EPC 695B
All humans have personality traits.
These are well-ingrained ways in which
individuals experience, interact with, and
think about everything that goes on around
them.
Personality Disorders are collections of traits
that have become rigid, and work to
individual’s disadvantage, to the point that
their personality disorders impair functioning
or cause distress.
All of the DSM-IV-TR personality disorders
are patterns of behavior and thinking that
have been present since early adult life and
have been recognizable in the client for a
long time.
Personality disorders are probably
dimensional, not categorical
This means that their components (the
traits) are present in normal people, but are
accentuated in those with the disorders in
question.
A lasting pattern of inner experience and behavior
that markedly deviates from norms of the client's
culture.
1. The
pattern is manifested in at least two of these
areas:
a.
b.
c.
d.
Cognition (how the client perceives and
interprets self, others, and events)
Affect (appropriateness, intensity, lability, and
range of emotions)
Interpersonal functioning
Impulse control
2.
3.
4.
5.
6.
This pattern is fixed and affects many personal
and social situations.
The pattern causes clinically important distress
or impairs work, social, or personal functioning
This pattern has lasted a long time, with roots in
adolescence or young adulthood.
The pattern is not better explained by another
mental disorder.
The pattern is not directly caused by a GMC or
by the use of substances, including medication.
These general criteria are extremely
important. They identify vital points that
are central to the diagnosis of any
personality disorder.
To summarize, a personality disorder is:




Lifelong,
Affects many areas of the client's life,
Causes problems, and
Is not the product of another illness.
Let’s look together at the handout:
Morrison’s
Quick Guide to the Personality Disorders

See additional handouts:
Diagnosing Personality Disorders
 Personality Disorders
3.
To make a specific diagnosis - a semi-structured
interview can be used, augmented by a selfreport personality inventory.
a.
b.
Semi-structured interviews guide the therapist
through a series of questions that assess all of the
potential personality disorders.
Example: SCIS-II by Spitzer, Williams & Giffon
(Helps to avoid impressions that rely on only
one or two symptoms rather than the full criteria set.)
Millon Clinical Multiaxial Inventory II (MCMI-I) is a selfreport measure. Self report inventories tend to
indicate more personality disorder pathology than
reported by clinical interviews. Thus, the inventories are
only suggestive of possible diagnoses and alternatives.
Personality disorders are more vulnerable to
error of diagnosis than Axis I disorders.
Diagnostic errors occur most often when the
therapist fails to adhere to the diagnostic
criteria or when the therapist has a gender
or cultural bias.
For example: The counselor may only
see one key symptom and make or rule
out a diagnosis without carefully looking
for the entire cluster of symptoms
required to meet DSM criteria.

For example:
A study by Morey and Ochoa
(1989) found that, when a client
with a borderline personality
disorder had a symptom of little
sexual interest, the client was not
diagnosed correctly because
clinicians believe that clients with
borderline personality disorder are
sexually promiscuous.

A study by Ford and Widiger (1989) also
found that failure to adhere to criteria made
it more likely that the clinician would be
influenced by gender and cultural
background of client.
◦ For example, clinicians making diagnoses of
histrionic and antisocial personality disorder were
affected in their diagnoses by the sex of the
client (women seen as histrionic, men as
antisocial), but when asked to assess, using
given criterion symptoms, they were not biased
by client sex.
1. If a client has an Axis I diagnosis, but a personality
disorder is the main reason the client has come for
evaluation, (Principal Diagnosis) should be attached to
the Axis II diagnosis.
Axis I 312.32 Kleptomania
Axis II 301.6 Dependent Personality Disorder
(Principal Diagnosis)
2. A frequently used defense mechanism can be indicated
on the Axis II line:
Axis II 301.0 Paranoid Personality Disorder; frequent use of
projection
See DSM-IV-TR, p. 811: Defense Mechanism and Coping
Styles
3. If your client's personality disorder
preceded a psychotic disorder (most
often Schizophrenia), the diagnosis
might read:
Axis I
295.10
Schizophrenia, Disorganized
Type, Continuous, With Prominent
Negative Symptoms
Axis II 301.22 Schizoid Personality Disorder
(Premorbid)
Please look at handout:
Correlation between Axis II
Personality Disorders
and Axis I Mental Disorders
Now look at:
Profile of Characteristics
of Personality Disorders
in your packet
a.
b.
c.
d.
e.
Central characteristic: unjustified distrust and
suspicion of others.
Because the client fears exploitation, s/he will not
confide in others – even those who have earned
his/her trust.
Client reads unintended meaning into benign
comments and actions.
Client will interpret specious occurrences as
the result of deliberate intent and will harbor
resentment for a long time, perhaps forever.
These clients are rigid, often litigious, and
have an especially urgent need to be self-sufficient.
f.
To others, these clients appear to be cold, calculating, and
guarded people who avoid both blame and intimacy.
g. When interviewed, they may appear tense and have trouble
relaxing.
h. This disorder is especially likely to create occupational
difficulties; these clients are so aware of rank and power
that they frequently have trouble dealing with superiors
and co-workers.
i. Although it is far from rare (about 1% of the general
population), it rarely comes to clinical attention. Usually
diagnosed in men.
Its relationship (if any) to the development
of Schizophrenia, Paranoid Type, remains unclear.
Treatment Options
◦
◦
◦
◦
Supportive psychotherapy,
Confronting beliefs about therapist,
Pharmacotherapy,
Behavioral Therapy
Countertransference
◦ Anger,
◦ Withholding negative feedback
Case: Useful Work (DSM-IV-TR Casebook, p.
211)







Indifferent to the society of other people
Lifelong loners, who show a restricted emotional
range; they appear unsociable, cold and seclusive
Unusually succeed at solitary jobs others find
difficult to tolerate
May daydream excessively, become attached to
animals, and often do not marry or even have
long-lasting romantic relationships
Do retain contact with reality
Disorder is relatively common, affecting perhaps a
few percent of the general population
Men are at greater risk than women.
Treatment Options
 Supportive Therapy
 Pharmacotherapy
 Cognitive reorientation therapy
 Group Therapy
Countertransference: As watch film, see what
feelings he engenders in you.
Film: Jerry - Schizoid Personality Disorder
a.
b.
c.
d.
e.
f.
From early age have lasting interpersonal deficiencies
that severely reduce capacity for closeness with others.
Also has distorted or eccentric thinking, perceptions,
and behaviors that can make these clients seem odd.
Often feel anxious when with strangers and have almost
no close friends.
May be suspicious and superstitious
Peculiarities of thought include magical thinking and
belief in telepathy or other unusual modes of
communication.
May talk about sensing a "force" or "presence," or have
speech characterized by vagueness, digressions,
excessive abstractions, impoverished vocabulary, or
unusual use of words.
May eventually develop Schizophrenia.
h. Many are depressed when first come to clinical
attention.
i. Eccentric ideas and style of thinking also place
these clients at risk for becoming involved with
cults.
j. Gets along poorly with others and, under
stress, may briefly become psychotic.
k. Many marry and work.
l. Occurs as often as Schizoid Personality
Disorder
g.
Overlapping Diagnoses:
Axis I: Paranoid Schizophrenia; Mood Disorder;
Obsessive-Compulsive
Axis II: Borderline; Schizoid
Treatment Options
◦ Pharmacological
◦ Supportive Therapy
Counter-transference
◦ Underestimating importance of treatment to client. Why
would that happen?
Case: Wash Before Wearing (DSM-IV Casebook, p. 289)
a.
b.
c.
d.
e.
f.
Chronically disregard and violate rights of other
people; these individuals cannot or will not
conform to the norms of society.
Some are engaging con-artists; others may be
graceless thugs.
Women are often prostitutes.
Seem superficially charming, but are aggressive
and irritable.
This personality disorder affects nearly every life
area: In addition to substance use, there may be
fighting, lying, and criminal behavior of every
conceivable sort: theft, violence, confidence
schemes, and child and spouse abuse.
Claim to have guilt feelings, but do not appear to
feel genuine remorse for this behavior.
f.
g.
h.
i.
j.
k.
l.
m.
n.
Claim to have guilt feelings, but do not appear to feel
genuine remorse for this behavior.
Manipulative interactions with others make it difficult to
decide whether or not complaints are genuine.
About 3% of men, but only 1% of women have this disorder.
Accounts for 3 out of every 4 penitentiary prisoners.
More common among lower class populations and runs in
families; probably both genetic and environmental.
Disorder decreases possibly with increasing age. Individual
mellows out after 30; however, still are substance users.
Death by suicide or homicide is sometimes their lot.
Can't get this diagnosis if antisocial behavior occurs only in
the context of substance abuse. Crucial to learn whether
clients have engaged in illicit acts when not using
substances.
Only one-half of children with anti-social background
eventually develop the full adult syndrome.
Overlapping Diagnoses
Axis I Major Depression; Substance abuse
Axis II Borderline; Narcissistic
Treatment Options:
◦ Morrison: No known effective treatment
◦ Others have said:
 Pharmacotherapy;
 Marital/Family;
 Behavioral (i.e., token economies, assertiveness
training; education);
 Cognitive Therapy
Countertransference: Watch your feelings when you see
the film.
◦ Gullibility
◦ Suspiciousness
Film: Antisocial Personality Disorder (Tape 3) George #8
a.
b.
c.
d.
e.
f.
g.
This concept was devised about the middle of the 20th
century. Clients were originally (and sometimes still are)
said to be on the borderline between neurosis and
psychosis.
The existence of this disorder is disputed by many
clinicians.
As the concept has evolved into a personality disorder, it
has achieved remarkable popularity, perhaps because so
many clients can be shoe-horned into its definition.
About 1-2% of general populations may legitimately
qualify for this diagnosis.
These clients have a pattern of instability throughout adult
live.
The most over-used diagnosis in the DSM-IV. Many of
these clients really have Axis I disorders that are more
readily treatable, such as Major Depressive Disorder,
Somatization Disorder, and Substance-related Disorders.
Often appear in crisis of mood, behavior, or interpersonal
relationships.
h.
i.
j.
k.
l.
m.
n.
Many feel empty and bored; they attach
themselves strongly to others, then become
intensely angry or hostile when they believe that
they are being ignored or mistreated.
Impulsively try to harm or mutilate selves.
These are cries for help, anger, or attempts to
numb selves.
Can have brief psychotic episodes, but resolved
so quickly that these are seldom are confused
with psychoses like schizophrenia.
With all the mood swings, it is difficult for the
client with this diagnosis to achieve fell potential
Truly miserable and about 10% commit suicide.
Antecedents: abandonment; abuse
Overlapping Diagnoses
Axis I
Major depression; Dysthymic Disorder; Adjustment
Disorder
Axis II
Histrionic; Narcissistic; Schizotypal; Antisocial
Treatment Options
◦ Expressive psychodynamic therapy;
◦ Object Relations;
◦ Supportive Psychotherapy;
◦ Brief psychotherapy;
◦ Cognitive-behavior therapy
In therapy, it is important to:
◦ Address client’s disappointments,
◦ Confront behavior (“When you sleep with every man you date,
I wonder what is happening with you.”)
◦ Understand that behavior is often a result of loneliness and
abandonment issues in childhood
◦ Know that you will be overvalued and undervalued, as well as
loved and hated.
◦ Countertransference Feelings: Guilt, Rage, Wanting to rescue and reject
client
Case: “Empty Shell,” p. 237
a.
b.
c.
d.
e.
f.
g.
Have long-standing excessive emotionality and attentionseeking that seeps into all areas of lives.
Satisfy need to be on center stage in two main ways: (a)
their interests and topics of conversation focus on their own
desires and activities; and (b) their behavior, including
speech, continually calls attention to themselves.
Over-concerned with physical attractiveness.
Express themselves so extravagantly that it seems like a
parody of normal emotionality.
May be promiscuous or have a normal sex life, others may
have difficulty with frigidity or impotence.
Moods seem shallow.
Low tolerance for frustration may spawn temper tantrums.
h.
i.
j.
k.
l.
m.
Quick to form new friendships, also quick to
become demanding.
Have trouble with tasks that require logical
thinking such as doing mental arithmetic.
May succeed in jobs that set premium on
creativity and imagination.
This disorder is not well studied, but if quite
common.
May run in families.
Classical client is female, but disorder can occur in
men.
Overlapping Diagnoses
Axis I: Mood Disorders; Somatization Disorder
Axis II: Borderline; Narcissistic
Treatment Options
◦
◦
◦
◦
◦
Pharmacological;
Behavioral;
Psychodynamic;
Supportive;
Group;
Countertransference
Seductive
Indifference
Case: My Fan Club (DSM-IV-TR Casebook, p. 84).
Case encompasses both Histrionic and Narcissistic
Personality Disorders.
a.
b.
c.
d.
e.
Lifelong pattern of grandiosity (in behavior
and in fantasy), thirst for admiration, and lack
of empathy.
Permeates most aspect of lives.
Client feels s/he is unusually special.
Commonly exaggerate accomplishments to
make self seem bigger than life.
(These traits are true only of adults. Children
and teenagers are naturally self-centered; this
doesn't imply ultimate personality disorder)
Despite grandiosity, have fragile self-esteem
and often feel unworthy.
f.
g.
h.
i.
j.
Sensitive about own feelings, but have little
apparent understanding of the feelings and needs
of others and may feign empathy.
Because they tend to be concerned with grooming
and value youthful looks, they may become
increasingly depressed as they age.
Disorder was very poorly studied. Now studied
more; people not come for therapy
Most clients are men.
There is no information about family history,
environmental antecedents, or other background
material. Perhaps mirroring was imperfect. Not
seen as person - who child really is. False Self.
Overlapping Diagnoses
Axis I Major depression; Adjustment disorder with depressed
mood
Treatment Options
Psychodynamic
Brief Supportive Therapy
Behavioral
Paradoxical
Object Relations
Client-centered
Cognitive
In therapy, it is important to:
◦ Use metaphors; e.g., cold
◦ Interpret behavior (“When you act so coldly with your wife after
she doesn’t understand you, I think that has roots in your
childhood when your mother was so distant when you didn’t
please her.”)
◦ Use visualization; e.g., crevice
Countertransference: Please the client, Anger, Retaliation
Feels inadequate and is socially inhibited and
overly sensitive to criticism.
b. Present throughout adult life; however,
avoidant
traits are common in children and do not
necessarily imply eventual personality
disorder.
c. Self-effacing and eager to please others.
d. Can lead to social isolation, as he/she may
misinterpret innocent comments as critical.
e. Hangs back in social situations.
a.
Tends to have few close friends.
g. Comfortable with routine.
h. Sparse research. Uncommon and almost no
information about sex distribution and
family pattern.
i. This disorder may be associated with a
disfiguring illness or condition.
j.
Not often seen clinically, for client tends to
come for evaluation only when another
illness supervenes.
f.
Overlapping Diagnoses
Axis I: Anxiety disorder; Dysthymia; Major depression;
Adjustment Disorder with Depressed Mood.
Axis II: Dependent; Passive-aggressive
Treatment Options
◦ Behavioral (systematic desensitization; assertiveness training)
◦ Cognitive
◦ Paradoxical (Prescribing avoidant behaviors; prescribing
rejections)
◦ Psychodynamic
◦ Importance of therapeutic relationship
Countertransference Case:
◦ Pushing the client
◦ Over-protectiveness
Case: The Jerk (DSM-IV-TR Case Book. p. 124)
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
Feels the need to be taken care of.
Desperately fears separation
Client’s behavior can become so submissive and
clinging that it may result in others' taking advantage
or rejecting the client
Feels helpless and uncomfortable when client is alone.
Needs much reassurance, so has trouble making
decisions.
May tolerate considerable abuse (even battering)
DPD may occur commonly, but it has not been well
studied.
Afraid of independence, because then others will reject
him/her
Found more often among women than men.
Some writers believe that it is difficult to distinguish
this diagnosis from Avoidant Personality Disorder.
Overlapping Diagnoses
Axis I:
Axis II:
Anxiety disorders; Mood disorder
Histrionic; Narcissistic; Avoidant; Schizotypal
Treatment Options
◦
◦
◦
◦
◦
Behavioral (Assertiveness Training; Exposure to anxiety situations)
Cognitive therapy
Family and marital therapy
Group therapy
Psychodynamic therapy
Countertransference
◦ Guilt
◦ Over-protectiveness
◦ Rejection
Case:
Blood is Thicker Than Water (DSM-IV Case book, p. 179)
a.
b.
c.
d.
e.
f.
g.
h.
i.
Perfectionistic and preoccupied with orderliness; needs to exert
interpersonal and mental control.
Many with this personality disorder have no actual obsessions
or compulsions at all, though some eventually develop OCD.
Rigid perfectionism often results in indecisiveness, preoccupation
with detail, and insistence that others do things their way.
Sometimes savers, refusing to throw away even worthless objects
they no longer need.
List makers who allocate their own time poorly, workaholics who
must meticulously plan even their own pleasure.
May resist authority of others, but insist on their own.
May be perceived as stilted, stiff, or moralistic.
Condition is fairly common. Diagnosed more often in males than
females.
Probably runs in families
Overlapping Diagnoses
Axis I
Axis II
Mood Disorders; Anxiety Disorders
Avoidant; Dependent
Treatment Options
◦ Behavioral (In vivo exposure; compulsive rituals; obsessive
ruminations)
◦ Cognitive (thought-stopping; cognitive restructuring)
◦ Paradoxical approaches (to oppositionalism)
◦ Supportive
◦ Psychodynamic (problems collaborating with intellectualizing
defenses; resistance; focusing on affect; use of humor).
Countertransference
◦ Boredom
◦ Power struggles
◦ Collusion
Case:
The Workaholic (DSM-IV Case book, p. 147)
a.
Used for clients who have insufficient features for
a better-defined personality disorder, but who
appears to have long-standing personality traits
that have cause difficulties in many life areas.
b.
Can also be used for other personality disorders
that have not yet received official DSM sanction.
c.
Many individuals have long-standing personality
traits, but these traits cut across several
personality disorders and they don’t completely
meet the criteria for any one of them.
Case: Stubborn Psychiatrist (DSM-IV Case book, p.
166)