1
UNDERSTANDING PERSONALITY DISORDERS
Presented by Catherine R. Barber, Ph.D.
catherine.romero.barber@gmail.com
Sponsored by Institute for Brain Potential
OBJECTIVES
Primary Objectives
a. List key brain regions influencing social reasoning and conduct.
b. Identify features of and effective treatments for paranoid, schizoid, schizotypal,
antisocial, borderline, histrionic, narcissistic, dependent, avoidant, obsessivecompulsive, passive-aggressive, and depressive personality disorders.
c. Describe personality disorders that may underlie hypochondriasis, body
dysmorphic disorder, selected eating disorders, and substance abuse.
d. Review principles that facilitate the transformation of personality.
Secondary Objectives
A. Differentiate categorical and dimensional models of personality pathology.
B. Describe basic theoretical models of personality disorder etiology.
C. Identify practical strategies for working with personality-disordered clients.
D. Recognize and learn to cope with counter-transference.
AGENDA
9:00 – 10:00 AM
Orientation
Introduction to Personality Disorders
Theories of Personality Disorders
10:00 – 10:30 AM
Cluster A: Odd/Eccentric
10:30 – 10:45 AM
Morning break
10:45 – 11:30 PM
Cluster B: Dramatic/Emotional
11:30 – 12:00 PM
Cluster C: Anxious/Avoidant
12:00 – 1:00 PM
Lunch break (presenter available for questions at 12:30 – 1:00)
1:00 – 1:30 PM
Common Co-morbid Conditions
1:30 – 2:30 PM
Practical interventions
2:30 – 2:45 PM
Afternoon break
2:45 – 4:00 PM
Specific treatment approaches
Conclusions and Evaluations
2
PRESENTATION OUTLINE
I.
Introduction to Personality Disorders
A. Differentiating personality style from personality disorder
1. Personality style: The way in which a person relates to oneself, others, and the
world. Comprises various traits or tendencies as well as habits or behaviors.
2. Personality disorder: An enduring and pervasive pattern of perception, thought,
and behavior that falls outside of social norms, is usually inflexible and
maladaptive, and thus causes impairment or distress.
3. We all have a personality style. Our style may even include traits or habits that are
represented in one or more of the personality diagnoses. However, if these do not
cause impairment or distress to oneself and/or others, we would not consider them
pathological. Some behaviors that we will discuss in the context of personality
disorders may actually be adaptive, depending on the context. Example: attentionseeking (performing arts); extreme concern with order and detail (research, school,
clerical tasks, etc.); suspiciousness (investigational or intelligence agencies).
4. Sometimes the line is not clear! Example: Eccentric or quirky behavior may
bother others but not the individual who is eccentric.
B. Models of personality pathology
1. Various models of personality pathology exist. These typically conceptualize
personality disorders as either categorical/prototypical or dimensional constructs.
Examples:
a. Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text
Revision (DSM-IV-TR; APA, 2000): The most commonly used diagnostic
system in the U.S. Uses a prototypical model of diagnosis, in which a
person is said to have a personality disorder if he or she has a minimum
number of features that are considered prototypical for the disorder. This
model facilitates communication, but important information may be
missed and category might not fully represent a “real life” construct. Also,
most contemporary research does not support the distinctness of the DSMIV-TR categories (i.e., there is a lot of overlap across disorders, and the
criteria within each category are highly heterogeneous). Similarly,
research does not generally support the construct or predictive validity of
these categories (Depue & Lenzenweger, 2005). The risk of “reifying”
diagnoses is substantial.
b. Five-factor model/the “Big Five” (e.g., McCrae & Costa, 1996): One of
the most common dimensional systems, this model suggests that
personality (and thus personality pathology) can be defined in terms of 30
dimensional facets organized into 5 higher-order dimensions: Openness to
experience, conscientiousness, agreeableness, extraversion, and emotional
stability. There is substantial evidence to support these 5 factors or traits,
which are strongly heritable (i.e., genetically based). The model is useful
3
because it contains more information and looks at personality strengths
and weaknesses as falling on a spectrum. However, downsides include the
lack of built-in information about what point on the continuum a
“disorder” begins and the lack of user-friendliness of this system due to its
lack of context for each trait (Rottman et al., 2009).
c. Shedler-Westen Assessment Procedure (SWAP: e.g., Westen, Shedler, &
Bradley, 2006): This method combines prototypical and dimensional
information to provide a profile of how much or how little an individual is
similar to each cluster of descriptors.
2. Assessment: Multiple tools exist to assess the presence and type of personality
disorder. Among the most common:
a. Structured Clinical Interview for DSM-IV Personality Disorders (SCID-II;
First et al., 1997)
b. Minnesota Multiphasic Personality Inventory – 2 (MMPI-2; Butcher et al.,
1989)
c. Personality Assessment Inventory (PAI; Morey, 1991)
d. Millon Clinical Multiaxial Inventory – III (MCMI-III; Millon et al., 2006).
3. Bottom line: Although we will review the DSM-IV-TR personality disorder
prototypes, keep in mind that traits and all other aspects of personality can be
described as falling somewhere along a continuum. For the purposes of treatment,
it is far more useful to identify, understand, and address the problematic thoughts,
behaviors, emotions, etc., than simply to assign a specific personality disorder
diagnostic category.
C. A few more caveats about diagnosing
1. Although we will discuss what constitutes a “disorder,” and visual illustrations
will be used to highlight various aspects of the personality disorders, it is critical
that sufficient information be gathered before actually making a diagnosis or
otherwise drawing a conclusion that a person has a personality disorder. It is
rarely acceptable to conclude that someone has a personality disorder on the basis
of a single conversation or other limited observation.
2. It is also not useful to engage in “distance diagnosing,” that is, drawing
conclusions about someone’s personality without actually having met them or
spent some time with them.
3. A common misconception is that all patients who are “difficult” have personality
disorders. “Difficult” patients may be difficult for a variety of reasons, including
but not limited to the presence of a personality disorder. We will discuss how to
manage difficult patients in general, but keep in mind that separate techniques
may be necessary to manage personality-driven difficult behavior.
D. The scope of personality disorders and current thought regarding treatment
1. American Psychiatric Association (2000) prevalence estimates range from 0.5%
to 2.5% in the general population. However, a recent study of a community (non-
4
2.
3.
4.
5.
6.
II.
clinical) sample (Lenzenweger et al., 2007) suggests that about 10% of all adults
may meet criteria for a personality disorder.
These numbers are even higher in clinical settings (about 2-10% in psychiatric
outpatient settings and 10-30% in psychiatric inpatient settings; APA, 2000).
Just as personality traits are fairly well-set by mid-childhood, personality
disorders emerge in childhood and crystallize by adolescence. However,
clinicians do not diagnose personality disorders until a person is 18 or older
Because personality disorders involve every aspect of a person’s experience—
perception, thought, emotion, behavior—they are notoriously challenging to treat.
However, they are not completely intractable. Unfortunately, many clinicians are
insufficiently equipped to treat personality disorders, and there continues to be
considerable stigma associated with these conditions.
Most clinicians do not think of personality disorders in medical terms, where the
disorder is an “illness” to be “cured.” Rather, the disorders comprise “patterns”
or “tendencies” to be “modified” and/or “coped with.”
As with all other psychiatric disorders, personality disorders have biological bases
that are beginning to be better understood. Yet there are few psychiatric disorders
in which the environment plays so large a role in their development. As we
discuss etiology, keep in mind that aspects of nature and nurture contribute to the
development of personality disorders.
Theories of Personality Disorders
A. Psychodynamic/Psychoanalytic
1. This category comprises many theories, not just one. However, these theories
generally share common features, such as an emphasis on early experiences in the
development of personality, the role of the unconscious, and the function of
defense mechanisms.
2. One of the most commonly used theories in contemporary psychodynamic
practice is object relations theory (e.g., Kernberg, 1993). This suggests that the
ways in which people experience and respond to themselves, others, and the
world are heavily influenced by emotions linked to early experiences with
significant others. These experiences become internalized as “object relations”
and provide a template for future interactions.
3. Object relations theory has much utility for the understanding of the different
personality disorders. Various authors (e.g., McWilliams, 1994; Van Denburg,
1994) have described characteristic object relational patterns for the main
personality disorders, which will be highlighted as we discuss each disorder.
B. Cognitive-behavioral
1. This category also comprises several theories. However, all accept the cognitive
model: An individual’s perceptions and assumptions shape his or her emotional
and behavioral responses. Events trigger interpretations, which in turn influence
emotions and behaviors. Emotions and behaviors, in turn, influence thoughts.
5
2. Cognitive theorists have identified three levels of cognitive processes that shape
people’s emotions and behavior:
a. Automatic thoughts: spontaneous thoughts that are influenced by one’s
unique learning history and that may or may not be true.
b. Schemas: organizing beliefs about the self, others, and the world.
c. Cognitive distortions: interpretive heuristics or biases that contribute to
dysfunctional thinking when overused.
Beck and other clinical researchers (e.g., Beck et al., 2004; Young et al., 2003)
have, in turn, described and researched common schemas associated with various
personality disorder, which we will also examine.
3. Principles of reinforcement are involved in learning (and extinguishing) the
thoughts and behaviors that make up personality. Reinforcement and punishment
are responsible for the frequency and strength of most behaviors. Behaviors that
are followed by something pleasant or by the removal of something unpleasant
will strengthen and occur more often. Behaviors followed by something
unpleasant or the removal of something pleasant will weaken and occur less often.
4. We also learn through observation and modeling. What we see others (e.g.,
parents, siblings, peers) do in turn influences what we do.
C. Biological
1. Thinking of disorders in terms of “biological” versus “psychological” or
“environmental” is a misunderstanding. Every behavior, thought, feeling, and
experience is biologically based, as all of these originate in the brain, a biological
organ. However, the brain responds to something—it is constantly receiving and
processing information that comes from the environment.
2. Therefore, it is much more useful to focus on what areas of the brain and which
brain processes go awry in psychological disorders, and how both physical factors
(e.g., genetics, head injuries, medical diseases) and environmental factors (e.g.,
learning history, trauma) affect brain chemistry. We can hypothesize about the
origin of specific personality deficits by examining individuals who have known
damage to a specific structure of the brain and observing their behavior. Examples:
a. Temporal lobe epilepsy and personality (e.g., Lanteaume et al., 2009;
Monaco et al., 2005).
b. Frontal lobe damage and psychopathy (e.g., deOliveira-Souza, 2008)
3. Personality disorders, like most disorders, involve nearly all aspects of brain
functioning: perception, memory, speech, executive functioning, and social
reasoning, among others. Thus, many brain areas may be malfunctioning in
someone with a personality disorder. However, key regions implicated in
personality disorders include the prefrontal cortex and the limbic system (Barlow
& Durand, 2009; Coccaro & Siever, 2005).
a. Prefrontal cortex: Responsible for executive functioning, which comprises
planning, decision making, behavioral activation and inhibition, and
reasoning. This region selects and implements behaviors based on internal
goals.
6
b. Limbic system: A complex system of cortical and sub-cortical structures
(including the amygdala) that supports and regulates emotion, long-term
memory, autonomic functions (e.g., heart rate, sleep/wake cycle, hunger,
thirst, sexual arousal, etc.), and the reward center.
c. These regions interact, forming circuits that underlie complex phenomena
such as social reasoning, self-image, motivation, and impulsivity.
4. Within each brain region, chemical messengers or “neurotransmitters” facilitate or
inhibit the firing of neurons, which causes communication between neurons. Key
neurotransmitter systems implicated in personality pathology include serotonin
(5-HT), norepinephrine, and dopamine. Examples of specific relationships that
have been observed among neurotransmitter activity and behavior include:
a. Serotonin and mood, impulsivity, and appetitive behaviors.
b. Norepinephrine, arousal, and risk-taking behaviors.
c. Dopamine/opiods, pleasure, and reinforcement.
d. Dopamine and psychotic symptoms (delusions and hallucinations).
5. Given the role of neurotransmitters in brain functioning, it stands to reason that
psychopharmacological interventions (i.e, medications) may benefit individuals
with personality disorders. To some extent, this is true, particularly when it comes
to helping people with emotion dysregulation, impulsivity, and thought
disturbance. However, medication is rarely (if ever) enough to change personality,
given that most behaviors are highly complex and the result of years of learning
and practice! Thus, most clinicians strongly recommend psychotherapy to
address the unique interplay of traits and learned behaviors that make up a
personality disorder.
a. Benefits of pharmacotherapy for personality disorder symptoms.
b. Common side effects of medications used in the treatment of personality
disorders.
D. An integrative approach: Many clinicians and researchers conceptualize
personality disorders in terms of biological components, internal psychological
processes, and environmental and social factors. This “biopsychosocial” model
will be used as we discuss each personality disorder.
1. We will review 12 personality disorders, 10 of which are listed in the DSM-IVTR and two of which are commonly accepted personality disorders in clinical
literature (and are listed in DSM-IV-TR “for further study”). In addition to
examining DSM-IV-TR criteria, we will examine the following for each
personality disorder:
a. Characteristics of the disorder and DSM-IV-TR Diagnostic criteria (from
APA, 2000)
b. General population prevalence estimates (from Lenzenweger et al., 2007;
Torgerson et al., 2001)
c. Common defense mechanisms (from Gabbard, 2005; McWilliams, 1994;
PDM Task Force, 2006)
d. Object relational patterns (from McWilliams, 1994; Van Denburg, 1995)
e. Cognitive schemas (from Beck et al., 2004; Young et al., 2003)
7
f. Key neurobiological mechanisms (from Coccaro & Siever, 2005)
2. A few words about DSM-IV-TR clusters: Grouping or “clustering” personality
disorders by the surface characteristics that they hold in common is a common
clinical approach taken by the DSM to facilitate communication. However, there
is scant research suggesting that disorders within a given cluster are etiologically
or fundamentally related. Remember not to fall into the “reification” trap!
III.
The Personality Disorders
A. Cluster A: Odd/Eccentric
1. Paranoid Personality
a. Characterized by suspiciousness, distrust, guardedness, grudges, hostility,
and covert vengefulness.
b. Occurs in approximately 0.5-2.5% of the general population.
c. Common defenses: projection, projective identification, reaction formation.
d. Object relations: Others are dangerous and/or “users.”
e. Common self schema: “I’m vulnerable.”
f. Key neurobiological findings: scant evidence about specific pathology;
disorder may be more common in relatives of people with schizophrenia.
2. Schizoid Personality
a. Characterized by detachment, restricted emotional expression, isolation,
minimal interest in sexual or social experiences, lack of pleasure, and
indifference.
b. Occurs in approximately 1.7- 4.9% of the general population.
c. Common defenses: withdrawal, intellectualization.
d. Object relations: The social world is engulfing.
e. Common self schemas: “I’m a misfit.”
f. Key neurobiological findings: largely unknown. The disorder may be
more prevalent in relatives of people with schizophrenia.
3. Schizotypal Personality
a. Characterized by discomfort with relationships, eccentric behavior,
psychotic-like symptoms.
b. Occurs in approximately 0.6-3.3% of the general population.
c. Common defenses: withdrawal, fantasy.
d. Object relations: Others are experienced as piecemeal and incoherent.
e. Common schemas: “I am defective.”
f. Key neurobiological findings: Substantial evidence for the role of
dopamine (excess – psychotic symptoms; deficit – cognitive symptoms).
Ventricular enlargement is often seen, though frontal lobes are relatively
well-preserved (which may serve as a buffer to the development of fullblown schizophrenia).
B. Cluster B: Dramatic/Emotional
8
1. Antisocial (Sociopathic) Personality
a. Characterized by disregard for and violation of the rights of others, lack of
remorse, and manipulation. May include a component characteristic of
psychopathy that entails an interpersonal style that is cunning and
charming.
b. Occurs in approximately 0.7-1.0% of the general population.
c. Common defenses: omnipotent control.
d. Object relations: Others are selfish, manipulative, and not worthy of
respect.
e. Common schemas: “I’m vulnerable.”
f. Key neurobiological findings: Serotonin plays a strong role in impulse
control and aggression (insufficient serotonin  poor impulse regulation
and increased aggression). Decreased autonomic arousal also is common
(i.e., reduced “fight or flight” response when facing risks). Pleasure center
(fueled by dopamine) may also be overactive. Increased amygdala
activity is associated with aggression (e.g., Siever, 2008).
2. Borderline Personality
a. Characterized by instability in affect regulation, interpersonal relationships,
self-image, and behavior. Often involves chronic suicidal ideation and
behavior, as well as self-injury.
b. Occurs in approximately 0.7-1.6% of the general population.
c. Common defenses: splitting, projective identification.
d. Object relations: Others are unpredictable and inconstant.
e. Common schemas: “I’m defective.” “I’m vulnerable.” “I’m helpless.”
“I’m bad.”
f. Key neurobiological findings: Serotonin is implicated in impulse control
and emotion regulation. Imaging studies demonstrated reduced anterior
insula response (King-Casas et al., 2008). There is a possible role of
peptide (e.g., opioids, oxytocin) dysfunction (Stanley & Siever, 2010).
3. Histrionic Personality
a. Characterized by excessive emotionality and attention-seeking behavior.
b. Occurs in approximately <1.0-2.0% of the general population.
c. Common defenses: repression, regression, conversion, sexualizing, acting
out.
d. Object relations: Same-sex others are of little value; those of the opposite
sex are powerful, exciting,
e. Common schemas: “I’m nothing.”
f. Key neurobiological findings: Unknown.
9
4. Narcissistic Personality
a. Characterized by grandiosity, need for admiration, and lack of empathy.
Two subtypes are often identified: malignant/oblivious and
fragile/shy/hypervigilant.
b. Occurs in approximately <1.0% of the general population.
c. Common defenses: idealization, devaluation.
d. Object relations: Others are better than I am; I must be better than they are
to feel good.
e. Common schemas: “I’m inferior.”
f. Key neurobiological findings: Unknown.
C. Cluster C: Anxious/Avoidant
1. Avoidant Personality
a. Characterized by social inhibition, feelings of inadequacy, and
hypersensitivity to criticism.
b. Occurs in approximately 5.0-5.2% of the general population.
c. Common defenses: symbolization, displacement, projection,
rationalization, avoidance.
d. Object relations: Others who are more powerful can provide safety.
e. Common schemas: “I’m undesirable.”
f. Key neurobiological findings: Most closely related to social phobia, which
is marked by dopamine deficiencies.
2. Dependent Personality
a. Characterized by an excessive need to be taken care of, submissiveness
and clinginess, and fears of separation.
b. Occurs in approximately 0.6-1.5% of the general population.
c. Common defenses: regression, reversal, avoidance.
d. Object relations: Others are powerful and their care is essential.
e. Common schemas: “I’m helpless.”
f. Key neurobiological findings: Unknown.
3. Obsessive-Compulsive Personality
a. Characterized by a preoccupation with orderliness, perfectionism, and
mental and interpersonal control, to the detriment of flexibility, openness,
and efficiency.
b. Occurs in approximately 2.0-2.4% of the general population.
c. Common defenses: isolation of affect, reaction formation, intellectualizing,
moralizing, undoing.
d. Object relations: Others try to exert control, which must be resisted.
e. Common schemas: “My world can go out of control.”
f. Key neurobiological findings: Unknown.
10
D. Other problematic personality styles under review
1. Passive-aggressive (Negativistic)
a. Characterized by the tendency to deny negative emotions (e.g., anger)
while acting them out in a covert or indirect way (e.g., by withholding
affection, giving the “silent treatment,” etc.)
b. Prevalence estimates vary too widely (e.g., 1% to 10% of the general
population; 20% of adolescents!) to be reliable.
c. Common defenses: projection, externalization, rationalization, denial.
d. Object relations: Others require conforming to their rules.
e. Common schemas: “I should only have to do what I want; others’ needs
are not as important.”
f. Key neurobiological findings: Unknown.
2. Depressive
a. Characterized by self-criticism, judgment, intense guilt, dejection.
b. Reliable prevalence estimates are not available.
c. Common defenses: introjection, reversal, idealization of others,
devaluation of the self.
d. Object relations: Others will criticize, reject, or abandon.
e. Common schemas: “I am fundamentally bad.”
f. Key neurobiological findings: Unknown.
E. DSM-5 Proposed Classification System (from www.dsm5.org). Changes to the
way personality disorders are diagnosed have been proposed by the Personality
Disorders Task Force. Some of the changes include:
1. A new general definition of personality disorder based on severe or extreme
deficits in core components of personality functioning and elevated pathological
traits.
a. “Personality disorders represent the failure to develop a sense of selfidentity and the capacity for interpersonal functioning that are
adaptive in the context of the individual’s cultural norms and
expectations.” (from dsm5.org)
2. 5 identified severity levels of personality functioning ranging from 0 (No
impairment) to 4 (Extreme impairment).
3. 5 personality disorder (PD) types (Antisocial/Psychopathic, Avoidant, Borderline,
Obsessive-Compulsive, and Schizotypal have been proposed, pending empirical
validation), each defined by core PD components and a subset of:
4. 6 broad, higher order personality trait domains, with 4-10 lower-order, more
specific trait facets comprising each, for a total of 37 specific trait facets
(proposed, pending empirical validation). Trait domains include Negative
Emotionality, Introversion, Antagonism, Disinhibition, Compulsivity, and
Schizotypy.
Note that this system would incorporate both dimensional and prototypical elements.
11
IV.
Common Co-morbid Conditions and the Role of Personality
A. Hypochondriasis and other Somatoform Disorders
1. Somatic/physical expression of emotions is common in individuals with histrionic,
dependent, and obsessive-compulsive personality disorders. This may represent
an effort to obtain attention, to keep others close, or to express emotions.
2. Hypochondriacal fears are usually not assuaged by reassurance by a physician,
repeated medical tests, and other forms of “proof” that no illness exists.
3. Cognitive-behavioral treatment has the most empirical support, although there is a
role for SSRI’s to address the anxiety component of this disorder.
4. If hypochondriasis occurs within the context of a personality disorder, the
interpersonal functions of hypochondriasis must be addressed.
5. Emotional disclosure via expressive writing may be a useful approach for
individuals with hypochrondriasis or other pain syndromes of unknown origin.
B. Body Dysmorphic Disorder (BDD)
1. BDD involves severe distortion in perception of one’s appearance, resulting in
obsession over the “flawed” body part(s) and, at times, extreme efforts to change
the body part(s).
2. BDD is often comorbid with Borderline Personality Disorder and Avoidant
Personality Disorder, likely for different reasons.
3. Treatment general focuses on modifying cognitive distortions and exposing the
individual to the “flawed” body part(s) while preventing typical problematic
responses. Note that plastic surgery is rarely effective in changing the individual’s
perception of himself/herself.
4. Pharmacological agents (e.g., SSRI’s such as Citalopram) may also be effective.
C. Eating Disorders
1. The eating disorder category comprises several distinct and overlapping diagnoses,
including anorexia nervosa, bulimia nervosa, and binge-eating disorder (the latter
of which is included in DSM-IV-TR as a category for further study). All involve
some disturbance of eating; however, significant emotional concerns generally
underlie the problematic behavior pattern(s).
2. Eating disorders (especially bulimia and binge-eating) are common in individuals
with Borderline Personality Disorder and may represent different aspects of the
diagnosis (e.g., impulsivity, self-destructiveness, dichotomous thinking, identity
diffusion). Interestingly, DBT has shown effectiveness in the treatment of
bulimia.
3. Obsessive-compulsive personality disorder may be involved in anorexia.
4. The presence of a personality disorder in the context of an eating disorder may
make the eating disorder particularly hard to treat, especially if personality traits
strongly support the eating disorder.
12
D. Substance Abuse
1. A large percentage of individuals with personality disorders also have a substance
use disorder (abuse or dependence). This is especially true for antisocial and
borderline personalities, as these are marked by impulsivity and stimulus-seeking.
2. The presence of a personality disorder makes substance use treatment
significantly more difficult. Dual diagnosis-focused programs may be most
appropriate.
V.
Pathways to Transforming Personality
A. Practical interventions for helping people with personality disorders
Numerous simple strategies can target global problems. These are useful for
therapists, health professionals, other service providers, family members, coworkers, etc.
1. Problem: Lack of social awareness. Intervention: Most people with personality
disorders either lack awareness of their interpersonal behavior or cannot generate
skillful interpersonal behaviors on command. Social awareness can be developed
through self-monitoring, modeling, and feedback/self-disclosure.
2. Problem: Disabling thoughts. Intervention: Most intense emotions don’t just
“happen.” They are usually a response to a thought, assumption, interpretation, or
belief. Pervasive, negative thinking patterns (e.g., schemas) can be overcome
through cognitive strategies. Examples include identification and monitoring of
automatic thoughts, examining and weighing evidence for and against thoughts,
and generating alternative, balanced thoughts.
3. Problem: Perpetual pessimism. Intervention: Pessimism is an acquired (learned)
explanatory style in which the worst is assumed. At extreme levels, pessimism
can lead to hopelessness; both characteristics are associated with negative health
outcomes (e.g., Smith & MacKenzie, 2006). Fortunately, optimism can be
increased through many of the strategies that are useful for modifying disabling
thoughts. Modeling optimistic/benign attributions and encouraging behavioral
experiments to test beliefs can change explanatory style over time.
4. Problem: Lack of gratitude, empathy, and/or forgiveness. Intervention: Numerous
aspects of positive psychology are critical for transforming personality,
particularly in light of their benefits on emotional and relational health. Strategies
for increasing these factors include benefit-finding, mentalizing, and expressive
writing.
5. Problem: Lack of self-care. Intervention: Self-care (including religious and
spiritual practices, when relevant) is the foundation for mental health and runs
13
through several models of therapy. Strategies include attending to nutrition,
exercise, and sleep; increasing mastery; and finding meaning and purpose.
B. Managing counter-transference
1. Keep theory in mind; it will help you empathize with the patient.
2. Remember that it’s (usually) not you; don’t take behavior too personally.
3. On the other hand, be open to the possibility that you could be contributing to the
situation; Stay attuned to your own treatment-interfering behavior.
4. Consult with colleagues—a consultation team is an excellent option for mental
health professionals working with numerous personality-disordered patients.
C. Examples of difficult behavior in individuals with personality disorders, and
methods for addressing each:
1. Help-rejection and other resistance: This cuts across personality disorder
categories. Assess and modify readiness to change using MI techniques.
2. “The button radar”: This is particularly common in Antisocial PD and Borderline
PD. Practice acceptance and maintain confident stance.
3. Lack of trust: This is particularly common in Paranoid PD. Provide objective
information and address concerns directly.
4. Decreased attachment capacity: This is particularly common in Schizoid and
Schizotypal PD’s. Stay solution-focused while providing a safe environment and
engaging in usual rapport-building activities.
5. “Attention-seeking”: This is particularly common in Histrionic PD, Narcissistic
PD, and Borderline PD. Use non-pejorative language, refrain from reinforcing
undesired behavior, and determine the motivation for the behavior.
6. Aggression: This is particularly common in Antisocial PD. Conduct risk
assessment, create a safety plan, link behavior with consequences and desired
goals.
D. General strategies for working with individuals with personality disorders
1. Set boundaries and observe limits; use a treatment contract that explicitly sets out
the terms and parameters of treatment.
2. Self-monitor your own reactions and practice self-disclosure judiciously.
3. Provide rationales for treatment strategies; answer questions thoroughly and nondefensively.
4. Balance validation with change.
5. Highlight consequences of treatment-interfering behaviors, including
consequences to the treatment relationship.
6. Encourage mentalizing.
7. Use an empirical approach – measure change quantitatively, and shift course as
necessary.
E. State-of-the-art treatment models
14
1. Dialectical Behavior Therapy (Linehan, 1993a; 1993b; Lynch et al., 2007)
a. Biosocial model of BPD
b. Functions and modes of therapy
c. Levels of disorder, stages of treatment, and target hierarchy
d. Skills training: Core mindfulness skills, Distress Tolerance, Emotion
Regulation, Interpersonal Effectiveness
2. Schema Therapy (Young et al., 2003)
a. Maladaptive coping styles: overcompensation, avoidance, and surrender
b. Strategies for change: cognitive, behavioral, and experiential
3. Mentalization-based Therapy (Bateman & Fonagy, 2006, 2009)
1.
“Keeping mind in mind”
2.
Mirroring and empathy
4. Motivational Interviewing (Miller & Rollnick, 2002)
1.
Stages of change
2.
Resistance as a relationship variable
3.
Eliciting and strengthening “change talk”
15
References
American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental
Disorders, 4th ed., text revision (DSM-IV-TR). Washington, DC: American Psychiatric
Association.
Barlow, D. H., & Durand, V. M. (2009). Abnormal psychology: An integrative approach, 5th ed.
Belmont, CA: Wadsworth Cengage Learning.
Bateman, A. W., & Fonagy, P. (2006). Mentalization-based treatment for borderline personality
disorder: A practical guide. Oxford, England: Oxford University Press.
Bateman, A. W., & Fonagy, P. (2009). Randomized controlled trial of outpatient mentalizationbased treatment versus structured clinical management for borderline personality disorder.
American Journal of Psychiatry, 166, 1355-1364.
Beck, A. T., Freeman, A., & Davis, D. D. (2004). Cognitive therapy of personality disorders, 2nd
ed. New York: Guilford.
Butcher, J. N., Dahlstrom, W. G., Graham, J. R., Tellegen, A., & Kaemmer, B. (1989). The
Minnesota Multiphasic Personality Inventory-2 (MMPI-2): Manual for administration
and scoring. Minneapolis, MN: University of Minnesota Press.
Coccaro, E. F., & Siever, L. J. (2005). Neurobiology. In J. M. Oldham, A. E. Skodol, & D. S.
Bender (Eds.), The American Psychiatric Publishing textbook of personality disorders
(pp. 155-170). Washington, DC: American Psychiatric Press, Inc.
de Oliveira-Souza, R., Hare, R. D., Bramati, I. E., Garrido, G. J., Azevedo, I. F., Tovar-Moll, F.,
& Moll, J. (2008). Psychopathy as a disorder of the moral brain: fronto-temporo-limbic
grey matter reductions demonstrated by voxel-based morphometry. Neuroimage, 40,
1202-1213.
Depue, R. A., & Lenzenweger, M. F. (2005). A neurobehavioral dimensional model of
personality disturbance. In M. F. Lenzenweger & J. F. Clarkin (Eds.), Major theories of
personality disorders (pp. 391-453). New York: Guilford.
First, M. B., Gibbon, M., Spitzer, R. L., Williams, J. B. W., & Benjamin, L. S. (1997).
Structured Clinical Interview for DSM-IV Axis II Personality Disorders. Washington,
DC: American Psychiatric Press, Inc.
Gabbard, G. O. (2005). Psychodynamic psychiatry in clinical practice, 4th ed. Washington, DC:
American Psychiatric Press.
Kernberg, O. (1993). Object relations theory and psychoanalysis. New York: Jason Aronson.
16
King-Casas, B., Sharp, C., Lomax-Bream, L., Lohrenz, T., Fonagy, P., & Montague, P. R. (2008).
The rupture and repair of cooperation in borderline personality disorder. Science, 321,
806-810.
Lenzenweger, M. F., Lane, M. C., Loranger, A. W., & Kessler, R. C. (2007). DSM-IV
personality disorders in the National Comorbidity Survey Replication. Biological
Psychiatry, 62, 553-564.
Lanteaume, L., Bartolomei, F., Bastien-Toniazzo, M., (2009). How do cognition, emotion, and
epileptogenesis meet? A study of emotional cognitive bias in temporal lobe epilepsy.
Epilepsy and Behavior, 15, 218-224.
Linehan, M. M. (1993). Cognitive behavioral therapy for borderline personality disorder. New
York: Guilford.
Linehan, M. M. (1993). Skills training manual for treating borderline personality disorder. New
York: Guilford.
Lynch, T. R., Trost, W. T., Salsman, N., & Linehan, M. M. (2007). Dialectial behavior therapy
for borderline personality disorder. Annual Review of Clinical Psychology, 3, 181-205.
McCrae, R. R., & Costa, P. T., Jr. (1996). Toward a new generation of personality theories:
Theoretical contexts for the five-factor model. In J. S. Wiggins (Ed.), The five-factor
model of personality: Theoretical perspectives (pp. 51-87). New York: Guilford.
McWilliams, N. (1994). Psychoanalytic diagnosis. New York: Guilford.
Miller, W. R., & Rollnick, S. (2002). Motivational Interviewing: Preparing people for change.
New York: Guilford.
Millon, T. Davis, R., Millon, C., & Grossman, S. (2006). The Millon Clinical Multiaxial
Inventory – III. Pearson Assessments.
Monaco, F., Cavanna, A., Magli, E., Barbagli, D., Collimedaglia, L., Cantello, R., Mula, M.
(2005). Obsessionality, obsessive–compulsive disorder, and temporal lobe epilepsy,
Epilepsy and Behavior, 7, 491-496.
Morey, L. C. (1991). Personality Assessment Inventory professional manual. Odessa, FL:
Psychological Assessment Resources.
Rottman, B. M., Ahn, W., Sanislow, C. A., & Kim, N. S. (2009). Can clinicians recognize DSMIV personality disorders from Five-Factor Model descriptions of patient cases? American
Journal of Psychiatry, 166, 427-433.
Siever, L. J. (2008). Neurobiology of aggression and violence. American Journal of Psychiatry,
165, 429-442.
17
Smith, T. W., & MacKenzie, J. (2006). Personality and the risk of physical illness. Annual
Review of Clinical Psychology, 2, 435-467.
Stanley, B. & Siever, L. J. (2010). The interpersonal dimension of borderline personality
disorder: Toward a neuropeptide model. American Journal of Psychiatry, 167, 24-39.
Torgerson, S., Kringlen, E., & Cramer, V. (2001). The prevalence of personality disorders in a
community sample. Archives of General Psychiatry, 58, 590-596.
Westen, D., Shedler, J., & Bradley, R. (2006). A prototype approach to personality disorder
diagnosis. American Journal of Psychiatry, 163, 846-856.
Van Denburg, E. J. (1995). Object relations and the MCMI-III. In P. Retzlaff (Ed.), Tactical
psychotherapy of the personality disorders: An MCMI-III approach (pp. 111-136). New
York: Allyn & Bacon.
Yeomans, F. E., Clarkin, J. F., & Kernberg, O. (2002). A primer for transference-focused
psychotherapy for the borderline patient. Northvale, NJ: Jason Aronson.
Young, J. E., Klosko, J. S., & Weishaar, M. (2003). Schema therapy: A practitioner’s guide.
New York: Guilford.
Recommended Websites
www.behavioraltech.com
www.borderlinedisorders.com
www.borderlinepersonalitydisorder.com
www.bpdcentral.com
www.dsm5.org
www.motivationalinterview.org
www.mclean.harvard.edu/research/clinicalunit/psychosocial.php
www.menningerclinic.com
www.schematherapy.com
Please contact Catherine Barber if you would like a copy of the slides:
catherine.romero.barber@gmail.com