21

37 Diagnostic Threshold: At least 5 of 8 DSM IV Criteria Most Notable behavioral aspects: Superficial and coercive mood states Typically Comes Across as: Childlike and hysterical Most Important Differential Diagnoses: 1. Borderline Personality Disorder 2. Narcissistic Personality Disorder 3. Dependent Personality Disorder Typical Axis I Comorbidity: 1. Major Depressive Disorder 2. Hypochondriasis 3. Intermittent Explosive Disorder Empirical Data: 1. No long-term outcome studies 2. No controlled psychotherapy studies Possible Biological Underpinnings: 1. Emotional lability from early childhood 2. Low threshold for limbic and hypothalamic stimulation Possible Developmental Risk Factors: 1. Reinforcement of attention-seeking and manipulative behavior 2. Parental role modeling of excessive expressiveness Themes: I am incompetent to handle life myself, so you must do it for me. I must be loved and admired by everyone or I am worthless. 22

38 Major cognitive errors: Emotional reasoning Overgeneralization Global thinking Prognosis: Guarded Biggest Danger: Escalated adult temper-tantrums possibly including self-destructive acts Most Reliable Indicator: Superficiality of emotional expressiveness Interesting Tidbits: 1. Most common of the four Cluster B s, but the least research and study of any 2. Really, really annoying behavior 3. Millon subtypes: Theatrical - Affected, put-on, stagy Vivacious - Vigorouse, charming, bubbly, spirited, impulsive, playful, animated, infantile, labile, high-strung, pouting, demanding, overwrought, a hanger-on Appeasing - Seeks to placate, mend, patch-up, smooth over troubles, yielding, compromising, conceding Disingenuous - Underhanded, double-dealing, scheming, contriving, plotting, crafty, egocentric, insincere, deceitful, calculating Tempestuous - Impulsive, moody, stormy, inflamed, turbulent Bottom Line: A person who is childlike in their impressionistic thinking and who throws fits to get their way and to make other people handle things for them. 23

39 Narcissistic Personality Disorder I m special; so special; I gotta have some of your attention, give it to me! I m Special by The Pretenders Pervasively: Grandiose, Self-Righteous, Self-Aggrandizing Primary Deficiency: Equality Diagnostic Threshold: At least 5of 9 DSM IV Criteria Most Notable behavioral aspects: 1. Consistent self-aggrandizing 2. Consistent devaluing of others 3. Excessive investment in looking good Typically Comes Across as: Entitled, arrogant, self-righteous, demeaning, grandiose, and belittling. Most Important Differential Diagnoses: 1. Borderline Personality Disorder 2. Obsessive-Compulsive Personality Disorder 3. Bipolar Disorder Typical Axis I Comorbidity: 1. Major Depressive Disorder 2. Addictive Disorders 3. Intermittent Explosive Disorder 24

40 Empirical Data: 1. 3-year followup study: 80% showed some decline in narcissistic traits over time 20% still met full NPD criteria Life experiences seem to eventually have an impact on narcissistic traits But only in those who can experience depression year followup study Subjects achieved a moderate level of functioning Seems largely rooted in biology Childhood experiences did not seem correlated to diagnosis Possible Biological Underpinnings: 1. Unknown, but Oslo study showed 77% concordance rates in identical twins Possible Developmental Risk Factors: 1. Aggrandizing environment 2. Other psychological and developmental aspects not well studied and poorly understood Themes: I m better than everyone else, there are no limits on my abilities and talents. You are bad if you do not appreciate how special I am. Major cognitive errors: Overgeneralization Selective Abstraction Rationalizing Justifying Prognosis: Poor to Good Biggest Danger: Antisocial acts 25

41 Most Reliable Indicator: 1. Arrogant, Haughty Behaviors 2. Entitlement Interesting Tidbits: 1. Least common Cluster B disorder 2. Masterson had additional diagnosis of Closet Narcissist Appears only minimally disordered initially Sustained feelings of boredom, meaningless, futility, and hollowness 3. Freud first coined the term for use in psychology, Heinz Kohut popularized it as a disorder 4. Millon Subtypes: Elitist - Facade of specialness bears little resemblance to reality, cultivates social status by association Unprincipled - Deficient conscience, unscrupulous, amoral, disloyal, fraudulent, decweptive, arrogant, exploitive, charlatan, contemptuous, vindictive Amorous - Seductive, enticing, beguiling, tantalizing, glib and clever, indulges hedonistic desires (Lowen s Phallic Narcissist) Bottom Line: Arrogant individuals who believe they are exempt and entitled and are rageful when they feel thwarted. 26

42 Cluster C General 12 year followup study done in England: Cluster C patients did not improve with aging Some disordered traits actually increased over time Anxiousness Vulnerability Conscientiousness (not a disordered trait) Many withdrew from people, became Axis I symptomatic, and were highly dysphoric Avoidant Personality Disorder You don t see anything dad, it s all jello and pudding with you. Timothy Hutton s character to Donald Sutherland s character in the film Ordinary People Pervasively: Timid, Shy, Distant Primary Deficiency: Resilience Diagnostic Threshold: At least 4 of 7 DSM IV Criteria Most Notable behavioral aspects: Timidity even with the people closest to them. Typically Comes Across as: Nice, kind, fragile, scared, anxious 27

43 Most Important Differential Diagnoses: 1. Social Anxiety Disorder 2. Schizoid Personality Disorder 3. Shizotypal Personality Disorder 4. Dependent Personality Disorder 5. Borderline Personality Disorder Typical Axis I Comorbidity: 1. Agoraphobia 2. Generalized Anxiety Disorder 3. Dysthymia 4. Major Depressive Disorder 5. Hypochondriasis 6. Social Anxiety Disorder Empirical Data: 1. Treatment data are encouraging that it can be successfully treated 2. Empirically differentiated from Social Anxiety Disorder and Schizoid Personality Disorder Possible Biological Underpinnings: 1. Dominance of sympathetic nervous system results in hypervigilance 2. Lowered autonomic arousal threshold 3. Trait of shyness repeatedly shown to have strong genetic components 4. Hypersensitivity 5. Slow to warm up or fearful infant temperament 6. Maturational irregularities Possible Developmental Risk Factors: 1. Parental rejection 2. Peer-group rejection 28

44 Themes: I m inadequate and cannot tolerate rejection. Life is unfair because people criticize and hurt me, but I still want someone to like me. I must be vigilant and hyperalert, and if I can t make life work I can always retreat to my fantasies of how life should be. Major cognitive errors: Catastrophic thinking Overgeneralization Prognosis: Poor to Good Biggest Danger: Low socioeconomic-functioning Most Reliable Indicator: Refusal to be involved unless certain they ll be liked Avoids occupational activities with a lot of interpersonal contact due to fear of shame or ridicule. Interesting Tidbits: 1. Millon coined the term in 1969 and did the work that distinguished Avoidant from Schizoid 2. Gabbard states that Avoidant appearing prior to age 11 renders treatment ineffective 3. Recent studies indicate that Avoidant has the lowest quality of life of any Axis II condition 4. Alternate names considered: Phobic Personality; Anxious Personality 5. Millon subtypes: Self-Desterting - Blocks self-awareness, casts away untenable thoughts, suicidal Conflicted - Internally discordant, fears both independence and dependence, unsettled, hesitating, confused, 29

45 Phobic - Focuses avoidance on specific fearful symbols Hypersensitive - Intensely wary and suspicious, panicky, terrified, edgy, thin-skinned, high-strung, prickly Bottom Line: Pervasively shy, timid, anxious individuals who are hypervigilant about and terrified of criticism, contentiousness, or rejection. Dependent Personality Disorder I can t live, if living is without you; I can t live, I can give anymore. Without You by Harry Nilsson Pervasively: Dependent Primary Deficiency: Independence Diagnostic Threshold: At least 4 of 8 DSM IV Criteria Most Notable behavioral aspects: Excessive demand or need to be taken care of, producing clinging and submissiveness and fear of separation Typically Comes Across as: Needy, passive or demanding, clingy, unsatisfiable, dependent, and submissive Most Important Differential Diagnoses: 1. Borderline Personality Disorder 2. Dysthymia 30

46 Typical Axis I Comorbidity: 1. Panic Disorder 2. Dysthymia Empirical Data: Little empirical data on treatment. Possible Biological Underpinnings: 1. Fearful, withdrawing, sat infant temperament 2. Low energy threshold 3. Lack of physical vigor Possible Developmental Risk Factors: 1. Parental overprotection 2. Family with low expressiveness and high controllingness 3. Social humiliation and competitive deficiency Themes: I m nice, but inadequate or fragile. I can t take care of myself, so others must do it for me. It is worth any price to have others care for me. Major cognitive errors: Catastrophic thinking Prognosis: Moderate to good Biggest Danger: Suicidal tendencies if attachment is disrupted Most Reliable Indicator: Requires others to be responsible for the major portions of their life. 31

47 Interesting Tidbits: 1. Not included in DSM III - first appeared in DSM III-R, 50% comorbidity with Borderline Personality Disorder 2. Original formulation had only 3 criteria and was inherently gender-biased 3. Current formulation is reasonably gender-neutral 4. DSM IV criteria were specifically formulated in order to: Distinguish the abandonment fears from those in Borderline Highlight attach needs as more important than abandonment fears Highlight instrumental dependence - getting others to do for them 5. Millon Subtypes: Immature - Unsophisticated, childlike, inexperienced, gullible Disquieted - Restlessly perturbed, feels dread and foreboding, Apprehensive, vulnerable to abandonment Ineffectual - Unproductive, gainless, incompetent, useless, seeks an untroubled life, refuses to deal with shortcomings Accommodating - Gracious, neighborly, eager, benevolent, compliant, obliging, agreeable Selfless - Merges with others, absorbed, incorporated, becomes an extension of others Bottom Line: Dependent, clingy individuals who harbor secret terrors of being abandoned and alone and can be either submissive to others or demanding of others for caretaking. 32

48 Obsessive-Compulsive Personality Disorder What if this is as good as it gets. Jack Nicholson s character in the film As Good As It Gets Pervasively: Rigid Primary Deficiency: Flexibility Diagnostic Threshold: At least 4 of 8 DSM IV criteria Most Notable behavioral aspects: Demanding and exacting, unemotional and rigid, unempathetic and demeaning Typically Comes Across as: Insensitive, unreasonable, and a control-freak Most Important Differential Diagnoses: 1. Narcissistic Personality Disorder 2. Obsessive-Compulsive Disorder Paranoid Personality Disorder Typical Axis I Comorbidity: 1. Generalized Anxiety Disorder 2. Substance Use or Dependence 3. Dysthymia 4. Hypochondriasis Empirical Data: Little empirical data on treatment or outcome. 33

49 Possible Biological Underpinnings: 1. Possible anhedonic infant temperament 2. Often first-born Possible Developmental Risk Factors: 1. Parental demandingness or overcontrol 2. Excessive assignment of responsibility Themes: Because I m responsible if something goes wrong, I must be reliable, competent, vigilant, and rigorous. Life is excessively demanding. I must be in control at all times. I must be proper and perfect. Major cognitive errors: Excessive detail orientation Cognitive inflexibility Prognosis: Guarded Biggest Danger: Rage or despair when lacks control Most Reliable Indicator: So preoccupied with details they lose the point of the activity. Interesting Tidbits: 1. Freud coined the term in 1908: Anal character arising from defense against anal eroticism 2. Distinct from OCD - comorbidity is only 15% - 18% OCD is comorbid with some Axis II at least 50% of the time 3. DSM III called it Compulsive Personality Disorder - Obsessive added in DSM III-R 34

50 4. One of the most empirically studied and least controversial personality construct and diagnosis 5. Millon subtypes: Conscientious - Rule and duty-bound, earnest, hard-working, meticulous, painstaking, indecisive, inflexible, enormous self-doubt, dreads errors and mistakes Bedeviled - Pervasive ambivalence, feelings of being tormented, muddled, indecisive, confused, frustrated Parsimonious - Miserly, tight-fisted, ungiving, hoarding, unsharing, fearful of loss Bureaucratic - Seeks identity from authority figures, highhanded, intrusive, nosy, petty, small-minded, meddlesome, closed-minded Puritanical - Austere, self-righteous, bogoted, dogmatic, zealous, uncompromising, indignant, judgmental, grim, prudish Bottom Line: Rigid, emotionally constricted individuals who lack empathy and for whom no perfection or precision is sufficient. 35

51 Deleted and Appended Personality Disorders Depressive Personality Disorder Included in ICD-9 Was considered for inclusion in DSM IV and was not because: 1. Considered largely covered by Dysthymia on Axis I 2. Seems redundant to Avoidant, Dependent, and Borderline 3. Lacks empirical data (although there have been recent supportive data) Passive-Aggressive Personality Disorder (Yes, I know you re mad it was removed. Yes, I know you want it back. Yes, I know you re going to hate this - it s not coming back.) Name coined in 1945 by the U.S. War Department to label certain soldiers Included in DSM I Never been included in an ICD Was reluctantly included in DSM II and DSM III Removed from DSM IV because: 1. It is a psychoanalytic interpretation of a conflict between hostility and guilt 2. There are no epidemiological studies or data 3. It has poor statistical reliability 4. It has a strong overlap with other personality disorders 5. Millon suggests it is an aspect of Avoidant and Dependent 6. It has poor behavioral correlates Sadistic Personality Disorder Term coined in 1898 by Kraft-Ebing (who also coined the term masochism - interesting little fantasy life, I d guess) Not included in the DSM because: 36

52 1. Was seen as an attempt to put in a diagnosis to balance Self- Defeating Personality Disorder 2. Fears that it would mitigate legal responsibility 3. Little relevant data and few relevant studies 4. Largely psychoanalytic concept 5. Highly controversial 6. High overlap with: Narcissistic Personality Disorder (56%) Paranoid Personality Disorder (44%) Antisocial Personality Disorder (44%) Schizotypal Personality Disorder (35%) Borderline Personality Disorder (no specific stat) Histrionic Personality Disorder (no specific stat) Passive-Aggressive Personality Disorder (no specific stat) 7. It was basically promoted by mental health professionals working in forensics Self-Defeating Personality Disorder Also suggested as Masochistic Personality Disorder (There s that Kraft- Ebing guy again) Inclusion in Appendix of DSM III-R was extremely controversial Not included in DSM IV because: 1. Strong gender bias 2. Largely psychoanalytic in concept 3. High potential for misuse in areas such as domestic violence % comorbidity with other Axis II diagnoses: Borderline Avoidant Dependent 5. One of the lowest statistical reliability of any proposed Axis II pattern 6. Very little data 37

53 Part III: Advanced Interventions

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55 Part III: Advanced Interventions Interventions I: Guiding Principles 1. The fundamental goal of all personality disorder intervention: Reduce problems created by the disorder Improve the individual s adaptability in life 2. All intervention takes place within either: A Management context or A Treatment context 3. When Treating: You can also Manage 4. When Managing: You cannot Treat 5. All clients and patients can be Managed 6. Some patients can be Treated 7. If you try to treat someone who is not your patient: You will make things worse There are two types of people in your life - your family and your patients. Never confuse them. Mary Goulding, Evolution of Psychotherapy Conference, The more severe the disorder, the more varied, flexible, and diverse interventions need to be This is how we front-line clinicians differ from the theorists 38

56 Interventions II: What You Are Intervening In The Characteristics of a Disordered Personality 1. Trait Deficits (DSM Diagnosis) A narrow repertoire of responses that are repeated even when the situation calls for an alternative behavior or in the face of clear evidence that a behavior is inappropriate or is not working. (Skodol, pg 42, in Oldham, Skodol, & Bender) Diagnosis: Deficiency: Excess: Paranoid: Trust Suspiciousness Schizoid Attachment Indifference Schizotypal Conformity Oddities Antisocial Integrity Exploitation Borderline Consistent Extremeness Histrionic Shame Expressiveness Narcissistic Equality Self-Righteousness Avoidant Resilience Timidity Dependent Independence Submissiveness OCPD Flexibility Rigidity 2. Lack of Productive Self-Awareness (Observing Ego) Can t see their own part in difficulties, do the same thing over and over, don t learn from experience, lack productive insight 3. Unproductive Escalations (Drama) Embroil themselves and others in unproductive escalations - upsets, conflicts, blaming, etc. 4. Deficient Problem-Solving Avoids, distracts, becomes aggressive or passive instead of searching for, finding, implementing, and accepting solutions 39

57 Patients with personality disorders tend to be notoriously poor interpersonal problem solvers. (Heim & Westen, pg 18, in Oldham, Skodol, & Bender) 40

58 Interventions III: The Options for Intervention 1. Management Management Overview The Fundamental Goal of Management is: Harm Reduction 1. Keep them from driving you crazy 2. Keep things from getting worse 3. Reduce or limit chaos, upset, and bad consequences 4. Make things better if it is possible to do so 5. Get them to consider treatment The Advantages of Management: 1. No agreement is required 2. No treatability is required 3. No motivation is required 4. It can be done unstructured and informally 5. It is relatively safe 6. It can be done with individuals who are not your treatment patients The Disadvantages of Management: 1. It does not produce self-propagating change 2. It does not get them better 3. It does not create new personality resources 4. Its effects are limited 5. Treatment techniques are inappropriate 41

59 2. Treatment Treatment Overview The fundamental goal of treatment is: Improvement 1. Increased flexibility and adaptability 2. Better self-awareness and self-management 3. Diminished unproductive escalations 4. Improved problem-solving The Advantages of Treatment: 1. It is designed to improve their functioning 2. It is designed to produce self-perpetuating improvements 3. It is designed to get people to behave better 4. It is designed to get people to feel better 5. It provides you with some emotional insulation 6. It is structured and planned The Disadvantages of Treatment: 1. Agreement is required 2. Treatability is required 3. Motivation is required 4. It can only be done formally 5. It can be emotionally dangerous, it is uncomfortable and verbally invasive 6. It can only be done with individuals who are treatment patients 42

60 Interventions IV: How to Choose an Approach The Elements to Consider 1. Their DSM IV Axis II Diagnosis Management Treatment Paranoid OK If highly Treatable Schizoid OK No Treatment Schizotypal OK If at least moderately Treatable Antisocial OK No Treatment Borderline OK If moderately Treatable Histrionic OK Treatment OK Narcissistic OK Treatment OK Avoidant OK Treatment OK Dependent OK Treatment OK OCPD OK Treatment OK 2. Their DSM IV Axis I Diagnosis or Diagnoses Will the Axis I (s) be impairing of Axis II treatment Is it treatable in addition to Axis II treatment 3. Their History Management is Indicated When: 1. The person has a history of failed treatment 2. The person has a history of worsening in treatment 3. The person has a history of abusing the medical or mental health system 4. The person cannot or will not create a Treatment Frame 5. The setting is not appropriate for a Treatment Frame 6. The person has little or no motivation 7. The person fits the concept of untreatable 8. The person is not a psychotherapy patient or client 9. The person is someone in your personal life 10. The person has an Antisocial diagnosis 43

61 Treatment is Indicated When: 1. The patient has no history of treatment 2. The patient has a history of successful or neutral treatment 3. The patient has no system-abusing history 4. The patient can make a Treatment Frame 5. The setting supports making a Treatment Frame 6. The patient has sufficient motivation 7. The patient has sufficient treatability 4. Their Treatability Some of these (the more the merrier): 1. Ability to form a relationship with the therapist 2. High intelligence 3. Unusual talent(s) 4. Attractive 5. Productive Obsessive-Compulsive traits 6. Sober or in recovery 7. Motivated 8. Can talk about their own weaknesses 9. Can trust or be loyal 10. Can weigh contingencies Few or none of these (these are not so good, I m afraid): 1. Unresponsive depression 2. Unresponsive substance abuse 3. History of felony arrests 4. History of lying 5. History of conning 5. Your Position If you are a mental health counselor or a therapist you can consider Treatment If you are not a mental health counselor or a therapist you should consider Management 44

62 6. Your Setting If you work in a therapeutic setting you can consider Treatment If you do not work in a therapeutic setting you should consider Management 7. Your Relationship to Them If they are a patient or client being seen for therapy or mental health counseling you can consider Treatment If they are a patient or client who is not being seen for therapy or mental health counseling or your relationship with them is personal or they are not a client, viz. a coworker, boss, employee, etc., you should consider Management 8. Your History Do their patterns match old patterns in your life that could result in your having a distorted response to them to or a likelihood of your getting unproductively embroiled in their patterns 45

63 Interventions V: How to Manage Management Fundamental Management Principles Management Mindset: 1. You are not trying to get them better 2. You are not trying to get them to see 3. You are being as benign as possible 4. You are trying to not make things worse 5. You are planting seeds Goals of Management: 1. Stay out of the Drama 2. Don t make the Drama worse 3. Keep the Drama from spreading 4. Make things better if appropriate 5. Get them to consider Treatment 6. Take immediate action at warning signs Fundamental Management Techniques 1. Stay Out of the Drama 1. Most Important technique: Keeping your own behavior appropriate at all times, no matter what they do Always have your Observing Ego activated Pay attention to the nature and quality of the immediate conversation than the content of the conversation Common Drama hooks (How they try to get you into it): Paranoid: Unjustified accusations Demeaning interpretations of motives 46

64 Schizoid: Schizotypal: Antisocial: Nonresponsiveness Lack of attention to issues or emotions Odd statements or behavior Strange interpretations Oh, come on, it s no big deal Threats Borderline: Emotional blackmail Excessive demands Histrionic: Narcissistic: Avoidant: Dependent: O/C: Helplessness Pouting Demeaningness Rage Insults Refusal to address issues Unwillingness to talk about things Helplessness Passivity Criticism Demandingness 2. Most Important Ability: To be able to smile and nod no matter how you feel The drama will try to hook you into misbehaving 3. Second Most Important Ability: To be able to look thoughtful even when you have no idea what to do Being able to be with them nonreactively is key 47

65 4. Attend to agreements Make agreements specific and behavioral Note agreement violations Don t let things slide 5. Use a 3-1 ratio of validations and positive communication behaviors to confrontations and negative communication behaviors Don t get trapped into a spiral of negative reciprocity (When in doubt, see Second Most Important Ability, above) 6. When giving explanations, do not demand agreement Explain so the explanation has been made and you have said what you need to say 7. Say no simply, directly, and unequivocally Be prepared for an extinction burst response See Second Most Important Ability, above) 8. When in doubt, drop into uncomplicated attention Don t be in a rush (See Most Important Ability, above) 9. Spend most of your conversations talking about irrelevant things Watch out for trying too hard and going over and over 10. Keep your perspective One-Step-Removed Visualize yourself and them as separate, distinct entities Keep your Observing Ego active 11. Keep your focus on whatever is your larger purpose Don t get sidetracked into irrelevant conflicts 12. When in doubt, slow down and use fewer words Watch out for trying too hard 48

66 13. Violate the symbiosis Say and do the unexpected 14. Think of your demeanor as the equivalent of spraying them with pleasant, cool water while you re talking Soothing, calm 15. Only help after you have freely offered it and they have agreed Don t jump in too fast RESCUERS ALWAYS BECOME VICTIMS 16. Use an SET dialectic Support Empathy Truth 2. Don t Make the Drama worse 1. The Fundamental Technique: Reframing Frame your response with a meaning they can accept Don t beat them over the head emotionally If they don t get it, try another framing 2. Use and create benign interpretations of them, you, and others Diminish malevolent interpretations of you and others 3. Be willing, at times, to be defined as the one who is wrong Don t defend yourself beyond basic and simple responses Watch out for the emotional blackmail of getting into the Drama to avoid being the one considered to be wrong 49

67 4. When making points, do so in a distancing, sharing style rather than putting it on them style Watch out for your own sneaky hostility When they have distance from it, they can hear it better 5. Predict what is going to happen Take out the sting by preparing them 3. Keep the Drama from Spreading 1. The Fundamental Technique: Clarity ALL DRAMA HAS ITS ROOTS IN AMBIGUITY ALL DRAMA HAS ITS ROOTS IN AMBIGUITY ALL DRAMA HAS ITS ROOTS IN AMBIGUITY When in doubt - clarify, clarify, clarify 2. Don t be a go-between Watch out for getting set up to fail with others 3. Don t go around gathering agreement that they re wrong Get consultation or advice, but don t feed any splitting 4. Empathize without providing practical help Don t jump in too fast RESCUERS ALWAYS BECOME VICTIMS 5. Offer practical help only when it is appropriate Watch out for feeling victimized by doing too much or offering too much 6. Use behavioral language to reduce escalations Break things into component parts 7. Make all agreements clear and specific Effective agreements are the foundation of good management 50

68 8. Work with others to help them avoid getting caught in the drama Give a benign interpretation of the disordered individual, too Remember - they re doing the best they can 4. Make Things Better if it is Possible to Do So 1. The Fundamental Technique: Training Use behaviorist principles rather than insight principles: Reinforcement Punishment Negative Reinforcement Extinction 5. Get Them to Consider Treatment 1. The Fundamental Technique: Highlighting their pain Even if they re wrong about what their pain is or where it s coming from 2. Phrases designed to plant the seeds of help-seeking behavior I really don t think it has to be this way You know, some things don t get better on their own Is there something that would make you want to get help? What needs to happen before you are willing to get help? Well, it s really sad for me to see this happening I don t blame you for not wanting to get help about it; it s a really hard thing to do It s so hard to see our own part in these kinds of things, isn t it? I m sorry, it s just so hard for me to watch this happening I know we have different views on it, and that you don t agree with mine Are you sure you want to hear my thoughts on it? I d really hate to see worse things happen to you 51

69 I think it d be worth it I see you as being happier 6. Watch for Warning Signs and Take Action When You See Them 1. The Fundamental Technique: Disengagement Warning Signs: 1. You start repeating yourself over and over 2. You find yourself desperately tying to get them to see 3. You re doing a lot of arguing 4. You are defending yourself a lot 5. You find yourself trying to get them better 6. You think they have successfully provoked you into their Drama 7. You find yourself trying to get them to change 8. You feel an enduring upset 9. You feel victimized 10. You want to hurt them 11. You want to kill them 12. You re afraid of them 13. They suddenly start making significantly more trouble for you 14. They are insulting, criticizing, or demeaning in an intolerable way 15. You feel despair 16. You feel coerced or emotionally blackmailed 17. You feel you are in a no win situation 2. Get consultation Find someone not caught in the drama to advise 3. Interrupt the pattern Do something different - anything 52

70 4. Clarify what you are holding onto that has you biting on the Drama What s the cost you re avoiding? 5. Monitor your energy Getting too tired is a major danger 6. Breathe, for goodness sake! Slowly, deeply, as in mindfulness meditation 53

71 Interventions VI: How to Treat Treatment Fundamental Treatment Principles Treatment Mindset They are doing the best they can And they need to do better They cannot see what they re doing And they must be learn to identify their part The disorder is not their fault And their life is their responsibility They cannot control themselves And they must change what they re doing Their views are disorder-consistent And they don t work in the real world Their relationships are destructive And the relationship with you must be constructive They have difficulty being motivated And they must work hard You have a substantial risk of failure And you must proceed expecting to succeed Goals of Treatment 1. The fundamental goal is to improve adaptability Reduce Unproductive Escalations Increase Problem-Solving Enhance Observing Ego Reduce Deficits 2. Treatment can involve Improving the presenting complaint Improving their resources for handling life 54

72 3. Treatment is best when it is targeted, specific, and clearly defined Fundamental Treatment Techniques 1. Connections Clarifying all cause-and-effect 2. Observations Pointing out those areas of reality that they are disregarding 3. Confrontations Clarifying the unclear 4. Transference Interpretations Addressing experiential deficits The Types and Order of Treatment 1. Brief (Focal): 1-6 Sessions Emphasis: Constrain the Drama Techniques emphasized: Behaviorist 2. Short-Term (Cognitive-Behavioral): 6-10 Sessions Emphasis: Increase Problem-Solving Techniques emphasized: Behaviorist, some Insight-Oriented 55

73 3. Mid-Term (Mix of Cognitive-Behavioral and Analytic): Sessions Emphasis: Develop Observing Ego Techniques emphasized: Insight-Oriented, some Behaviorist 4. Long-Term (Analytic) 30+ Sessions Emphasis: Develop New Traits Techniques emphasized: Insight-Oriented The Moment-to-Moment Fluid Process of Treatment 1. Focus on a target Drama Problem-Solving Observing Ego Deficits 2. Apply a technique 3. Look for a change 4. Repeat or move to new target 56

74 Interventions VII: How to Proceed 1. Have an Assessment Conversation Diagnose and consider Management and Treatment 2. Have an Attachment Conversation Create an alliance in order to establish influence Reflect understanding of their presenting complaint Empathize with their pain Use Support and Validation 3. Have a Motivation Conversation Amplify their motivation Typical motivation problems: Low self-directedness Passivity Demoralization Trouble trusting others intentions Treatment will take forever and won t be worth the effort Nobody can help them I am who I am It s all other people It s other people s problem if they can t accept me as I am It s only a medical problem I just need medication Motivation enhancers: Break problem into pieces that don t feel overwhelming Identify and admit legitimate incentives for not changing Identify dilemmas: Approach-Approach Approach-Avoidance Avoidance-Avoidance Not passing the problem on to future generations Not waiting until things get worse or there s a crisis 57

75 Stop their increasing anxiety and worry about the problem Note the repetitive nature of the patterns Note that some things don t get better on their own Frame their working on the problem as a sign of strength Compare them to your Phantom Patient Present a cost-benefit analysis of treatment Define how the problem used to be adaptive but has outlived it usefulness Convey that the problem is something that is understood and treatable Praise them for even being willing to consider treatment Talk about how things can get better 4. If Treating, Create the Treatment Frame A Treatment Frame is an agreed upon plan of working between you and the patient about how you are going to proceed, where the terms of the plan are dominated by the needs of the treatment rather than the characteristics of the disorder. The Treatment Frame 1. Confines the patient s behavior to that which is tolerable to the clinician 2. Defines contingencies for breaking the frame 3. Teaches the patient how to be a patient 4. Creates a secure attachment between the patient and the clinician 5. Creates a longer-term mindset in the patient - enhances patience 6. Defines mutually agreeable practical elements of treatment Time Place Frequency Duration Vacations and absences Cancellations and rescheduling Extra sessions 58

76 Telephone calls Emergencies Behaviors No-Shows Suicidality Consistency 7. Must be done where the requirements are met Setting where frames are supported Professional in a position to create frames Patient with sufficient motivation to make a frame Diagnosis Sufficient treatability Realistic practical elements 8. Key feature: If the frame is ever violated, the treatment must stop while the violation is defined and repaired. If it cannot be repaired, the treatment is terminated and the patient is referred 5. If Managing, Begin a Reframing Conversation 6. If Treating, attend to Axis I issues, especially if pressing Be aware of possible limitations of effectiveness due to the Axis II deficits 7. If Treating, Initiate the Treatment Procedures From a cognitive neuroscience perspective, the internalization of the therapeutic relationship gradually builds a new neural network with a different type of object representation and a corresponding selfrepresentation. The old networks are not completely obliterated by the treatment, but they are relatively weakened or deactivated while the new networks based on the treatment relationship are strengthened. (Gabbard, pg 191, in Oldham, Skodol, and Bender) 8. If Managing, Proceed with Appropriate Management Techniques See section on Management techniques 59

77 Part IV: Initiating the Treatment Procedures

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79 Part IV: Initiating the Treatment Procedures: Choosing Treatment Targets Target #1: Constrain the Drama Fundamental Technique: Clarifying Connections ALL DRAMA HAS ITS ROOTS IN AMBIGUITY 1. Define Current Connections 2. Make New Connections Hierarchies of Drama Targets 1. By Dangerousness Life Threatening Acute Suicidality Homicidality Violent Relationships Advanced Drugs or Alcohol Physically Harming Parasuicidality Abusive Relationships Excessive Drugs or Alcohol Dangerous Addictive Behavior Impulsive Behavior Provocative Behavior High-Risk Activities Volatile Relationships Uncontrolled Anger Depression 60

80 Escalated Relationships Conflict Therapy-Interfering Showing up drunk or high Breaking agreements Inappropriate behavior Threats Distressing Behavior Mood Relationships 2. By Interpersonal Level of Drama Third Degree Life-and-Death Second Degree Lying, Hiding, Sneaking First Degree Socially Acceptable 3. By Degree of Passive Behavior 1. Violence or Incapacitation Shut-down/Physical coerciveness 2. Agitation Repetitive, non-goal-directed activity Shifts discomfort to others 3. Overadaptation Ignoring implications 4. Doing Nothing No response, avoidance 5. Nonreflective Coercion Passive-aggressive inaction 61

81 Treatment Techniques Medication See section on medications Environmental Controls Hospitalization Residential Placement Partial Hospitalization Group Home Significant Others/Parent Training/Coaching Special Classroom Consequences and Contingencies Contracts Legal Involvement Behavioral Chaining Defining Cause-and-Effect Interaction The Environment and Their Thoughts, feelings, behaviors Ambiguity Reduction Distinguishing Confusion from indecision Uncertainty from lack of knowledge Creating Behavioral Options Possible responses The Phantom Client Rationales for alternative actions Contingencies Defining contingencies and consequences Creating contingencies and consequences Support Providing and finding sources 62

82 Accurate Empathy Calm escalations because message received Reassurance Matter-of-Factness Conversational tone Tone of possibility Implied tolerability, lack of awfulness A hassle, not a horror Rationalization Reasons - make them up if need be Anticipation Predict to remove shock value Advice OK to use under one condition When you have no personal stake in them taking your advice Training Anger management Anxiety management Distress tolerance Emotional regulation Impulse control Sensitivity reduction Provide New Information Teach, often the most obvious things Paradox Push the same direction in order to produce resistance 63

83 Prohibit Tell them directly to not do something Interpret Other People to Them Benign interpretations New possibilities of interpretation Metaphor Stories, analogies Predicate Matching Verbal Visual Kinesthetic 64

84 Target #2: Increase Problem-Solving Fundamental Technique: Confrontation WHERE PROBLEM-SOLVING BREAKS DOWN, DRAMA BEGINS Confront where they derail the problem-solving process Normal Problem-Solving Process 1. Identify the problem 2. Define the problem Behavioral Language As the problem currently exists 3. Generate possible alternative solutions Behavioral Language 4. Evaluate the possible solutions Pros and cons Preferences 5. Choose and implement a solution or solutions 6. Evaluate the outcome 7. Make adjustments Personality Disordered Problem Solving Process 1. Failure to identify something as a problem or 2. Failure to define the problem or 3. Failure to generate possible alternative solutions or 4. Refusal to evaluate the possible solutions or 5. Failure to choose and implement a solution or solutions or 6. Failure to evaluate the outcome or 7. Failure to make adjustments or Fundamental Technique: Teach normal problem-solving process 65

85 Issue Number 1: Failure to Identify Something as a Problem Deficit in identifying problem existence Techniques 1. Confrontation of denial Directly point out the nature of the problem 2. Interpretation of others viewpoints of it as a problem Point out collective conclusion 3. Connections to bad consequence Repeatedly connect the problem to the bad consequence 4. Reframing Give the problem a more tolerable meaning 5. Clarification Phrase the problem in behavioral language 6. Pattern identification Point out the repetitive nature of the problematic pattern 7. Predict future difficulties Note the likely future course of the problem Issue Number 2: Failure to Adequately Define the Problem Deficit in identifying problem significance Techniques 1. Translation into Behavioral language Translate global, conceptual terms into behavioral terms 2. Use words having to do with seeing and hearing Primitive, simple, observational language 66

86 Issue Number 3: Failure to Generate Possible Alternative Solutions Deficit in view of problem solvability Techniques 1. Present possibilities Possibilities have no demand quality, they are theoretical 2. Present alternatives Alternatives are realistic possibilities 3. Confront immediate dismissal of possible solutions Separate generation of alternatives from evaluation of them 4. Encourage Encourage them to keep thinking creatively 5. Push Push them to keep generating alternatives 6. Demand Push them hard to keep generating alternatives 7. Empathize with imperfection of all solutions Note that imperfections of solutions is tolerable Issue Number 4: Refusal to Evaluate the Possible Solutions Deficit in solution acceptance Techniques 1. Cost-benefit analysis Show that every solution has good and bad involved 2. Positive and negative of every solution Review the good and bad of every solution 67

87 3. Tolerance and acceptance of imperfections Work to increase tolerance of imperfections Issue Number 5: Failure to Choose and Implement a Solution Unwillingness to change Techniques 1. Support Reassure that adopting solutions is worth the trouble 2. Reassurance Note that solutions are not inherently permanent 3. Tolerance Help find ways to tolerate the discomfort of changing 4. Flexibility All solutions need tweaking 5. Reminders of tentative nature of solution implementation There are always more possibilities out there Issue Number 6: Failure to evaluate the outcome Setting up the process for failure Techniques 1. Get them to stay with the process Watch for them getting out of the process too soon 2. Reassurance Keep encouraging them 68

88 3. Distress tolerance Keep encouraging acceptance of some discomfort Issue Number 7: Failure to make adjustments Validation of self-righteous view that nothing will help Techniques 1. Confront any dismissiveness Point out premature conclusions 2. Empathize with imperfections Share personal experience with imperfect solutions 3. Remain neutral Don t get invested in one particular solution 69

89 Target #3: Enhance Observing Ego Fundamental Technique: Observations OBSERVING EGO IS PRODUCTIVE SELF-AWARENESS Techniques 1. Identification of pattern repetition Enlarge their view of their responses 2. Identify automatic responses Name their unconscious, automatic reactions 3. Identify internal and external triggers for automatic responses Note the patterns involved in their automatic, unconscious responses 4. Interpret others motives Challenge their misinterpretation of others motives 5. Use The Phantom Client Compare their reaction to a hypothetical other 6. Reflective Listening Mirror their responses and reflect their affect 7. Teach how others respond Teach them about others feelings and reactions 8. Paraphrase Make awareness easy to hold 9. Praise for self-awareness comments Give positive feedback for seeing negatives in self 70

90 10. Reframe reactions as understandable And therefore OK to see and OK to acknowledge 11. Ask the shrinky questions requiring self-analysis How does that feel? What do you think when that happens? What is that like for you? Is that the same or different as...? 12. Draw associations and parallels Point out historical repetitions Occurrences Experiences Behaviors Feelings Past to present 13. Transference Interpretations Focus on howow they re responding to you 14. Countertransference interpretations Use your response to them to interpret patterns 15. Clarification Define global terms specifically Investigate anything unclear or undefined 71

91 Target #4: Install Traits Fundamental Technique: Transference Interpretations Traits are Fully Present Only in Immediate Experience Define excesses, deficiencies, and distortions The Alternatives for Trait Changes 1. Elimination of a Trait Thoughts Feelings Behavior Experience 2. Modification of a Trait Change portions 3. Replacement of a Trait Same thing in a new way 4. Creation of a Trait Something they don t already have or do Thoughts Feelings Behavior Experience Techniques 1. Transference Interpretations Here-and-now experiential connections 2. Become less active, use fewer words Require them to talk more, to comment more 72

92 3. Use silence as confrontation Violate typical conversational patterns 4. Reflective listening 5. Exploratory questions 6. Overturn the dialogue imperative Make comments that are inconsistent with the expected 7. Connect feelings, experiences, thoughts, behavior, and environmental cues Be alert to subtle cues and responses 8. Maintain a focus on the relationship Don t let discomfort or lack of clarity continue 9. Analyze therapeutic ruptures Use upset feelings as a tool to explore patterns 10. Use current occurrences as examples of general patterns Use everything as an example, holographically 11. Maintain the dialectic Balance positives and negatives Balance confrontations and validations 73

93 Target of Deficits by Diagnosis Paranoid Their Excess of Behaviors that: Search for cues indicating malevolence Maintain perceptual vigilance, scanning the environment for dangers Create conflict with authority figures Counterattack in response to a perceived threat or slight Maintain muscular tension Involve blaming and accusing Reject others influence, suggestions, requests, or demands Start or perpetuate arguments Threaten Their Excess of Thinking About: The meaningfulness of small things ( making mountains out of molehills ) Others untrustworthiness Others mistreatment The ways in which others guise real motives behind a facade of innocence How others are devious, deceptive, treacherous, covertly manipulative The danger they will be taken in by others Potential danger from others secret motives Potential betrayals of those close to them Dangers to their privacy or risk of personal exposure Events being personal and meaningful Their Excess of Feelings of: Fear - that others will undermine them or take advantage of them Fear - that others want to interfere with them 74

94 Anxiety - about the world being dangerous Anger - over being mistreated and abused Vulnerability Self-sufficiency Vengeance Their Excess of Interpersonal Functioning that Involves: Distancing Treating others as adversaries Being on guard Triggering bad treatment or hostility from others Attributing problems to others abusiveness and mistreatment Being secretive Shunning overtures of nurturing from others Excessive and inappropriate jealousy Rivalry Stubbornness Arguing Arrogance and contemptuousness Being provocative Their Excess of their Sense of Self as: A righteous victim Vulnerable and endangered Unique Special Singled out Their Excess of Outcomes Involving: Losses - jobs, relationships Rejection Isolation Being the target of others anger and derision Violence Legal authorities 75

95 Being investigated Financial problems Loss of resources Their Deficit of Behaviors that: Display or admit doubts and insecurities Relax their muscles Express forgiveness Do what others request Creates productive discussions Acknowledge personal fault, error, or mistake Resolve disagreements or conflict Self-discloses Their Deficit in Thinking About: Other people s positive attributes Doing positive or kind things for other people Pleasant outcomes Happiness, comfort Relief Events being impersonal or benign Their Deficit of Feelings of: Trust Acceptance Humor about self and others Safety Comfort Relaxation and serenity Optimism Warmth, tenderness, affection Neediness Cooperation Their Deficit in Thinking About: 76

96 Self-disclosure Expressing warm, tender feelings Non-malevolent motives in others Empathy Concern for weakness or suffering Good-natured competition Their Deficit in their Sense of Self as: A member of a community or team Competent to face life s ups and downs Ordinary Equal to other people Someone with flaws and faults Someone who does things wrong Their Deficit of Outcomes Involving: Harmonious relationships Promotions at work Invitations from others to participate with them Financial security Stable marriage and family life Peace and harmony Expanding resources New possibilities 77

97 Schizoid Their Excess of Behaviors that: Distance and create isolation Involve silence Involve passivity Their Excess of Thinking About: Needing space Relationships being messy, undesirable, and problematic Their Excess of Feelings of: Being alone and a loner Life being bland and unfulfilling Blankness Autonomy Emptiness Their Excess of Interpersonal Functioning that Involves: Treating others as an annoyance or as intrusive Treating people as replaceable objects Isolation Their Excess of their Sense of Self as: Alone Empty A misfit Misunderstood Their Excess of Outcomes Involving: Being overlooked Being left out Low levels of self-care 78

98 Their Deficit of Behaviors that: Engage other people Express emotions Work in tandem with others Are energetic Their Deficit in Thinking About: Other people Things that make them feel good Possibilities Wishes and desires Their Deficit of Feelings of: Closeness Warmth toward others Excitement Anticipation Optimism Their Deficit in Interpersonal Functioning that: Produces intimacy Is reciprocal Relates to others Nurtures others Their Deficit in their Sense of Self as: The member of a community or team Needy Similar to other people Appealing Their Deficit of Outcomes Involving: Getting what they want Creating value Forming relationships Reaching goals 79

99 Schizotypal Their Excess of Behaviors that: Deviate from social norms Take unnecessary risks Offend or confuse other people Are socially inappropriate Don t make sense Their Excess of Thinking About: How gifted or insightful they are The way the world works Themselves Being strange or defective Grandiose ideas or plans Strange ideas Anxiety Being different Being special Their Excess of Feelings of: Their Excess of Interpersonal Functioning that Involves: Behaviors that offend or confuse people Isolation Demeaning or belittling others Special Defective Dead Alien Gifted Their Excess of Their Sense of Self as: 80

100 Their Excess of Outcomes Involving: Social isolation Losses - jobs, relationships Financial difficulties Being hurt or rejected Doing dangerous things Their Deficit of Behaviors that: Are rationally thought-out Are appropriately goal-directed Are socially acceptable Make sense Are logical Their Deficit of Thinking About: Practical consequences Obvious cause and effect How they affect others Their Deficit in Feelings of: Being similar to other people Being ordinary Peace Satisfaction Happiness Their Deficit of Interpersonal Functioning that: Empathy Acknowledging others positive attributes Nurtures others Their Deficit in Their Sense of Self as: Ordinary Intact The member of a community or team Similar to other people 81

101 Their Deficit of Outcomes Involving: A stable lifestyle Financial success Stable relationships Achieving life goals Getting what they want 82

102 Antisocial Their Excess of Behaviors that: Attack, involve aggression Lie Cheat Steal Break rules and agreements Hurt others Their Excess of Thinking About: How to get away with things Themselves How to con others The world being a dog-eat-dog place Being entitled Their Excess of Feelings of: Being mistreated by others Entitlement Outrage and self-righteousness Anger Fearing being the victim Their Excess of Interpersonal Functioning that Involves: Exploitiveness Lying Physical violence Treating others as weak or patsies Their Excess of Their Sense of Self as: Being a loner Being strong and autonomous A winner in a world of losers Needing to look out for themselves 83

103 Their Excess of Outcomes Involving: Trouble with the law Trouble with other people Unstable finances Losses - jobs, relationships Care for others Tell the truth Their Deficit in Behaviors that: Their Deficit in Thinking about: How others feel Their Deficit in Feelings of: Empathy Guilt and remorse Their Deficit of Interpersonal Functioning that Involves: Equality Concern for the other person Reciprocity Social sensitivity Their Deficit in Their Sense of Self as: The member of a community Ordinary Stability Safety Their Deficit in Outcomes Involving: 84

104 Borderline Their Excess of Behaviors that: Are punitive toward others Are self-punitive and self-destructive Are impulsive Demand attention from others Involve a diverse assortment of shifting problems and symptoms Express unusual symptoms or combinations of symptoms Are impulsive and poorly planned behavior that is later acknowledged as foolish or crazy Involve brief periods of psychotic symptoms Produce frequent crises Their Excess of Thinking About: Confusion about goals, priorities Being alone forever Others being dangerous and hurting them Being a bad person who needs to be punished Their Excess of Feelings of: Emptiness Anger Guilt Entitlement Over-reactions to changes Strong ambivalence on many issues Their Excess of Interpersonal Functioning that Involves: Excessive demands Inappropriate anger Blaming Intense and out-of-proportion emotional reactions Stable intimate relationships Idealization or denigration of others 85

105 Extreme misinterpretation of others meanings A low tolerance for direct eye contact Defective Victimized Entitled Abused Their Excess of Their Sense of Self as: Their Excess of Outcomes Involving: Abandonment Self-harm Anger from others Losses Their Deficit of Behaviors that: Are proportional to the situation Are consistent Effectively solve problems Solutions Their Deficit of Thinking About: Their Deficit of Feelings of: Adequacy I m OK-You re OK Their Deficit of Interpersonal Functioning that Involves: Accurate empathy Self and other forgiveness Stable Ordinary Defined Their Deficit of Their Sense of Self as: 86

106 Stability Solutions Their Deficit of Outcomes Involving: 87

107 Histrionic Their Excess of Behaviors that: Are attention-getting Are emotive Are childlike Are dramatic Are sexually provocative Are demanding Their Excess of Thinking About: Being the center of attention Other people being interested in them How they look What they need What they feel What they are entitled to Poignance Anger Their Excess of Feelings of: Their Excess of Interpersonal Functioning that Involves: Seductiveness Demandingness Entitlement Their Excess of their Sense of Self as: Glamorous Unique The object of envy The object of desire Their Excess of Outcomes Involving: Public scenes Upset 88

108 Distancing by others Their Deficit of Behaviors that: Attend to detail Take care of others Are altruistic Their Deficit in Thinking About: The needs of others How others feel Being ordinary Rational plans and solutions Peace Calmness Contentment Enough Their Deficit of Feelings of: Their Deficit in their Sense of Self as: Ordinary The member of a group An equal Competent Rational Grown-up Their Deficit of Outcomes Involving: Creative solutions Gratitude from others 89

109 Narcissistic Their Excess of Behaviors that: Are boastful Are demanding Seek glory, wealth, power, prestige Are competitive Strive to demonstrate superiority Are Haughty Are arrogant Are presumptuous Are entitled Exaggerate of talents and achievements Their Excess of Thinking About: Being special Being superior Others being inferior Their Excess of Feelings of: Being special Being superior Self-righteousness Anger Hypersensitivity Sustained feelings of boredom, meaninglessness, futility, hollowness Their Excess of Interpersonal Functioning that Involves: Being demanding Belittling others Insulting others Devaluing others Expectations of special treatment Expectation of exemption from rules 90

110 Expectations of being served Their Excess of Their Sense of Self as: Being special Being unique Being important Being exempt Their Excess of Outcomes Involving: Escalation Rage Others anger Arguments Threats Their Deficit of Behaviors that: Are empathetic Express understanding Acknowledge personal limitations Their Deficit of Thinking About: How others feel Their Deficit of Feelings of: Being ordinary Being identified with a group Their Deficit of Interpersonal Functioning that Involves: Cooperation Serving others Expressions of need Their Deficit of Their Sense of Self as: Ordinary Similar to others 91

111 Their Deficit of Outcomes Involving: Cooperation Others feeling good 92

112 Avoidant Their Excess of Behaviors that: Avoid Put safety first Are reactive rather than proactive Risks Problems Their Excess of Thinking About: Their Excess of Feelings of: Fears of being hurt, rejected, and unsuccessful Problems or failure being intolerable Anxiety Sadness Social vulnerability Their Excess of Interpersonal Functioning that Involves: Hanging back Avoiding issues Being timid Their Excess of Their Sense of Self as: Inept, incompetent Being no good Being worthless Being unlovable Unable to tolerate unpleasant feelings Withdrawal Isolation Their Excess of Outcomes Involving: 93

113 Are assertive Take risks Success Security Challenge Strength Their Deficit of Behaviors that: Their Deficit of Thinking About: Their Deficit of Feelings of: Their Deficit of Interpersonal Functioning that: Gregariousness, outgoingness Self-disclosing Strong Capable Appealing Their Deficit of Their Sense of Self as: Their Deficit of Outcomes Involving: New relationships Overcoming obstacles 94

114 Dependent Their Excess of Behaviors that: Are help-seeking Are attaching That cling Caretakers Their Excess of Thinking about: Their Excess of Feelings of: Desperately needing others Fear of being alone Their Excess of Interpersonal Functioning that Involves: Submissiveness Their Excess of Their Sense of Self as: Helpless Weak, needy, incompetent Needing a strong person to lean on Their Excess of Outcomes Involving: Conformity Lack of individuality Stagnation Their Deficit of Behaviors that: Are self-sufficient Independence Being strong Their Deficit of Thinking about: Their Deficit of Feelings of: 95

115 Their Deficit of Interpersonal Functioning that Involves: Independence Achievement Their Deficit of Their Sense of Self as: Strong Self-sufficient Their Deficit of Outcomes Involving: Independence 96

116 Obsessive-Compulsive Their Excess of Behaviors that: Are perfectionistic Involve details Are demanding Are punitive Withhold Are controlling Their Excess of Thinking About: Avoiding errors Other people s sloppiness or frivolity Work Producing Details Their Excess of Feelings of: Anxiety Fear of being overwhelmed Their Excess of Interpersonal Functioning that Involves: Demandingness Exactingness Self-righteousness Their Excess of Their Sense of Self as: Responsible Needing to compensate for deficiencies Being right Their Excess of Outcomes Involving: Being late Things being unfinished Procrastination 97

117 Their Deficit in Behaviors that: Complete things Relax muscular tension Express understanding Are light Are flexible Their Deficit in Thinking About: Pleasure Relaxation The big picture Calmness Empathy Tolerance Partnership Their Deficit of Feelings of: Their Deficit of Interpersonal Functioning that Involves: Empathy Understanding Deferring to others Delegating Their Deficit of Their Sense of Self as: Always right The only one who can Always needing to be in control Their Deficit of Outcomes Involving: Others being empowered Fun, enjoyment, and relaxation Nonsignificance, play Partnership 98

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119 Part V: Personality Disorders in Children

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121 Part V: Personality Disorders in Children Overview Prevalence Rates of personality disorders in children and adolescents: 1. Help-seeking populations 46% of 13 year-olds evaluated at outpatient clinic met criteria for an Axis II Most kids seen at psychiatric clinics have met criteria for Axis II for average of 2 years 2. Non help-seeking populations 9-19 years olds studied Mean age of 16.3 years 31.2% met criteria for moderate personality disorder 17.2% met criteria for severe personality disorder 3. Peak percentages of diagnosability seen at age: 12 for boys 13 for girls Studies consistently demonstrate that enduring personality patterns are apparent by the end of preschool Clinicians are often reluctance to diagnose because: 1. Label implies severity and nonmalleability 2. Concerns over prejudicial reactions Downside of reluctance: Insufficient and inaccurate treatment Personality Disorder-Relevant Normal Developmental Milestones: 1. Recognition of oneself by name and in a mirror by age 3 2. Sense of shame by age 2 99

122 3. Primitive empathy by age 2 4. Steadily moderating impulsivity over time 5. Abstract operational reasoning by middle childhood 6. Age where behavior is most predictive of adult functioning: Diagnosis - General Personality Disorder patterns are often most apparent during: 1. Situations of heightened interpersonal demand viz., establishing a new friendship, increasing intimacy 2. Demands for competition, involving a risk of failure and/or humiliation viz., taking a test, participating in team sports, performance 3. Demands for autonomy viz., agreeing to sleep-overs, beginning high school, autonomous school and/or job functioning 4. Unstructured situations viz., group activities, free time 5. Heightened developmental or transitional demands Grade school to junior high transition is a good predictor 6. When environment changes Kids with PD tend to respond with desperate and destructive attempts to recreate a context characterized by caregiver s ineptitude, inconsistency, and unreliability Maladaptive pattern, but familiar and provides some measure of safety, coherence, control, and attachment General Diagnostic Indicators: 1. Consistency of patterns for at least one year 2. Childhood mood disorders 3. Childhood anxiety disorders 4. Childhood-onset dysthymia 100

123 5. Life-Course patterns (as opposed to Phase-Specific ) Life-Course involves Early (preadolescent) age of onset History of conduct problems History of depression History of anxiety Phase-Specific involves Late onset (typically adolescence) Inappropriate parenting Unusual or excessive situational stressors Deviant peer relationships 6. Very difficult adolescence In reality most have a reasonably smooth transition to adulthood Few are actually involved in delinquency or substance abuse The majority retain an overall positive view of their families 7. Early onset of patterns 1. The earlier, the more chronic and severe it tends to be 2. The more likely it is to be heavily genetically loaded 8. Substance abuse Risk Factors for Child and Adolescent Substance Abuse 1. High levels of stimulus-seeking 2. Increased heart rate (excitement) when drinking 3. Early (early adolescent) drinking 4. Early (early adolescent) heavy drinking 5. Evidence of Cluster B personality disorder 9. Explosive temper 10. Poor academic functioning 11. Unstable levels of competence and self-control 12. Consistent impulsiveness 13. Feelings of worthlessness or inferiority 14. Accident-proneness, getting hurt a lot 15. Teasing others a lot 16. Being teased a lot 17. Peer group frequently gets into trouble 101

124 18. Chronically nervous, tense, or high-strung 19. Consistently disliked by other kids 20. Overly fearful or anxious 21. Clumsy or poorly coordinated 22. Preferred peers are substantially older or younger 23. Excessive sulking 24. Excessive talking 25. Age-inappropriate preoccupation with sex 26. Chronic worrying 102

125 Cluster A: The Mature Type Paranoid Personality Disorder in Children 1. Easily jealous 2. Feels others are out to get him or her 3. Secretive, keeping many things to his or her self 4. Pervasively suspicious Relevant Criteria From Adult Diagnosis: 1. Suspects that others are exploiting, harming, or deceiving him or her 2. Is preoccupied with doubts about the loyalty or trustworthiness of those close to him or her 3. Is reluctant to confide in others out of fear the information will be used maliciously against him or her 4. Reads hidden demeaning or threatening meanings In benign remarks In benign events 5. Persistently bears grudges Unforgiving of slights, insults, or injuries 6. Perceives attacks on his or her character or reputation that are not apparent to others Quick to become angry or to counter-attack 103

126 Schizoid Personality Disorder in Children 1. Prefers being alone to being with others 2. Does not get along with other kids 3. Demonstrates strange or odd behaviors 4. Withdrawn 5. Has strange or odd ideas 6. Male (4:1 male to female occurrence) 7. Deficient empathy 8. Deficient emotional attachment 9. Rigid mental set 10. Single-minded pursuit of special interests viz. collections 11. Odd styles of communicating (can be over-talkativeness, esp. in girls) 12. Disintegrates into weeping, rage or aggression when pressed to socially conform 13. Unusual fantasies 14. Loner 15. Distinguish from Aspergers Higher level of intelligence Less clumsy 16. Higher Verbal IQ than Performance IQ Relevant Criteria From Adult Diagnosis: 1. Neither desires nor enjoys close relationships, including being part of a family 2. Almost always chooses solitary activities 3. Takes pleasure in few, if any, activities 5. Lacks close friends or confidants other than first-degree relatives 6. Appears indifferent to praise or criticism 7. Shows emotional coldness, detachment or flattened affect 104

127 Schizotypal Personality Disorder in Children 1. Family history of schizophrenia 2. Odd behaviors 3. Magical thinking 4. Ritualistic or repetitive behaviors 5. Tangential cognitive associations 6. Social passivity or disengagement 7. Hypersensitivity to criticism 8. Nervously reactive to events Excessive social anxiety does not appear until adulthood Relevant Criteria From Adult Diagnosis: 1. Unusual perceptual experiences Bodily illusions Odd thinking and speech 2. Suspiciousness or paranoid ideas Inappropriate or constricted affect 3. Lack of close friends or confidants other than first-degree relatives 105

128 Cluster B: Immature Type Antisocial Personality Disorder in Children More is known about its early signs than any other PD 1. Conduct Disorder diagnosis before adolescence All adult antisocial individuals were diagnosed with Conduct Disorder 2. Family history of impulse disorders 3. Irritable and hard-to-manage from very early years 4. By age 3 Extreme impulsivity Extreme irritability 5. Intentional aggression - predatory and planned 6. Deficits in receptive listening 7. Deficits in reading 8. Deficits in problem-solving 9. Deficits in expressive speech, writing, and memory 10. Language use is superficial 11. Peer relationships marked by Coercion, control, lack of empathy Deceptiveness, exploitation, dropping or turning on friends Developmentally similar to friendships of 4-year-olds Nonreciprocal No best friend or lasting friendships Friends are interchangeable Friends are deviant 12. Speech is detached from affect Seems contrived, inauthentic and detached 13. Omits, minimizes, denies own problems or faults 14. Insightful about the intentions, feelings, and thoughts of others 15. Imitates others in order to deceive 16. Behavior is unaffected by rewards and punishments 106

129 17. Marked deficiencies in abstract meaning abilities 18. Lack of internal controls 19. Ruthlessness 20. Cruelty to animals 21. Cruelty to other children 22. Destruction of own or others property 23. Lack of guilt after misbehavior Indifference and withdrawal 24. Frequent fights 25. Impulsive and acts without thinking 26. Lies 27. Cheats 28. Running away from home 29. Stealing outside the home 30. Threatens others 31. Truancy 32. Vandalism 33. Antisocial behavior is alone and individual, not just part of group affiliation 34. Low school achievement 35. Self-aggrandizement 36. Lack of empathy 37. Substance abuse 38. Antisocial behavior ages 7-11 (most predictive of trouble with the law) Police arrests age 7-11 predict a chronic life course of offending 39. Adolescent phase-specific involves Rebellion against authority Desire to attain adult privileges Antisocial behavior diminishes with opportunities for work an marriage 40. Victim-oriented crimes Planning to catch victim unaware 41. Selecting others based on antisocial lifestyle 107

130 Borderline Personality Disorder in Children 1. Defined by a cluster of characteristics No single feature is specific and always present 2. Not Borderline Syndrome of Childhood noted in 1982 by Ciccheti, involving: High impulsivity Depressed Suicidal Attentional problems Deficient in concept-formation abilities Micro-psychotic symptoms Not predictive of developing adult BPD, only 1 study, and risk for variety of Axis II disorders But no Axis I (including bipolar) disorders seen 3. Parents with Impulse-spectrum disorders Criminality Substance abuse 4. Childhood history of Trauma Abuse Neglect 5. Lack of impulse control A hallmark characteristic 6. Deficient tolerance for anxiety, depression, or frustration 7. Impulsive aggression 8. Severe family dysfunction Chaotic parent-child interactions 9. Disturbed peer relationships Possessiveness Attempts at omnipotent control 10. Frequent arguing 11. Frequent complaints of loneliness 12. Cruelty, bullying, meanness to others 108

131 13. Deliberate self-harm 14. Taking about killing themselves 15. Suicide attempts (1/3 of suicidal children and adolescents fit BPD) 16. Destroys his or her own things 17. Complains that no one loves him or her 18. Physically attacks other children 19. Frequent and sudden changes in mood or feelings 20. Temper tantrums or hot temper 21. Multiple neurotic and behavioral symptoms that should have been outgrown Obsessions, phobias, compulsions, hysterical reactions 22. Unaffected by positive life experience 23. Fail to learn from experience 24. Relates to peers as others to Lean on, control, idealize, or devalue 25. Intense and free-floating anxiety Fears of complete and traumatic loss 26. Dangerous levels of aggression 27. Differ from psychotic disorders of childhood by 1. Identity disturbance 2. Annihilation anxiety 3. Primitive and impulse-driven thinking 4. Oddities of motor functioning 5. Ineffective impulse control 6. Ineffective conscience 7. Addicted to pretend play 8. Overly active fantasy activity 9. Performance well below ability 10. Alternates between clinging and withdrawing (Unpredictable interpersonal connections) 11. Unpredictable and fluctuating behavior 12. Initially can seem only mildly disturbed 13. Lack of depth of understanding others 14. Deficient social tact 109

132 15. Depression combined with hostile rage reactions 16. Passive or mute expression of anger 28. Same as psychotic disorders of childhood in 1. Feelings of loneliness 2. Separation anxiety 3. Hyperactivity 29. Pre-preschool signs 1. Soft neurological signs 2. Pregnancy complications 3. Low birth weight 4. Prematurity 5. Temper tantrums 6. Head-banging 7. Rocking 30. Preschool signs 1. Intolerance of maternal separation 2. No established standards for good and bad 3. Inability to express a variety of feelings in a controlled fashion 4. Sexual identity uncertain or confused 31. School-aged signs 1. Failure of consistent gender-role identity in fantasy play 2. Deficient impulse control 3. Unpredictable emotional states Emotions expressed in sudden and abrupt ways 4. Peer interactions strained, unpleasant, tense, or difficult 5. Shifting and age-inappropriate lack of autonomy from parents 6. Deficient group identity 32. Preadolescents and Adolescents 1. Insufficient sense of identity or self Sense of me as independent entity is deficient Perceive themselves as different or unusual 2. Do not anticipate gratification or satisfaction 3. Play is not enjoyable 4. Deficient age-appropriate mastery or self-esteem 110

133 5. Common affective states involving apathy, anhedonia, worthlessness 6. Well-put-together one moment, falling apart the next 7. Rigidly adheres to rules one moment, impulsively violates them the next 8. Deficient abstract thinking ability 9. Deficient struggle for emancipation 10. Unrealistic perceptions of family 111

134 Histrionic Personality Disorder in Children All diagnostic characteristics are theoretical and anecdotal There are no specific data on early characteristics or precursors 1. Theatrical over-expression of emotions 2. Seductiveness used as attempt to gain attention 3. Demanding of attention 4. Interpersonal behavior seems stereotyped 5. Fantasies seem cartoonish, caricatures 6. Experience self as not in control and not responsible 7. Feels that reality is not really reality 8. Acts younger than chronological age 9. Fluid changes in mood 10. Excitable 11. Suggestible 12. Global in focus and attention 13. Statements of ideas or feelings are unclear and overly general 14. Associations are partial 15. Boys Pseudo-masculine Deny feelings Affects seem superficial Exhibitionistic risk-taking Sexuality used to gratify dependency needs Premature ejaculation 16. Girls Pseudo-feminine Seem to be incompetent Passive Indirectly manipulative Emotionally over-reactive Seductive and provocative, but surprised at the response Sexuality used to control others Orgasmic dysfunction 112

135 Narcissistic Personality Disorder in Children 1. Grandiose goals 2. Requiring constant admiration 3. Fragile self-esteem 4. Reaction of rage or emptiness to unmet needs 5. Hypersensitivity to interpersonal stressors 6. Frequent complaints of boredom 7. Frequent bragging or boasting 8. Disobedience at home 9. Feels he or she has to be perfect 10. Frequent clowning, showing off 11. Pathological instead of Normal narcissism Need for dependence and admiration is not fulfilled by ageappropriate gratification and attention Lack of reciprocity and gratitude in response to nurturing - entitlement and exploitive Claims of grandiosity go beyond playful fantasy Cannot tolerate losing, even to the point of losing friends over it Demands on the environment are unrealistic or cannot be fulfilled Appears to be untrusting of adult caretakers Denies dependence No one else can be equally special Nothing is ever enough Trusts only to the degree of immediate gratification of needs Mild frustration results in over-reaction and rejection Requires excessive admiration and positive mirroring 12. Comorbidity Depressive disorders Anxiety disorders Separation anxiety Trouble leaving caregivers Difficulty leaving the house Trouble participating in sleep-overs 113

136 Obsessive-Compulsive Disorder Phobias 13. Deficient empathy 14. Low frustration tolerance 15. Peer relationships nonreciprocal 16. Fluctuating school performance 17. Lack of ability to apply themselves 18. Gaze aversion 19. Tuning others out 20. Inhibited play 21. Obsession with own image in mirrors 22. Adolescents Boys Pretentious, posturing, boastful, disregarding rules Girls Aloofness, detachment, indifference 23. Exhibitionism 24. Families Abusive to siblings Parental narcissism Idealization of the child Parents use child to gratify own self-esteem Discourage autonomy Parents depressed and insecure Indulgent Intrusive Violation of generational boundaries Relevant Criteria From Adult Diagnosis: 1. Grandiose sense of self-importance Exaggerates achievements and talents Expects to be recognized as superior without achievements 2. Believes he or she is special and unique Can only be understood by other special people 114

137 3. Lacks empathy Unwilling to recognize or identify with the feelings and needs of others 4. Envious of others Believes others are envious of him or her 5. Arrogant, haughty behaviors or attitudes 115

138 Cluster C: Anxious Type Avoidant Personality Disorder in Children 1. Early problems with shyness 2. Severe difficulties making friends 3. Fears he or she might think or do something bad 4. Self-conscious 5. Easily embarrassed 6. Timid 7. Avoids extracurricular activities 8. Excessive anxiety about evaluation of peers 9. Expects to be criticized or rejected 10. Emotionally constricted due to fear of sounding foolish 11. Transitions troublesome due to fears and inhibitions in new situations 12. Excessive avoidance of risks 13. Actively tries to extract reassurance from others as to acceptability 14. Perfectionistic and rigid 15. Trouble bouncing back after difficulties 16. Avoidance of activities is inconsistent with expected level of development 17. Chronic feelings of inadequacy 18. Differs from normal shyness Not just slow to warm up Has a chronic sense of inadequacy 19. Onset prior to age 11 predicts nonrecovery (ouch) 20. Very similar to adult Avoidant Personality Disorder 21. Families Anxious and avoidant parents Coercive parents Critical, perfectionistic, violates generational boundaries 116

139 Relevant Criteria From Adult Diagnosis: 1. Preoccupation with being criticized or rejected 2. View of self is as being socially inept, personally unappealing, or inferior to others 117

140 Dependent Personality Disorder in Children 1. Dependence inappropriate to developmental age 2. Acts too young for his or her age 3. Clings to adults, overly dependent 4. Stores up and saves things he or she does not really need 5. Sullen or irritable 6. Whiny 7. Overconcerned with meekness or cleanliness Relevant Criteria From Adult Diagnosis: 1. Has difficulty making everyday decisions Needs excessive advice and reassurance 2. Difficulty initiating projects or doing things on his or her own Lack of confidence in own judgment (Not lack of motivation or energy) 3. Goes to excessive lengths to obtain nurturing and support Will volunteer to do unpleasant things to get this 4. Uncomfortable or helpless when alone Exaggerated fears of being unable to care for him or herself for him or herself 5. Unrealistically preoccupied with fears of being left to take care of him or herself 118

141 Obsessive-Compulsive Personality Disorder in Children 1. Families Perceived by child to be more demanding (Only 1 study, parents not different from normal in level of demands) 2. Hard-working 3. Unemotional 4. Perfectionistic 5. Emotionally constricted during play and leisure 6. Rigid 7. Stubborn 8. Overly neat and correct 9. Competitive 11. Overly self-critical 12. High need for control 13. Unnecessary undoing and erasing on homework 14. Destroys things out of anger and frustration 15. Excessive worry 16. Expectations are excessive 17. Chronic dissatisfaction with results 18. Depression 19. Temper tantrums 20. Distress about school 21. Underachievement 22. Highly reactive to sudden changes in environment Relevant Criteria From Adult Diagnosis: 1. So preoccupied with details, rules, lists, order, organization, or schedules that the major point of the activity is lost 2. Is unable to discard worn-out or worthless objects even when they have no sentimental value 3. Rigid and stubborn 119

142 Additional Information on Treating and Managing Axis II Disorders in Children Parent Training Programs Helping the Noncompliant Child Forehand and Long, 1988 Forehand et. al, 1979 Long, Forehand, Wierson, and Morgan, 1994 Videotape Modeling Group Discussion Webster-Stratton, 1996 The Oregon Social Learning Center Programs Patterson and Chamberlin, 1988 Patterson and Forgatch, 1995 Patterson, Reid, Jones, and Conger, 1975 Parent-Child Interaction Therapy Eyberg, Boggs, and Algina, 1995 Modification of the Oregon Model Bank, Marlowe, Reid, Patterson, and Weinrott, 1991 Defiant Children: Second Edition: A Clinician s Manual for Assessment and Parent Training Russell Barkley, 1997 (Guilford) Managing the Defiant Child: A Guide to Parent Training Russell Barkley, 1997 (Guilford) Your Defiant Child: Eight Steps to Better Behavior Russell Barkley and Christine Benton, 1998 (Guilford) 120

143 Alterations in Treatment for Children and Adolescents General Principles 1. Adjust language for developmental appropriateness 2. Use extra validation comments 3. Listen more intently for missing elements in child s awareness and self-reports 4. Explain other people more often 5. Use a lot of reframing to interpret their reactions 6. Explain their parents motivation to them Play Therapy 1. Use Play Therapy as a Context for Axis II Work Look for their generation of, engagement in, or abilities for: Drama Problem-Solving Observing Ego Traits 2. Use peer Interactions when available 3. Note repetitive patterns and suggest alternatives 4. Use teaching Problem-Solving Empathy 121

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145 Part VI: Personality Disorders in Couples

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147 Part VI: Personality Disorders in Couples Why Couples Therapy is Uniquely Difficult There is a common aphorism that when people marry they become one. But no one ever explains what kind of a one they become: a healthy one, a symbiotic one, a fused one, or a parasitic one. Joan Lachkar, in Carlson and Sperry, pg 259 Couples may very well be the most difficult patient population for any therapist. Arthur Freeman and Carol Oster, in Calson and Sperry, pg 97 Couples are a guarded-prognosis group because: 1. They come for treatment the latest of any clinical population After problems have existed for an extended period of time After problems have escalated out of control After problems have created a backlog of bad feelings 2. They come for therapy as a last ditch effort Just to be sure it won t work 3. The come after a high-level relationship trauma An affair Violence 4. Their Interlocking disorders create circular behavior patterns Their presenting complaint usually involves: 1. Behavioral complaint We fight all the time We never talk He (she) had (has) an affair 2. Psychological complaints 122

148 Relevant Diagnostic Distinctions 1. Distressed vs. Conflictual: Couple (From Carlson & Sperry) Distressed: Retain empathy Use observing ego for own and other s emotional state Attachment is secure Conflictual: Treat each other as though malevolent Use coercive behaviors with each other Blame, accuse, and withdraw Attachment is insecure 2. Axis I disorder in one or both partners 3. Axis II disorder in one or both partners 4. Individual disorder vs. Relationship disorder: 1. Well-delineated disorder of relationship 2. Well-delineated relationship problems that are associated with individual disorders 3. Individual disorders that are triggered or worsened by relationship factors 4. Individual disorders in a relationship 5. Marital Drama Switch: Paranoid Searches for safety and an ally, finds inevitable betrayal Reacts with rage, retaliation, aggression and assaultiveness Schizoid Searches for safety and self-determination, finds isolation and Reacts with withdrawal 123

149 Schizotypal Searches for understanding and reassurance, finds inevitable alienation Reacts with distorted thinking Antisocial Searches for self-gratification, finds inevitable trouble Reacts with rage and flight Borderline Searches for wholeness, finds inevitable badness instead Reacts with rage, self-loathing, terror of abandonment and annihilation, and sincere but false promises of goodness Histrionic Searches for perfect caretaking, finds inevitable disappointment Reacts with coercive, rageful dependency Narcissist Searches for perfect mirroring, finds inevitable disappointment Reacts with rage, devaluing, guilt, withdrawal Avoidant Searches for safety, finds inevitable vulnerability Reacts with furtive concealment and withdrawal Dependent Searches for unconditional caretaking, finds inevitable fear Reacts with disguised hostility Obsessive-Compulsive Searches for perfection, finds inevitable disappointment Reacts with rage, frustration, and domination 124

150 Couples Treatment Treatment Assumptions 1. There are real and practical conflicts present in the relationship 2. The interlocking disorders are responsible for the lack of resolution to the conflicts 3. The partners are together because they fit each other s psychological template 4. Both partners may, or may not, have equally severe disorders 5. Couples therapy is not intended to fix the relationship It makes it work as well as it can work 6. The distress or conflict do not resolve because they are actually a necessary part of the relationship and are serving some purpose 7. The more sever the PD, the more individual work required 8. The more conflictual (as opposed to distressed) the relationship, the more individual work required 9. The more distressed (as opposed to conflictual) the more conjoint work is possible 125

151 Treatment Process Couples Motivation Enhancers: If you don t fix it here, you ll just go off and do it again Find out why and how you got into this mess Fundamental Purpose of Couples Treatment: 1. Decrease circular patterns involving Blaming, attacking, counterattacking, and distancing Gottman s Four Horsemen of the Apocalypse: Criticism Contempt Defensiveness Stonewalling 2. Increase circular patterns involving Interest Affection Caring Appreciation Empathy Acceptingness Joy Humor 3. Enable partnership problem-solving Collarboration and partnership Postitive communication behaviors Problem-solving pattern See section on Normal Problem-Solving Process 126

152 Treatment Contexts 1. Conjoint vs. individual therapy Dependent upon whether the drama can be constrained in the sessions If so, then can proceed conjointly If not, then individual work must be done Treatment Process 1. Get Axis I treated 2. Create a treatment frame 3. Clarify idiosyncratic and conceptual meanings Confront all lack of clarity 4. Confront self-feeding and destructive circular patterns Reward Punishment Negative Reinforcement 5. Acknowledge the grain of truth in each partner s position 6. Associate current feelings and reactions to historical, familial patterns Drawing association to family of origin (depersonalizing) Interpretation that it is out of BOTH of their hands, their families married each other in their unconscious 7. Change language from personal, conceptual, and presumptive to behavioral, observable, and neutral 8. Explain each partner to the other in a manner that generates understanding and empathy Of COURSE they react that way, because

153 9. Distinguish between thoughts, feelings, and behaviors Note that behaviors run the relationship 10. Confront over-reactions and distortions of perceptions of situations and each other 11. Don t try to make them the same in all things in a misguided attempt to avoid blaming 128

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155 Part VII: Personality Disorders in Families

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157 Part VII: Personality Disorders in Families Research Conclusion 1. Parents raise children more similarly than dissimilarly 2. Therefore, significant differences between siblings tends to be more related to inborn temperament rather than to parenting differences 3. Possible increase in risk for offspring of parental pathologies (All from Magnavita, 1997; except Borderline, which is from Paris s followup study) Paranoid parents may produce Paranoid Schizotypal Avoidant Obsessive-Compulsive Borderline Parents (Mothers) tend to Produce 1. Fewer children overall Study: of 78 borderline women, only 9 had children by age Children with an overall increased prevalence of psychiatric diagnoses 3. Children with an increased prevalence of impulse disorders 4. Children with an increased prevalence of Borderline Disorder of Childhood 5. Children with lower Global Functioning Scale scores Narcissistic parents may produce Schizotypal 129

158 Histrionic Narcissistic Avoidant Obsessive-Compulsive Psychotic parents may produce Paranoid Schizotypal Antisocial Borderline Developmentally arrested parents may produce Schizotypal Histrionic Avoidant Dependent Battering parents may produce Antisocial Borderline Histrionic Narcissistic Depressive parents may produce Schizotypal Avoidant Obsessive-Compulsive Chronically mentally ill parents may produce Antisocial Narcissistic Avoidant Obsessive-Compulsive 130

159 Somatic parents may produce Antisocial Avoidant Obsessive-Compulsive 4. Important reminder: Childhood experiences are not predictive of personality disorders, and personality disorders involve predisposing, inherited brain wiring to create a vulnerability in the child. So none of the possibilities listed are direct causeeffect. They are potential risk factors which, when combined with the inherited brain structures, may lead to personality disorder patterns. 131

160 The Fundamental Diagnostic Issue with Families Is this a Personality Disorder in a Family, or a Personality Disordered Family 1. There is a Personality Disorder in the Family when: 1. The family functions adaptively when the patient is absent 2. The patient is the most disturbed member of the family 3. Other parts of other family members lives are adaptive 4. Other family members have been appropriate in attempts to deal with the patient 5. There is low parental pathology 6. The other family members have allied for protection or support 2. It is a Personality Disordered Family when: 1. The patient is least disturbed member of the system 2. Strong negative countertransference to family 3. Severely malignant style of communication 4. Chronic dysfunction in large percentage of family members 5. Evidence of severe scapegoating 6. Severe degree of enmeshment among family members 7. Obvious and severe pattern of emotional, physical or sexual abuse or neglect 8. PD s diagnosed in multiple family members 132

161 Family Treatment Personality Disorder in a Family: Goals: 1. Treat the personality disorder in the family member 2. Assist the other family members in dealing with the disordered family member Need to feel more competent and in control 3. Parent training programs - work best when (Fonagy, 2000) 1. There are younger children in the family 2. There is less comorbidity 3. The conduct disturbance is less severe 4. Lowered SES disadvantage 5. Parents who stay together 6. Low parental discord 7. Family has good social support 8. Absence of parental antisocial personality 4. Break the cycle of nonreflective, coercive interactions with the patient 5. Help family members stop making things worse 6. Help family members have realistic expectations 7. Offer and help family members find support Methods: 1. Define the troublesome interactions with the patient 2. Assist family members in finding ways to work around the limitations of the patient 3. Assist family members in self-care 4. Teach the family members about the phenomenon they are dealing with: 133

162 How to Explain a Personality Disorder To a Patient or Significant Other General What we ve found is that sometimes people end up seeing the world through a particular mindset that is limited and inflexible. Because of this, the way they respond or the way they do things can seem puzzling or strange or difficult to people in the outside world because it doesn t seem to make sense. And they don t seem to think that they way they see things or they way they do things is wrong or is a problem. Their way of looking at the world makes complete sense to them, and the problem is that they may not be able to see things any other way, even if bad things happen because of the things they do or other people don t like them or some kind of information indicates that the way they see things is inaccurate. None of that makes any difference, and the person remains convinced that their viewpoint is right and that everyone else is wrong. It can be very frustrating to deal with someone who works this way, because they don t make sense to us and they may behave in ways that aren t very pleasant and they don t seem able to see that they way they re doing things isn t working very well. We re not really sure what causes someone to be this way. It seems to be some combination of inborn temperament and some kind of growing up that together result in this rigid and limited way of viewing themselves and others. But it is a very real phenomenon, and if you re going to deal successfully with this person, you ll need to start taking into account that they function differently than you expect them to or than most other people do. 134

163 Paranoid What happens is that they tend to feel a lot of worry that other people are somehow mistreating them or are intending or planning to treat them badly. The problem is while it might not be true, it seems absolutely true to them and it seems virtually impossible to convince them that it isn't true. No amount of arguing, persuading, or evidence seems to be able to change their minds. They seem to have some scary picture in their mind or maybe some past experience that convinces them that other people are betraying them or mistreating them. And whatever it is that goes on in their mind seems more believable to them than other people s denials or reassurance or even the facts. What can happen is that the person is so convinced that they re right that they try to uncover evidence to prove that they re right. They may ask questions over and over, search through other people s belongings, or try to trap or trick people into admitting that they re betraying them. They can also try to stop the mistreatment by becoming controlling, or demanding, or unreasonable, or preventing other people from going places or doing things. They may become accusatory and challenging. They may get madder and madder. People they're directing these behaviors toward often feel scared, frustrated, confused, or outraged. So what often happens is that a vicious circle gets going where the person gets angrier and angrier and more and more accusatory, and other people get more and more defensive and frightened. Sometimes this cycle gets worse and worse and things can get really out of hand and somebody can get hurt or some other bad thing can happen Emphasize: The role of fear The impotence of evidence and argument The vicious circle of escalation The danger 135

164 Schizoid What happens is that they don t seem to respond to other people very well. They seem distant, muted, or like they don t care. Other people can do a variety of things in response, such as trying harder and harder to get them to respond, or to get angry that they won t respond, or to try to figure out what they might have done to offend the other person and resulted in their withdrawing. But none of it works. But this person probably responds this way to pretty much everyone. They tend to be a loner, to not seem to be very interested in having relationships or friendships. While this is often puzzling to the people around them, the person seems quite content to be alone or to be involved in whatever kind of activity that most interests them. It might be a hobby, or a collection, or some kind of reading. But whatever it is, they would rather be involved in it than with other people. So if you re expecting to get your emotional needs met by them it can be very upsetting. Emphasize: Their comfort being solitary The futility of attempts to engage them The generalized nature of their reaction 136

165 Schizotypal What happens is that this person tends to see things differently from how most other people see things. Their reactions, their behavior, even the way they dress can seems strange or odd to other people. They may be uncomfortable with other people and seem nervous or anxious even when they know the other person pretty well. Other people may get confused trying to figure them out or to get them to act in a more conforming way. This person probably has little interest in conforming, and prefers to do things in their own, unique, idiosyncratic way. This can be frustrating or even frightening to people who care about them, because their seemingly strange way of viewing things can cause them difficulty when it comes to having relationships or even working and holding a job. Emphasize: Their unusual outlook and behavior Their disability The understandable upset of people around them 137

166 Antisocial What happens is that this person feels like it s a dog-eat-dog world, and to make their way they have to try to get the better of everyone else. So they feel fully justified in doing things that most of us consider to be wrong because to them it s every man for himself. So they may make promises that they don t keep, take advantage of situations, tell lies, or steal. To them it is all justified because it is their right to try to get by in the world, and they conclude that sometimes those kinds of things are required. They don t feel they re doing anything wrong, they feel it is everybody else s fault, and that they are never responsible. What often happens is that other people try to make excuses for the way they are, or to explain that they re not so bad. Generally people argue for this until they have been taken advantage of enough times to get fed up and then to not be willing to participate with the person again. Sometimes the person will make promise after promise that they ll change, but most often once they are not in trouble, they go back to their old ways. When people stop being able to be conned by the person, they usually move on to someone new who does not know, or believe, that they do those things and are vulnerable to them. In some cases the person can also escalate to violence or to criminal behavior in order to get what they want or to get back at someone else. Because of this it s usually best to be very careful when dealing with them and to have outside help and advice of how to handle them. Emphasize: Their pattern of violating agreements The denial that other people have about them The emptiness of most of their promises The danger 138

167 Borderline What happens is that this person reacts in ways that seem almost impossible to understand. You never know what to expect - one minute they re up, the next minute they re down. One minute they love you, the next minute they scream at you and tell you how awful they are. And then the next minute they act like nothing happened. Because their reactions are often so extreme and change so quickly, people can refer to them as being unstable and unpredictable. It can seem like they just need to snap out of it or that they need positive self-esteem. But despite all of the efforts from other people to talk some sense into them, they usually continue to over-react and to make upset and trouble for themselves and others. This person can be exasperating and frustrating to others, as no amount of reason or talking or persuading seems to make any difference. Sometimes they can seem like they understand, that they know they need to change, and the next minute they can insist that they are fine and that it is everybody else s fault. They can make what seems like a million promises and commitments to change, but if their bad feelings get triggered off in any way, they seem to sink back into chaos and crisis. This person can be frightening and upsetting to others because they can seem to be in so much emotional turmoil and to do things that cause themselves so much trouble. They may threaten, or attempt, suicide. They may intentionally hurt themselves. They may be seem to be in crisis after crisis after crisis. Most times other people end up feeling powerless and helpless when trying to help this person. Other people can change from being caring and kind to being angry and punishing to being distant and withholding. But because the strong inner feelings that drive the chaos don t really change in response to anyone s reactions, all of the attempts ultimately fail. In fact, the patterns often don t change without outside help or sometimes simply years of hard experience and maturing. 139

168 Emphasize: That strong internal feelings at the root of the patterns That they seem unstable That they create crises That other people are impotent in trying to change them That outside help and time are often needed 140

169 Histrionic What happens is that this person seems to behave like a needy little kid. They seem overly emotional and have to be the center of attention all the time. When they feel like they don t have enough attention they can have temper tantrums, or sulk, or threaten to run away or kill themselves. Other people may describe this person as shallow or superficial. This person is probably highly concerned with how they look and are overly concerned with their clothes and their appearance. In fact, they might dress overly sexy or in inappropriately revealing ways. But they probably seem to act like they don t dress that way, and may even express shock that other people react to them like they are either being seductive or inappropriate. Other people may get irritated or angry with this person because they are so demanding for attention. They may always change the conversation to themselves, and it may seem like they re using other people like an audience. They may also seem to have little common sense and seem unable to handle even simple life tasks and solving life problems. They may seem helpless, like the classic damsel in distress, even if the person is male. Emphasize: Demand for attention Seductiveness Appearance of incompetence 141

170 Narcissistic What happens is that this person makes other people mad because they seem to think they re better than everyone else. Their conversation may be focused solely on themselves, and no matter what someone else has or does they somehow seem to have or do more or better. They seem to think that they can do no wrong, and they may deny having even common human faults. That is, unless admitting to such things will make them look good. In fact, this person is all about looking good. They seem to have a tremendously inflated view of themselves, an unrealistically positive selfimage. At the same time, they seem to be very touchy and to be easily wounded by any criticism or negative feedback, no matter how small or accurate. When criticized they can become enraged or say how hurt they feel, and the other person can feel frightened of this person s anger or can feel like they have done something terrible. This person probably wants to be the center of attention at all times, and feels that they are entitled to special treatment. They expect others to admire them. They can even lie to make themselves more important and special, and they may become outraged or incensed if anyone accuses them of lying or exposes their lies. Emphasize: Inflated self-image Easy wounding Rage at wounding Entitlement Manipulative lying 142

171 Avoidant What happens is that this person seems painfully shy and afraid. They can seem like a frightened little kid who is afraid that other people won t like them. They probably have trouble in new situations, or striking up conversations, or revealing much information about themselves. Other people may find themselves trying to draw them out. Other people may describe this person as someone who has low self-esteem. It may seem to other people like this person just needs a self-esteem boost to be able to be OK and to feel better. But this person may frustrate people by not following through on social engagements, or by being distant or elusive. Other people may want to get to know this person or to get close to them, and they may be puzzled by this person s unwillingness to get into a relationship. People may describe them as furtive or hard to get to know. Emphasize: Shyness Trouble in new situations Frustrate attempts to help 143

172 Dependent What happens is that this person seems to be unable to think for themselves. They don t trust themselves or their own judgment, so they may as for constant help, or instruction, or reassurance. It s like they need someone else to run their life for them. This can be flattering to other people at first, because this person seems real receptive to others opinions. But then people probably start getting tired of it and don t want to have to tell them how to do everything. People may get irritated by them or feel like they re hanging onto them. Other people can start wanting to avoid them or to get rid of them. It can be hard, though, because it can look like this person really can t manage without someone else to tell them what to do. So other people can end up feeling in a bind of wanting to help them but being angry that this person needs so much advice and reassurance. Emphasize: Lack of trust in themselves Need for constant caretaking Irritation of most people in response 144

173 Obsessive-Compulsive What happens is that this person seems like a control freak. It s like everything has to be their way, or perfect, or just so. It s like they can t just go with the flow or let things happen. They seem to have to plan, and direct, and control everything. This person has a hard time with anything that s messy, or inexact. They may be demanding that everyone measure up to what it seems like to other people are impossible standards to meet. And they seem so inflexible, like they can t tolerate exceptions or any lack of perfection. This person may seem to be on edge a lot, too. They may seem sort of nervous or high-strung, and to be over-reactive. In fact, they may get angry over small things being wrong or out of place, or they may seem to make mountains out of molehills. Emphasize: Need for control Impossible standards Nervousness 145

174 A Personality Disordered Family Treatment Goals: 1. Break the cycle of nonreflective, coercive interactions in the family 2. Decrease circular patterns Blaming, attacking, counterattacking, and distancing 3. Increase circular patterns involving Interest Affection Caring Appreciation Empathy Acceptingness Joy Humor Methods: 1. Explore with families the cultural and multi-generational context for dysfunctional patterns 2. Meet and work with generational subgroups Challenge cross-generational boundary violations 3. Map nonreflective interactions 4. Point out self-defeating nature of responses 5. Connect internal states to behaviors and patterns 6. Make the covert overt 4. Initiate a cycle of mutuality through appreciation of self and other internal states 146

175 Part VIII: Group Treatment of Personality Disorders

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177 Part VIII: Group Treatment of Personality Disorders Evidence of Effectiveness of Group Treatment There are relative few controlled studies, but of those studies, in nearly all studies group treatment was found to be effective, helpful, and at times equal in effects to individual treatment. Advantages of Group Treatment for Personality Disorders 1. Adds power to the pressure to change 2. Can elicit the maladaptive patterns more easily 3. Removes some intensity from the relationship with the therapist 4. Other group members add additional Observing Ego function Disadvantages of Group Treatment for Personality Disorders 1. The risk of scapegoating 2. The risk of uncontrolled and chaotic group functioning 3. Escalated interlocking patterns between group memebers 147

178 Characteristics Specific to Group Treatment with Personality Disorders 1. Group treatment for personality disorders is more controlled and directed than are process groups for Axis I conditions or personal growth 2. Group treatment for personality disorders has a more individual focus than do process groups 3. The more severe the personality disorders of the group members, the more structured and didactic the group must be 4. Cotherapists are preferable if possible 5. Behavior within the group is always used as an example of members reactions in order to draw connections to their outside lives - behavior in group is never addressed as an end in itself 6. Group treatment for individuals with personality disorders is generally considered to be in addition to rather than instead of individual treatment 7. Strictly skills training groups are useful only when the patient is being seen in individual psychotherapy sessions that are consistent with the model used by the skills group Generally Suitable: Schizoid Schizotypal Borderline Histrionic Avoidant Suitability for Group Treatment by Diagnosis 148

179 Dependent Obsessive-Compulsive Generally Not Suitable: Paranoid Narcissistic Antisocial 149

180

181 Part IX: Medications

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183 Part IX: Medications Important - Please note: This section is designed to offer a general overview of some of the medication literature and to give clinicians some familiarity with the role of medications and the process involved in prescribing medications in the treatment of personality disorders. It is not designed to provide adequate information on which to base prescription decisions, and must not be used in that way. In order to make actual prescription decisions, an individual evaluation of a patient must be made by a medical mental health treatment professional who has been trained in the use and prescription of psychoactive medications in the treatment of personality disorders. Their decisions may or may not be consistent with the information in this section, as this information is general and from the literature and may or may not be applicable to any particular case or patient. Overview Medications are useful for targeted symptoms only: 1. Cognitive Disorganization (confused or disorganized thinking) Low-dose neuroleptics Generally used for the duration of the symptom 2. Transient psychotic episodes (typically Schizotypal and Borderline) Low-dose neuroleptics Generally used for the duration of the symptom 150

184 3. Paranoid Ideations Low-dose neuroleptics Generally used for the duration of the symptom 4. Pseudo-hallucinations Low-dose Neuroleptics Generally only used for the duration of the symptom 5. Severe quasi-psychotic features High-dose neuroleptics 6. Impulsive aggression SSRI s Low-dose neuroleptics Mood stabilizers 7. Depressed or anxious mood SSRI s 8. Anger and hostility SSRI s Effect appears to be independent of improved mood Low-dose neuroleptics 9. Self-mutilation High dose SSRI s Seem to have a specific anti-self-mutilation effect Data on Specific Drugs and Classes of Drugs Neuroleptics: Atypical neuroleptics are often preferred due to favorable sideeffect profile 151

185 Evaluation of effect: Effects should be apparent within a few days But may take several weeks There is no data regarding optimal duration of treatment Typical treatment time is about 12 weeks If good results, can continue for a few weeks post-crisis or symptom Zyprexa has been found to be useful in Borderline PD for: Anger Sensitivity Mood Psychotic features Hypersensitivity Feeling overwhelmed by any type of stimuli Being touchy SSRI s: Fluoxetene (Prozac) is the most studied Sertraline (Zoloft) seems similar in effect Venlfaxine (Effexor) also shows promise Some concern re: Paroxetine (Paxil) in kids Suicidal ideation and behavior seen Typical trial is about 12 weeks Research shows: 1. Effects on mood is modest Much less than that seen in use with melancholic depressions 2. Reductions in impulsivity are consistently observed Mood stabilizers Modest effects at best Lithium yields undramatic results Results inconsistent and equivocal Do not significantly stabilize mood in any personality disorder Some empirical evidence demonstrating reduced impulsivity Use cautiously due to concerns about toxicity and lethality 152

186 Carbamazine and Valproate Lack of evidence for use Carbamazine has shown triggering of melancholic depression in Borderine Halperidol (Nortriptyline) Poor compliance Gains were not maintained at followup Valproex Anti-impulsive effects quite strong Very weak antidepressant effects The Prescription Process 1. Patient must clearly understand what drug is and it is not designed to do Reduce unrealistic expectations Reduce pressure to change medication in search of a cure 2. The major problem with medications is compliance Gain as much collaboration as possible 3. Sometimes drugs can also have broader effects, so consider continued use when: 1. The drug manages persistent perceptual or cognitive symptoms 2. The drug manages hypersensitivity to stimuli 3. The drug improves impulsivity or anger and hostility 4. For paranoid, mild thought disorder or dissociation Start with atypical antipsychotic at 1/4 to 1/2 dose If nonresponse, increase the dose 153

187 If nonresponse, switch brand If partial response consider Divaproex Clozapine is useful only in refractory individuals If dissotiation is prominent, can consider Naltrexone 5. For depressed, angry, or labile mood Begin with SSRI at regular antidepressant dose If fails, try different brand If partial response, consider atypical antipsychotic or mood stabilizer If rejection sensitivity is prominent, can do a trial of MAOI s (Beware the cheese effect! ) When self-harm prominent, Naltrexone is a useful adjunct 6. For anxious, inhibited behavior Anxiety prominent, impulsivity not prominent Begin with SSRI If no response, try another If partial response, can add long-acting benzodiozepine If all fail, can try Beta Blocker or atypical antipsychotic 7. Avoid medications when: The patient has a history of abusing them Multiple trials have shown no effect Side effects are intolerable or dangerous Insufficient monitoring of compliance is available Other Medication Information The average number of medications prescribed by a patient diagnosed with Borderline is 4.5 Medications are said to be vastly overused with this population 154

188 Avoidant personality disorder is the only diagnosis with a specific medication response (a response to a specific drug) Venlfaxine (Effexor) Particularly effective at reducing avoidant traits 155

189 Part X: Crises

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191 Part X: Crises Rule #1 of Crisis Management: Someone In the Situation Must Not Be In the Crisis Purpose: To return the patient to their previous level of functioning as quickly as possible 1. Affective dysregulation Anxiety Panic Affective lability Anger Rage Depression Despondency Targets: 2. Behavioral disorganization and dyscontrol Suicidal, parasuicidal behavior Impulsivity Dissociation 3. Cognitive disorganization and dysregulation Confusion Impaired information processing 156

192 Techniques 1. Ensure Safety Hospitalization Danger to others Danger to self that cannot be managed in any other way Psychotic symptoms that are unmanageable Severe dissociative reaction Care of significant others Extra or extended sessions 2. Contain the Escalation Medication Environmental alterations Environmental stability Removal from situations 3. Address the dyscontrol Establish a connection with the patient Slow things down Communicate support and understanding Focus on affect before content Burst the bubble Use direct, straightforward and concrete statement Clearly define events, thoughts, feelings, and their connections Verbally bind them Enlarge the container End with a plan 157

193 Part XI: Prevention

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195 Part XI: Prevention All advice is educated guessing, as there are no direct data Recommendations 1. Identify at-risk population Neglect Abuse Parental incarceration or legal troubles 2. Perform early interventions designed to mitigate risk factors Nurse home visits Study found significantly reduced antisocial behavior in adolescents and reduced substance abuse in adolescence Techniques 1. Learn to parent against type 2. Begin instilling problem-solving at an early age 3. Use, encourage, and teach empathy 158

196

197 Part XII: Safety Issues

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199 Part XII: Safety Issues Suicide 1. The overall rate of suicide is low in personality disorders But a personality disorder diagnosis is an increase in risk over the general population 2. Suicide risk is most heightened in Antisocial Borderline Narcissist 3. Remember - past behavior is still the best predictor of future behavior Another reason to take a good history - do they have a history of violence against self or others 4. Always have good consultation or therapy available for you When in doubt, get a consultation Always document the consultation 5. Monitor Axis I Major Depressive Episode features as part of suicide assessment 6. Distinguish chronic suicidality from acute suicidality 7. Remember the traditional lethality list Strong degree of hopelessness Empty versus angry or upset Sudden calm or improved affect 159

200 Saying goodbye Giving away cherished items Telling others they are going to commit suicide 8. Remember that every case has individual variations No general sign or assessment method - including this list - is perfect or necessarily applicable to any particular patient or case 160

201 Part XIII: Violence Against Others

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203 Part XIII: Violence Against Others 1. The overall violence rate in personality disorders is low 2. Violence risk is increased in certain diagnoses Paranoid Antisocial Borderline (male) Narcissistic 3. Failing to establish and maintain appropriate professional boundaries (frame) increases the safety risk to the therapist 4. Past behavior is the best predictor of future behavior 5. If the therapist is strongly frightened, appropriate referral or transfer of the case may be wise, and consultation is essential 6. Follow standard of care and state laws regarding notifications of dangerousness 161

204

205 Part XIV: Liability Issues

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207 Part XIV: Liability Issues Liability in Suicide 1. Most lawsuits after suicide occur following inpatient treatment Claim of Premature discharge is often made 2. Most lawsuits involve patients with major Axis I disorders Very few involve patients with chronic suicidality 3. The elements most likely to lead to a lawsuit after a suicide 1. Failure to evaluate for medication 2. Failure to evaluate the need for hospitalization 3. Violation of professional boundaries 4. Failure to have/provide appropriate supervision and consultation 5. Failure to evaluate suicidality upon initial consultation 6. Failure to evaluate suicidality during changes in treatment 7. Failure to obtain a history or previous records 8. Failure to assess (viz., mental status exam, etc.) 9. Failure to accurately diagnose 10. Failure to establish a formal treatment plan 11. Failure to ensure a safe environment (removal of dangerous items) 12. Failure to document judgments, rationales, observations 162

208

209 Part XV: Self-Care

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211 Part XV: Self-Care Remember: Working with personality disorders is not infrequently very hard and very intense work. It can be very demanding emotionally. Keep this in mind, and make a concentrated effort to do the things that keep yourself in good running order both emotionally and physically. Here are some things that can help: 1. The single factor most responsible for a feeling of well-being in social service professionals is (can you guess?): Adequate rest 2. Ensure sufficient time off between reach-backs and after-burns 3. Engage in some kind of purely physical activity to counteract the emotional/psychological/intellectual activity of human services 4. Ensure an outlet for your angry/hostile side 5. Make sure that at least some of your attachments are secure attachments 6. Socialize with non human-services professionals 7. Have consultation/therapy available when you need them 163

212 8. Engage in activities different from human services that require your complete, undivided attention and concentration for some period of time9. Move around during the day 10. Do things that result in your laughing - the harder the better (If you re out of ideas, try the book Dave Barry s Greatest Hits, if it doesn t make tears run down your face, check your pulse - quick) 11. Finally - OK, so here are the good things you should do that you already know you should do but you don t do, so while my listing them won t make any difference because you still won t do them, I feel obligated to list them anyway even though it s hopeless: Eat right Exercise Meditate 164

213 Part XVI: References

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215 Part XVI: References and Bibliography Part I: Books Quoted in or Used For this Manual Highly Recommended Readings On Personality Disorders (With some editorial annotations) American Psychiatric Association (2000) DSM-IV TR, American Psychiatric Association Press, Washington, D.C. (Available from Barnes and Noble, Amazon.com) Now in its text revised edition, this is the standard diagnostic manual from which I took and adapted the professional diagnostic section. It is not perfect but it is also not stupid or useless. There is also an expanded edition with case examples and additional references. If you don t have a DSM in your personal library you certainly need to get one. Bleiberg, E. (2001) Treating personality disorders in children and adolescents: a relational approach. New York: Guilford Press. (Available from Guilford Press - 800/ ; ) One of only two books written on personality disorders in children, Bleiberg s is a fine text. Be ready for some heavy-duty, sometimes head-spinning, object-relations language in the cause part of the book. The treatment section is not that way at all and is practical and easy to understand. Kernberg, P., Weiner, A.S., & Bardenstein, K.K. (2000) Personality disorders in children and adolescents. New York: Basic Books. (Available from Amazon.com, ) The other book written on personality disorders in children, Kernberg s book is excellent. It is very practical, especially on diagnosis (less heavy object-relations language than Bleiberg s). It scrimps a bit on treatment, however, so Blieberg s book s got it beat there. LeDoux, J. (2002) Synaptic self: how our brains become who we are. New York: Viking Press. (Available at bookstores and from Amazon.com, ) While not a text on personality disorders per se, LeDoux s book is the best I ve seen at describing in understandable terms how the genetic and the experiential combine to form the functional biological (which LeDoux calls synaptic ). Despite the technical-sounding title, it is written in everyday, easy-to-read, layman s language. It is a fascinating read if you are as into these things as much as I am. If you re not, I understand - so go read a novel already. 165

216 Linehan, M.J. (1993) Cognitive behavioral treatment for borderline personality disorder. New York: Guilford Press. (Available from Guilford Press - 800/ , ) Widely regarded as the reigning guru of borderline personality disorder, Linehan s model is practical, realistic - and dauntingly demanding. If you want to understand borderline conditions from a cognitive-behavioral perspective (even if you lack the resources to institute her model), hers remains the essential text. Extensive, densely packed and detailed, it can be hard to read but is well worth the effort. She not only taught me a thing or two that I needed to know, but you gotta admire her guts - she only works with suicidal and parasuicidal borderline patients. Oldham, J.M., Skodol, A.E., Bender, D.S. (2005) The American psychiatric publishing textbook of personality disorders. American Psychiatric Press, Inc.(Available from APPI.) A huge volume, very comprehensive, a definitive work in the area. Oldham, J.M., Skodol, A.E., Bender, D.S. (2005) Essentials of personality disorder. American psychiatric press, Inc. (Available from APPI.) A companion volume to the one above. Sperry, L. (2005) Handbook of diagnosis and treatment of the DSM IV personality disorders. New York: Brunner/Mazel. (Available from BarnesandNoble.com, ) When people ask me for the one book that contains the best summary overview of personality disorders, I always send them to Sperry s 1995 book. Perhaps I like him so much because he sees the conditions in ways that are largely similar to the ways I see them, or because I have taken the liberty of adapting some of his work to my own. But for whatever reason I always find Sperry s work to be an impressive mix of the practical, realistic, easy to understand with the sophisticated. Millon s books are similar in scope but are much more complex and detailed (is there anything in this field that man does not understand?). Sperry, on the other hand, is a bottom line kind of guy, so he s a bit easier for most of us, and I like that. Wright, W. (1999) Born that way: genes, behavior, personality. New York: Routledge. (Available from Amazon.com.) If you can still manage to deny the important role of biology in the creation of personality and personality disorders, this book will show you the error of your ways. Interesting and at times even a little spooky, Wright chronicles the trials and tribulations of those investigating the role of genes and biology in behavior. Nine words: The data will drag you there, I guarantee it. 166

217 Part II: Biographical Literature Containing Depictions of Real People that are Consistent with Personality Disorder Diagnoses (the accuracy of the depictions is unknown) The best training for therapists is to have lunch with novelists and sea captains. Eric Berne, origin unknown (which means I forgot which book it s in) Anderson, C. (1999) Bill and hillary: the marriage. (Available in bookstores and from Amazon.com) Narcissist Bowden, M. (2001) Killing pablo: the hunt for the world s greatest outlaw. New York: Atlantic Monthly Press. (Available at bookstores and Amazon.com) Antisocial Douglas, J.E. (2000) The anatomy of motive; the fbi s legendary mind hunter explores the key to understanding and catching violent criminals. (Available from Amazon.com) Paranoid (among others) Downing, M. (2001) Shoes outside the door: desire, devotion, and excess at san francisco zen center. Washington, D.C.: Counterpoint Press. (Available at bookstores) Narcissist Jorgensen, E.W. & Jorgensen, H.I. (1984) Eric berne, master gamesman. (Available from out-of-print booksellers) Schizotypal Layton, D. (date?) Seductive poison: a jonestown survivor s story of life and death in the people s temple. (Available from Amazon.com) Borderline Levy, S. (date?) Rat pack confidential: frank, dean, sammy, peter, joey, and the last great showbiz party. (Available at bookstores and from Amazon.com) Narcissist, Borderline Michel, L., & Herbeck, D. (2001) American terrorist: timothy mcveigh and the tragedy at oklahoma city. (Available at bookstores and from Amazon.com) Obsessive-Compulsive 167

218 Pierson, R. (1989) The queen of mean: the unauthorized biography of leona helmsley. (Available from Amazon.com) Borderline Rule, A. (date?) The stranger beside me - ted bundy, the classic case of serial murder. (Available from Amazon.com) Antisocial Smith, S.B., (2000) Diana in search of herself; portrait of a troubled princess. (Available at bookstores and Amazon.com) Borderline Vise, David A. (2002) The bureau and the mole. New York: Atlantic Monthly Press. (Available at bookstores and from Amazon.com) Narcissist Weiner, T. (1995) Betrayal: the story of aldrich ames, an american spy. (Available from Amazon.com) Narcissist Watts, C., & Shors, D. (date?) Unabomber: the secret life of ted kaczynski. (Available from Amazon.com) Schizoid 168

219 Part III: Additional Recommended Readings on Personality Disorders Abramson, R. (1993). Lorezepam for narcissistic rage. Journal of Occupational Psychiatry, 14, Adler, L. (1992) Cognitive-interpersonal treatment of avoidant personality disorder. In P. Keller and S. Heyman (Eds.) Innovations in clinical practice: A source book, Vol. 11. Sarasota, FL: Professional Resource Exchange. Ahktar, S. (1990). Paranoid personality disorders: A synthesis of developmental, dynamic and descriptive features. American Journal of Psychotherapy, 44, Beck, A. Freeman, A., and Associates (1990). Cognitive therapy of the personality disorders. New York: Guilford Press. Benjamin, L. (1993). Interpersonal diagnosis and treatment of personality disorders. New York: Guilford Press. Beck, A.T. & Freeman, A. (1990) Cognitive therapy of personality disorders. New York: Guilford. Berger, P. (1987) Pharmacologic treatment for borderline personality disorder. Bulletin of the Menninger Clinic, 51, Bernstein, D., Useda, D., and Siever, L. (1993). Paranoid personality disorder. Review of the literature and recommendations for DSM-IV. Journal of Personality Disorders, 7, Carlson, J., & Sperry, L. (Eds.) (1998). The disordered couple. New York: Brunner/Mazel. Chessik, R. (1985) Psychology of the self and the treatment of narcissism. New York: Jason Aronson. Chodoff, P. (1989) Histrionic personality disorder. In T. Karasu (Ed.) Treatment of psychiatric disorders. Washington, DC: American Psychiatric Press, pp Clarkin, J.F., Yeomans, F.E., & Kernberg, O.F. (1999). Psychotherapy for borderline personality disorder. New York: John Wiley and Sons. Cleckley, H. (1941). The mask of sanity. St. Louis: Mosby. Clinical Psychiatry News (1991). Better personality disorders therapies foreseen. September, p

220 Cloninger, C. Svrakic, D., and Przybeck, R. (1993). A psychobiological model of temperament and character. Archives of General Psychiatry, 50, Everett, S., Halperin, S., Volgy, S., and Wissler, A. (1989). Treating the borderline family: A systematic approach. Boston: Allyn and Bacon. Finn, B., And Shakir, S. (1990). Intensive group psychotherapy of borderline patients. Group, 14, Freeman, Arthur, & Reinecke, Mark (2007). Personality disorders in childhood and adolescence. Wiley Press. Gabbard, G. (1990). On doing nothing in the psychoanalytic treatment of the refractory borderline patient. International Journal of Psychoanalysis, 70, Gertsley, L., McLellan, T., Atterman, A., et al. (1989) Ability to form an alliance with the therapist: A possible marker of progress for patients with antisocial personality disorder. American Journal of Psychiatry, 146, Goldberg, A. (1989). Self psychology and the narcissistic personality disorders. Psychiatric Clinics of North America, 12, Gunderson, J.G., & Gabbard, G.O. (2000) Psychotherapy for personality disorders. Washington, D.C.: American Psychiatric Press. Hirschfield, R., Shea, M., and Weise, R. (1991). Dependent personality disorder: Perspective for DSM-IV. Journal of Personality Disorders, 5, Kagan, J., Reznick, J., and Snidman, N. (1988). Biological basis of childhood shyness. Science, 240, Kalus, O., Bernstein, D., and Siever, L. (1993) Schizoid personality disorder: A review of current status and implications for DSM-IV. Journal of Personality Disorders, 7, Kantor, M. (1992). Diagnosis and treatment of the personality disorders. St. Louis: Ishiyaku Euroamerica. Kernberg, O. (1984). Severe personality disorders: Psychotherapeutic strategies. New Haven, CT: Yale University Press. Klein, R. (1989). Diagnosis and treatment of the lower-level borderline patient. In J. Masterson and R. Klein (Eds.), Psychotherapy of disorders of the self. New York: Brunner/Mazel. Kreisman, J.J. & Straus, H. (1989). I hate you, don t leave me: understanding the borderline personality. Los Angeles: The Body Press. 170

221 Lachkar, J. (1992) The narcissistic/borderline couple: A psychoanalytic perspective on marital treatment. New York: Brunner/Mazel. Linehan, M. (1993). Cognitive-behavioral treatment for borderline personality disorder. New York: Guilford Press. Livesley, W. J. (Ed.) (2001). Handbook of personality disorders: theory, research, and treatment. New York: Guilford Press. Lowen, A. (1983). Narcissism: denial of the true self. New York: McMillan. Magnavita, J.J. (2000). Relational therapy for personality disorders. New York: John Wiley and Sons. Masterson, J., and Klein, R. (Eds.). (1990). Psychotherapy of the disorders of the self. New York: Brunner/Mazel. Masterson, J.F., (2000). The personality disorders: theory, diagnosis, treatment. Phoenix: Zeig, Tucker and Co. McCormack, C. (1898). The borderline/schizoid marriage: The holding environment as an essential treatment construct. Journal of Marital and Family Therapy, 15, Mehlum, L., Fris, S., Iron, T., et al. (1991). Personality disorders 2-5 years after treatment: a prospective follow-up study. Acta Psychiatrica Scandinavica, 84, Millon, T. (1981). Disorders of personality. DSM-III, Axis II. New York: Wiley. Millon, T., and Everly, G. (1985). Personality and its disorders: A biosocial learning approach. New York: Wiley. Millon, T. (1999). Personality-guided therapy. New York: John Wiley and Sons. Millon, T., & Davis, R. (2000). Personality disorders in modern life. New York: John Wiley and Sons. Oldham, J. (1988). Brief treatment of narcissistic personality disorder. Journal of Personality Disorders, 2, Paris, Joel (2003). Personality disorders over time - precursors, course, and outcome. American Psychiatric Press, Inc. Quality Assurance Project (1991). Treatment outlines for borderline, narcissistic and histrionic personality disorder. Australia New Zealand Journal of Psychiatry, 25,

222 press. Robinson, David J. (2005). Disordered personalities, third edition. Rapid Psychler Siever, L. and Davis, K. (1991). A psychological perspective on the personality disorders. American Journal of Psychiatry, 148, Sperry, L (1999) Cognitive behavior therapy of DSM IV personality disorders: higly effective interventions for the most common personality disorders. New York: Brunner/Mazel. Sperry, L. (1995) Handbook of diagnosis and treatment of the DSM IV personality disorders. New York: Brunner Mazel. Sperry, L. (1990). Personality disorders: biopyschosocial descriptions and dynamics. Individual psychology, 46, Stein, G. (1992). Drug treatment of the personality disorders. British Journal of Psychiatry, 161, Stone, M. (1993). Abnormalities of personality: Within and beyond the realm of treatment. New York: Norton. Young, J.E. (1999). Cognitive therapy for personality disorders: a schema-focused approach. Sarasota: Professional Resource Press Yudofsky, Stuart F. (2005). Fatal flaws. American Psychiatric Press, Inc. 172

223 Cross Country Education complies with all rules and regulations set forth by the boards/associations to offer continuing education. It is imperative that you complete your evaluation so that proper reporting can be done. Instructions for Completing your Scan Evaluation Form 1. Use a No. 2 pencil or a blue or black ink pen only. 2. DO NOT bend or fold your Scan Evaluation Form. 3. Please make solid marks that fill the response completely without any stray marks. 4. Complete your first and last name in ALL CAPS (if you do not have enough space for you full name, simply use all boxes that are available.) 5. Write in your registration number in the appropriate box. 6. Mark your profession. 7. Fill in license number. 8. Clearly mark all boxes appropriately. 9. Complete the back page of the evaluation; your Seminar Evaluation Objectives are on the following page for you. 10. Return your completed Scan Evaluation form back to the instructor.

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225 Seminar Evaluation Objectives Personality Disorders: Advanced Treatment and Management Speaker: Gregory W. Lester, Ph.D. The purpose/goal of this activity is to learn how to identify personality disorders, assess them for intervention, and apply effective intervention models from Gregory W. Lester, PhD. Objectives: 1. Develop tools to perform integrated and flexible brief, short-term, and extended treatments? 2. Recognize how to diagnose and treat personality disorders in couples and families? 3. Outline diagnosis and treatment options for personality disorders and comorbid conditions in children? 4. Identify expanded methods for managing the behavior of personality disordered individuals? 5. Examine the latest data on prescribing and the use of medications with personality disorders?

226 We value our customers! That s why we would like you to take advantage of this special offer. This coupon is good for a $10 discount off of any program you choose to attend in the future. Thank you for choosing Cross Country Education to fulfill your educational requirements. Finding professional, one-day seminars in your area is now even easier visit our website at: Cross Country Education P.O. P.O. Box Box Brentwood, Nashville,TN TN (800) C O U P O N Include this coupon with your next registration for one of our one-day seminars and receive $10 off! OR Call our toll-free number at (800) and mention discount code DSPWBC to receive your discount. Limit one coupon per registration. May not be used with any other offer and may not be used retroactively

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