A Clinician’s Survival Guide for
Personality Disordered Patients
Mark Servis, MD
Senior Associate Dean for Medical Education
Roy Brophy Endowed Chair and Professor of Clinical Psychiatry
UC Davis School of Medicine
Objectives
• To recognize the major clinical presentations of
patients with personality disorders
• To understand the challenges of working with these
patients – i.e. to survive and sometimes even thrive
• To apply some of the principles of effective
management and treatment
No Disclosures
Personality
Each individual’s unique constellation of
defense mechanisms or coping skills used
to solve intrapsychic and environmental
conflict
Personality disorder
Inflexible, maladaptive defenses resulting
in a significant impairment of social,
interpersonal and/or occupational
functioning
Key diagnostic considerations
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State vs. Trait
Situational factors
Ego-syntonic
Age
Gender and cultural bias
Persistent and Pervasive
Etiology and epidemiology
• Epidemiology: 10-13% of general population
– 30-50% of psychiatric outpatients
– 70% of substance abusers
• Etiology: environment > genetic
– diathesis (temperament)-stress model
– early childhood abuse
Classification
• Cluster A - odd,
eccentric
– Paranoid
– Schizoid
– Schizotypal
• Cluster B - dramatic,
erratic
– Borderline
– Narcissistic
– Antisocial
– Histrionic
Classification
• Cluster C - anxious,
fearful
– Obsessive-compulsive
– Avoidant
– Dependent
Paranoid Personality Disorder
Clinical Features
• Suspiciousness, mistrustful, hypervigilant
• Often hostile, irritable – intent on protecting self
from a hostile and dangerous worl
• No cognitive distortions
• Using projection to rid self of unacceptable
impulses
Paranoid Personality Disorder
Examples
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Humphrey Bogart in The Caine Mutiny
David Duchovny X-Files
Linda Hamilton in Terminator 1 and 2
Jack Nicholson in A Few Good Men
Kiefer Sutherland in 24
Paranoid Personality Disorder
Treatment Strategies
• Be distant, honest and candid – accept emotional
reserve
• Always demonstrate respect
• Don’t challenge, insult or tease
• Be prepared for a long memory
• Acknowledge grain of truth in paranoid system
• Low dose antipsychotics may be helpful, but they
will never take it
Schizoid Personality Disorder
Clinical Features
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Unable to form intimate relationships
Social isolation
Constricted affect
No cognitive distortions
Fantasy as a primary defense
Schizoid Personality Disorder
Examples
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Sherlock Holmes
Michael Keaton as Batman
Sandra Bullock in The Net
Lt. Reginald Barclay in Star Trek
Schizotypal Personality Disorder
Clinical Features
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Odd and peculiar behavior
Idiosyncratic speech
Eccentric beliefs and paranoid tendencies
Unusual appearance
Inappropriate affect and social anxiety
Experiences “subtle” distortions of the
environment
• Genetic linkage to schizophrenia
• Dissociation as a primary defense
Schizotypal Personality Disorder
Examples
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Robert DeNiro in Taxi Driver
The Addams Family
Ally McBeal (except for relationships)
Kramer in Seinfeld (except for relationships)
Phoebe in Friends (except for relationships)
Antisocial Personality Disorder
Clinical Features
• Gratification which ignores societal limitations –
exploits others for personal gain
• Impulsive, manipulative
• Lack of superego function or conscience
• No guilt or sense of remorse
• Can be charming and seductive
• “Psychopath”, “Sociopath”
• Genetic vulnerabilities clearly established
• Acting out as primary defense
Antisocial Personality Disorder
Examples
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Jeff Bridges in The Jagged Edge
Hannibal Lecter in Silence of the Lambs
Sam Jackson and John Travolta in Pulp Fiction
Arnold Schwartzeneger, Sylvester Stallone,
Steven Segal, Bruce Willis, Chuck Norris, etc.
Antisocial Personality Disorder
Treatment Strategies
• Protect self and others
• Limit setting
• Shape patient’s behavior through reward and
reinforcement
• Make negative outcomes of “bad” behavior
explicit and enforceable
• Rewards of “good” behavior clear and consistent
Narcissistic Personality Disorder
Clinical Features
• Egocentric, grandiose, entitled – protecting fragile
self-esteem
• Arrogant, explosive
• Preoccupation with envy
• Hypersensitive to criticism, vulnerable to
depression and acute suicidality
• Limited capacity for empathy
• Defenses of idealization and grandiosity
Narcissistic Personality Disorder
Examples
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Richard Gere in Pretty Woman
Bill Murray in Groundhog Day
Robert Duvall in Apocalypse Now
Robert Redford in Indecent Proposal
Jerry Seinfeld on Seinfeld
Narcissistic Personality Disorder
Treatment Strategies
• Establish limits to entitlement, but do not confront
grandiosity
• Provide positive strokes when possible
• Be sensitive to fragility behind inflated ego
• Maintain positive, idealized transference
• Be prepared to feel used
Borderline Personality Disorder
Clinical Features
• Intense and chaotic relationships
• Unstable affect, angry, fear of abandonment
• Manipulative self-destructive behaviors and
suicide gestures; self-mutilating
• Identity disturbance
• Intact reality testing, but prone to brief psychotic
episodes and severe regression
• Genetic component likely
• Splitting as a primary defense
Borderline Personality Disorder
Examples
• Glenn Close in Fatal Attraction
• Jennifer Jason Leigh in Single White Female
Borderline Personality Disorder
Treatment Strategies
• Diagnosis and treatment of co-existent mood and
anxiety disorders
• Set limits, maintain treatment frame, focus on here
and now
• Address splitting aggressively – avoid seductive
trap of idealization and devaluation
• Establish that currency is words, not actions
• Pharmacotherapy includes antidepressants, mood
stabilizers, and low dose antipsychotics
Histrionic Personality Disorder
Clinical Features
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Dramatic, attention-seeking, exhibitionistic
Seductive, manipulative, impressionistic speech
Shallow and labile feelings
“Hysterical conversion”
Repression as a primary defense
Histrionic Personality Disorder
Examples
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Niles on Frasier
“Scarlett O’Hara” in Gone with the Wind
“Elaine” on Ally McBeal
Will and Grace, Karen and Jack
Obsessive-Compulsive Personality
Clinical Features
• Perfectionistic, constricted, moralistic
• Rigid, formal, emotionally cool
• Driven, competitive, overly concerned with
productivity and achievement
• “Workaholic”, unable to relax
• Need to be in control
• Not OCD
• Defenses of isolation of affect and undoing
Obsessive-Compulsive Personality
Examples
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“Spock” or Vulcans in Star Trek
Anthony Hopkins in Remains of the Day
Morgan Freeman in Seven
Courtney Cox in Friends
William Hurt in The Doctor
Obsessive-Compulsive Personality
Treatment Strategies
• Relinquish as much control as possible to the
patient
• Avoid power struggles, develop partnership
• Provide plenty of information and details
• Pharmacotherapy for OCD only
Avoidant Personality Disorder
Clinical Features
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Inhibited, introverted, shy
Extreme sensitivity to rejection
Desires relationships, but fears embarrassment
Inferiority complex
Similar presentation to social phobia
Devaluation as a primary defense
Avoidant Personality Disorder
Examples
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Clark Kent in Superman
The Lion in The Wizard of Oz
Hugh Grant in Four Weddings and a Funeral
“John” on Ally McBeal
Greg Medavoy in NYPD Blue
Dependent Personality Disorder
Clinical Features
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Excessive reliance on others
Permits others to make decisions for them
Subjugates personal needs to those of others
Tolerates mistreatment
Lacks assertiveness, helpless when alone
Passive-aggressive behavior as a primary defense
Dependent Personality Disorder
Examples
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Tom Hanks in Forrest Gump
“Edith Bunker” in All in the Family
Bruce Willis in Death Becomes Her
“Adrianne” in Rocky
You will know them by their
countertransference
Powerfully mobilizing feelings in the
clinician
Clinician vulnerabilities
• The need to “fix”everything and everyone
• Inflexibility in tailoring interactions to
patients and situations
• Gullible to extortion in relationships
• Being exhausted and burned out
Managing countertransference
• Take care of yourself or you cannot take
care of anyone else
• Do not take responsibility for things you
cannot control
• Remember that to be understood is
therapeutic for patients
Managing countertransference
• If you never make mistakes, you are not
learning anything
• Avoid furor therapeuticus - beware
sadistic impulses masquerading as treatment
• Enjoy the small victories
Final thoughts
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Managing disappointment
Facing personal limitations
Caring for self
Relying on others