Personality Disorders III

Problems with the DSM-5 Approach to

Personality Disorder
• Personality disorders are not stable over time – although the very
definition of personality disorders suggests that they should be stable
over time.
• About half of the people diagnosed with a personality disorder at some point
in life achieve remission i.e. did not meet the criteria for the same diagnosis
• Personality disorders appear to increase in adolescence and then decline over
time, with even more declines by late life.
• On the other hand, many people still have some symptoms after remission,
and many will relapse as the symprtomology of personality disorders wax and
wane over time.
• Even after remission, a diagnosis of a personality disorder can predict ongoing
difficulty in achieving a truly satisfying lifestyle.
• Personality Disorders are Highly Comorbid
• Comorbidity with each other : More than 50 percent of people diagnosed
with a personaliy disorder meet the diagnostic criteria for another personality
disorder
• i.e. The diagnostic criteria for schizotypical, avoidant and paranoid personality
disorder ephasize difficulty in forming close relationships, and so it is not
surprising tht these disorders often co-occur
Common Risk Factors Accross the Personality
Disorder
• Heritability
• Personality trait i.e. Negative affectivity
• Children in the Community Study (639 families with children aged 1-
11)
• Personality disorders are strongly related to early adversity.
• Child abuse or neglect
• Aversive or unaffactional parental styles
Treatment of Personality Disorders
• Many people with personality disorders enter treatment for a
condition other than their personality disorder
• Clinicians are encouraged to consider whether personality disorders
are present because their presence predicts slower improvement in
psychotherapy
• Psychotherapy is the treatment of choice for personality disorders;
there is an evidence that personality traits do change is
psychotherapy.
• Psychotherapy is often supplemented with medications but
medications have not been shown to adress the full spectrum of
personality disorder symptoms
• Psychodynamic theory suggests that childhood problems are at the
root of personality disorders, and so the aim is to help people
reconsider those early experiences, become more aware of how
those experiences drive their current behaviors and then reconsider
their beliefs and responses to those early events.
• Cognitive theory suggests that negative cognitive beliefs are at the
heart of the personality disorders. The aim of the cognitive therapy is
to a person become more ware of those beliefs and then to challenge
maladaptive cognitions.
Examples of Maladaptive Cognitions
• Avoidant: If people get to know me, they will reject me
• Obsessive-compulsive: If things get disorganized, horrible mistakes
will happen.
• Anti-social: People ask for exploitation
• Narcissistic: I am better than others, and people who ccannot
understand that they do not deserve my time.
Treatment of Schizotypical Personality &
Avoidant Personality
• Schizotypal personality disorder shares a good deal of overlap with
the etiology with schizoprenia: anti-psyhotic drugs –e.g. Risperdal
• The symptoms of avoidant personality disorder respond to the same
treatments that are effective for those with social anxiety disorder:
that is, anti-depressant medications as well as cogntivie behavioral
therapy
• Behavioral strategies for dealing with difficult situations and by exposure
treatment
Treatment of Borderline Personality Disorder:
Cognitive Behavioral Therapy
• a cognitive behavioral treatment strategy aimed at

• decreasing and improving impulse control and dichotomous thinking,

• increasing control over emotions,
• addressing assumptions,
• strengthening identity

• A core tenet of CBT is that one's basic assumptions play a central role in
influencing perception and interpretation of events and in shaping both behavior
and emotional responses (A. Beck, Freeman, et al., 1990;Beck, 1976,1987).
Source: Arthur Freeman, E. A., Mark H. Stone, P., & Donna Martin, P. (2006). Borderline
Personality Disorder : A Practitioner’s Guide to Comparative Treatments. Springer
Publishing Company.
• These basic assumptions or rules that govern individual thought and
behavior develop over years and are called schema.

• From these basic beliefs, automatic thoughts are generated.

• Automatic thoughts are the immediate conscious stream of thoughts
that are generated from schema.
• Automatic thoughts can be rational though still dysfunctional, biased,
or distorted.
• CBT therefore aims to help patients change these dysfunctional
thoughts and by testing and challenging these thoughts, alter the
underlying schema
• stating that the most frequently encountered BPD schema are
• dependence,
• lack of individuation,
• emotional deprivation,
• abandonment,
• mistrust,
• unlovability,
• incompetence.
• Strategies are aimed at reducing the symptoms directly, learning
newskills, and improving ability to cope with problematic situations
that can lead to emotional dysregulation
• The clinical skills and attributes key to successful treatment with a patient with
BPD include skills that foster collaboration, rapport, and consistency.
• J. Beck (1995) writes that many of the attributes essential for the cognitive
behavioral therapist are consistent with Rogerian theory and include
genuineness, empathy, and remaining nonjudgmental.
• In addition, the ability to create trust and rapport with the patient is essential.
• Rapport building begins with the first contact with the patient and continues
throughout the entire therapeutic process.
• Empathic statements, active listening, and correct summaries and reflection
encourage rapport and help build therapeutic alliance
Borderline Personality Disorder:
Dialectical Behavioral Therapy
• Dialectical behavior therapy (DBT), as developed by Marsha Linehan, is a
relatively new treatment approach for borderline personality disorder(BPD)
that draws heavily on cognitive-behavioral concepts and techniques but
has a unique twist:
• the addition of ideas and practices common to Zen Buddhist monks.

Source : Arthur Freeman, E. A., Mark H. Stone, P., & Donna Martin, P. (2006).
Borderline Personality Disorder : A Practitioner’s Guide to Comparative
Treatments. Springer Publishing Company.
• all-or-nothing thinking is a common information processing style.
• Usually people with BPD cannot conceive of being angry and loving
toward the same person in the same moment.
• Similarly, they cannot imagine accepting themselves exactly as they
are and viewing their "dysfunctional" behaviors as actually containing
a bit of wisdom and functionality.
• When a person with BPD can truly embrace opposite concepts,
ideas, and feelings in the same moment, a synthesis has occurred,
and in this synthesis is the basis of healing from the disorder
.
• from a dialectical standpoint there is "function within dysfunction; within
distortion there is accuracy; in destruction one can find construction"
(Linehan,1993, p. 32).
• Rather than conceptualizing BPD as a disorder that causes many
dysfunctional behaviors with underlying causes that need to be ferreted
out and cured, a dialectical view presumes that individuals are "capable of
wisdom with respect to their own life, although that capability is not always
obvious or even accessible" (Linehan, 1993, p. 33).
• The goal of this treatment is to help the person find that wisdom, find the
functionality that is presumed to be extant even if not apparent

Arthur Freeman, E. A., Mark H. Stone, P., & Donna Martin, P. (2006).
Borderline Personality Disorder : A Practitioner’s Guide to Comparative
Treatments. Springer Publishing Company.
• Being emotionally vulnerable, according to Linehan, means that the
person is physiologically "wired" to be highly sensitive to emotional
stimuli and capable of feeling and experiencing these stimuli with
great emotional intensity.
• A situation to which an average person would have a slight
emotional reaction would cause an emotionally vulnerable person to
have a very strong reaction.
• The emotionally vulnerable person will also take longer to return to
the original emotional baseline after the experience is over.
• The net result is that such individuals need more help learning to
soothe themselves and manage their emotions appropriately.
• If a child's feelings are constantly invalidated by being shown that
what she feels is wrong, stupid, or deserves punishment, she will
learn to inhibit and even invalidate those feelings herself, eventually.
• She will also fail to learn how to regulate her emotion appropriately
and will learn to suppress feelings and alternately explode.
• Moreover, the child will come to believe that her parents' perspective
was valid and she was just a bad kid who wasn't good enough, thus
damaging her self-esteem
• Another consequence of an invalidating environment is that the client did
not learn to grieve.
• Grieving is a natural process of allowing oneself to emotionally experience
a loss, receive appropriate support, and eventually be able to accept a
particular loss as a natural part of life.
• When successful grieving has occurred, the person can feel sad about
something but accept it as something that happened in the past and can
then feel reduced intensity of pain about it over time.
• If a person has appropriate support, loss and rejection can be tolerated.
The individual who knows how to ask for support can also learn how to
self-soothe
• The DBT treatment model is a very non-shaming, non-blaming approach.
• It begins by helping the client understand why she has the symptom
pattern that she does, and also proposes ways that she will ultimately be
able to change that.
• This approach employs a combi-nation of change strategies that are
standard in many cognitive behavioral therapy programs,but includes
"acceptance" strategies that are equally important but not present in many
other cognitive behavioral approaches.
• The acceptance strategies are the crucial ingredient that helps both the
client and the therapist remain hopeful, when both might be frustrated or
likely to give up hope if they believed the client would never get better
• One of the most important clinical skills necessary to deliver this treatment
is that therapists must be willing to view the client as a person who is
trying her best, using the most adaptive skills that she was able to learn,
and not perceive her as a mean, manipulative, or overly angry person.
• Even if the therapist at times gets annoyed or frustrated with the client, the
therapist's responsibility is to maintain a belief in the possibility for
him/her to improve,
• The therapist must remain aware of the difference between the client’s
ultimate effect on people and his/her intentions,and must continue to
respectfully view him/her as a person who is lacking skills, rather than a
person who intentionally hurts or manipulates others.
• Therapists who use a DBT approach must be willing to get team support through a
DBT consultation team.
• The team members support each other in their work because it is very taxing to
maintain the aforementioned attitude at all times.
• Fellow team members validate and normalize each other's emotional reactions,
remind each other when they have "anti-DBT" conceptualizations, and help each
other get the support they need to get back on track for the betterment of both
therapist and client.
• When therapists become judgmental, annoyed, and frustrated, they cannot be
effective with the client.
• Therapists must be willing to accept their own fallibility, be humble enough to
openly admit their lack of knowledge about how to proceed at times, and be willing
to seek consultation from colleagues.
• Sometimes therapists get angry or feel inadequate when clients don't get better
under their care.
• From a DBT standpoint, it is natural that a therapist working with BPD might feel
such things at times and would need validation and support.
• Thus, the consultation group helps the therapist in a way that is similarto how the
therapist's treatment helps the client
Narcissistic Personality Disorder:
Psychodynamic Approach
• There is consensus that NPD exists on a continuum.
• In the psychodynamic literature, one end of the continuum was
typified by the envious, greedy individual who demands the
attentions – described in detail by Kernberg
• The other end is more vulnerable to self fragmentation- by Kohut
• Oblivious vs. Hypervigilant

Source: Gabbard, G.O.

• Kohut believed that narcissistically disturbed individuals are
developmentally arrested at a stage at which they require specific
responses from persons in their environment in order to maintain a
cohesive self
• When such responses are not forthcoming, these individuals are
prone to fragmentations of the self
• Kohut understood this state of affairs as the results of the parents’
empathic failures.
• Specifically the parents did not respond to the child’s phase-
appropriate displays of exhibitionism with validation and admiration,
did not offer twinship experiences , and did not provide the child with
models worthy of idealization.
• Kernberg’s theoretical formulations differ sharply from those of Kohut.
• Kernberg saw the defensive organization of narcissistic personality as
strikingly similar to borderline personality disorder.
• He viewed it as one that operates at borderline level of personality
organization.
• He differentiated NPD from borderline personality on the basis of the
narcissistic’s integrated but pathological self.
• This structure is a fusion of the ideal self, the ideal object and the real self
• This fusion results in the destructive devaluation of object images
• Patients with NPD identify themselves with their idealized self-images in
order to deny their dependence on external objects
• They also deny the unacceptable features of their self-images by projecting
them onto others
• Kohut conceptualized the narcissistic self as an «archaic» normal self
that is simply frozen developmentally- the patient is a child in an
adult’s body.
• Unlike Kohut, Kernberg viewed the narcissistic self as a highly
pathological structure that in no way resembles the normal
developing self of children.
• He pointed out that the exhibitionistic self-display of children is
charming and enduring, in contrast to the greed and demandingness
of the narcissistic’s pathological self.
Obssesive Compulsive Personality Disorder
• Psychodynamic treatment for OCPD involves an insight-oriented approach that attempts to reveal how the OCPD
symptoms function to defend the individual against internal feelings of insecurity and uncertainty.
• When patients gain this insight, they then work to change their inflexible patterns of behavior and give up their
rigid demands for perfection in favor of a more reasonable outlook.
• One study suggested that supportive-expressive psychodynamic therapy is effective for treating patients with
OCPD and avoidant personality disorder (Barber et al. 1997).
• This study included 14 patients with OCPD and found significant improvement after 52 sessions but did not
include a control group.
• In two subsequent trials of mixed personality disorder (including some individuals with OCPD), patients treated
with brief psychodynamic treatments improved in terms of general functioning relative to waitlist control groups
(Abbass et al. 2008; Winston et al. 1994);
• however, neither of these two studies specifically investigated improvement among those with OCPD, and the
study outcomes did not assess for changes in OCPD symptoms specifically.
• Further research is needed to determine the effectiveness of psychodynamic treatments for OCPD.

• Source: Obsessive-Compulsive Personality Disorder, edited by Jon E. Grant, et al., American Psychiatric Association
Publishing, 2019. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/bahcesehir-
ebooks/detail.action?docID=5978719.
Created from bahcesehir-ebooks on 2021-05-07 04:43:37.
OCPD
• Hostile-dominant type:
• Behavioral
• Workaholic
• Risk for self-harm
• Verbally hostile
• Cognitive
• Perfectionistic toward self and others
• Mistrustful
• Somewhat eccentric Irritable
• Affective
• Chronically frustrated
• Negative temperament
• Difficulty with emotion regulation strategies and acceptance of emotion
• Interpersonal
• Hostile, critical/judgmental
• Rigid, controlling
• Low empathy
• Detached, emotionally unavailable.
OCPD
• Anxious Type
• Behavioral
• Workaholic
• Procrastination
• Socially avoidant
• Sleep disturbances
• Cognitive
• Perfectionistic toward self
• Self-critical
• Overattention to not meeting expectations of others
• Interpersonal
• Anxious Somatic symptoms (e.g., irritable bowel syndrome)
• Prone to worry, low mood
• Affective
• Submissive
• Avoidance of intimacy
• Cognitive-Behavioral Therapy Cognitive-behavioral therapy (CBT) typically involves a combination
of both cognitive and behavioral techniques.
• The general cognitive therapy approach to treating OCPD involves identifying and restructuring the
dysfunctional thoughts underlying maladaptive behaviors (Bailey 1998; Beck 1997; Beck and
Freeman 1990).
• For example, patients would be taught to challenge “all-or-nothing” thinking by considering the
range of possibilities that might be acceptable.
• Similarly, therapists might teach patients to recognize instances in which they overestimate the
consequences of mistakes (catastrophizing) by examining the realistic significance of minor errors.
• CBT also includes behavioral elements, such as exposure to feared situations and stimuli through
behavioral experiments (e.g., purpose fully making small mistakes and observing the actual
consequences) (Sperry 2003).
• Therapists may have difficulty establishing rapport with some OCPD patients because of their rigid
thinking styles and difficulty with emotional expression.
•
• Although several cognitive and behavioral approaches to OCPD have been described (Kyrios
1998), very little empirical research has been conducted to test these treatments.
• In an uncontrolled trial conducted in patients from Hong Kong, Ng (2005) recruited individuals with
treatment refractory depression who also met DSM-IV criteria for OCPD (American Psychiatric
Association 1994) and offered cognitive therapy focusing on the OCPD.
• Ten patients were treated, and after a mean of 22.4 sessions, all showed reductions in depression
and anxiety symptoms, and nine no longer met diagnostic criteria for OCPD.
• However, this study did not include a control group and had a small sample size.
• Strauss et al. (2006) conducted an open trial of cognitive therapy among outpatients with avoidant
personality disorder ( n = 24) and OCPD ( n =16) who received up to 52 weekly sessions.
• Results indicated that 83% of the patients with OCPD had clinically significant reductions in OCPD
symptom severity and 53% had clinically significant improvement in depression severity.
• However, this open trial did not include a comparison condition, such as a waitlist control group
• Self-evaluation overly based on achievement/ perception of how
others view me
Inflexible standards for
• 1. School: need to have best paper; need to get all A’s
• 2. Work: flawless writing
• 3. Morals: want others to see me as upstanding person

One possibility : Procrastination

• Another possibility:
• Overpreparation • Excessive research/editing of writing • Working up
to deadlines • Spending the bulk of writing time researching sources
instead of writing • Rigidity in morning routine

Results in :
Stress/worry about work deadlines
Lateness/”I’m letting others down”
Self-criticism: considers quality of his work as never good
enough/could be so much better
Perceives self as failure