personality disorders

Definition of Personality Trait

Enduring patterns of perceiving, relating to, and thinking about the environment and oneself that are exhibited in a wide range of social

and personal contexts

Definitional Features of Personality Disorder

Enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture and is manifested in at least two of the following areas:


• The pattern is manifested in at least two of the following areas: cognition, affectivity, interpersonal functioning, or impulse control (Criterion A)

• The enduring pattern is inflexible and pervasive across a broad range of personal and social situations (Criterion B)

• Leads to significant distress or impairment in social, occupational, or other important areas of functioning (Criterion C)


• The pattern is stable and of long duration, and its onset can be traced back to adolescence or early adulthood (Criterion D)

• The pattern is not better accounted for as a manifestation or consequence of another mental disorder (Criterion E)

• The pattern is not due to the direct physiologic effects of a substance or a general medical condition (Criterion F)

Three Clusters of Personality Disorders

• Cluster A (odd eccentric)– Paranoid– Schizoid– Schizotypal


• Cluster B (dramatic-emotional)– Antisocial– Borderline– Histrionic– Narcissistic


• Cluster C (anxious-fearful)– Avoidant– Dependent– Obsessive-compulsive

The Challenge of Working With Personality Disorders

• Patients typically come for therapy with presenting problems other than personality problems

• They require more work within the session• Longer duration of treatment• Greater strain on the therapist’s skills and

patience• Greater difficulty in treatment compliance

“Red Flags” for Identifying Personality Disorders

• A patient or significant other reports that the patient “has always done that” or has always been that way”

• The patient is not compliant with the therapeutic regimen• Therapy progress seems to have come to a complete stop for

no apparent reason• Patients often will seem unaware of the effect their behavior

has on others• Patient’s problems appear to be acceptable and natural for

them

Beck’s Theory of Personality Disorders

• Certain behavioral patterns or strategies that had adaptive value in evolutionary terms, become maladaptive in today’s society when these “strategies” become exaggerated


• A strong relationship exists between the cognitive patterns on the one hand and the affective and behavioral patterns on the other

Definition of Schemas

Schemas are relatively stable information processing structures that operate in a feed-forward system to guide the processing of information. They are not themselves conscious, although they can be recognized, evaluated, and their interpretations tested.

Characteristics of Schemas

• They integrate and attach meaning to events

• They can be described in terms of valence or level of activation

• They can be of a highly idiosyncratic content

Characteristics of Schemas

• They vary according to their function • When particular schemas are

hypervalent, the threshold for activation of the constituent schemas is low


• Each personality disorder has its own profile that can be characterized by core beliefs about the self and others and compensatory strategies associated with those core beliefs

Beck’s Profile of Personality Disorders

Personality Disorder

View of Self View of Others

Main Belief Main Strategy

Avoidant Vulnerable to rejection, Inept, Incompetent






CriticalSuperiorDemeaning







It’s terrible to be rejected; If people know the real me, they will reject me







It’s terrible to be rejected; If people know the real me they will reject me

Avoids evaluative situations





Paranoid RighteousInnocent NobleVulnerable






InterferingMaliciousAbusive motives






InterferingMaliciousAbusive motives

Be on guard, Don’t trust, Motives are suspect

Accuse orCounter-attack



View of Self

View of Others


Dependent NeedyWeakHelplessIncompetent



View of Self

View of Others



NurturantSupportiveCompetent



View of Self

View of Others




Need people to survive;Need steady flow of support, encouragement



View of Self

View of Others




Need people to survive;Need steady flow of support, encouragement

Cultivate dependent relationships



View of Self

View of Others


Obsessive-compulsive

ResponsibleAccountableCompetentFastidious



View of Self

View of Others




IrresponsibleCasualIncompetentSelf-indulgent



View of Self

View of Others





I know what’s bestDetails are crucialPeople should do better, try harder



View of Self

View of Others





I know what’s bestDetails are crucialPeople should do better, try harder

Apply rulesPerfectionismEvaluateControlCriticize



View of Self

View of Others


Narcisstic Special, uniqueSuperiorDeserve special rules



View of Self

View of Others



InferiorAdmirers of me



View of Self

View of Others




Since I’m special I deserve special rulesI’m better than others



View of Self

View of Others




Since I’m special I deserve special rulesI’m better than others

Use othersTranscend rulesManipulate



View of Self

View of Others


Schizoid Self-sufficientLoner



View of Self

View of Others



Intrusive



View of Self

View of Others



Intrusive Others are unrewardingRelationships are undesirable



View of Self

View of Others



Intrusive Others are unrewardingRelationships are undesirable

Stay Away

Cognitive Therapy for Personality Disorder

Background

Therapeutic Assumptions

• Therapy will often evoke anxiety because the patient is being asked to change “who they are”

• Patients with personality disorders often come to therapy with presenting issues other than personality problems

• Patients with personality disorders are more difficult to treat

• Therapy must take a tripartite approach• Schema work takes a much more central role in CT with

personality disorders• A much greater emphasis is placed on the client-therapist

relationship

Problems in Collaboration

• Therapist or patient may lack the skill to be collaborative

• Patients’ beliefs regarding the potential failure in therapy

• Patients’ beliefs (fears) regarding the effects of changing on significant others or himself

• Poor socialization to the cognitive therapy model• Frustration due to lack of progress

Cognitive Techniques

• Guided discovery• Labeling of inaccurate inferences• Collaborative empiricism• Examining explanations of others’ behavior• Scaling• Reattribution training• Deliberate exaggeration• Decatastrophizing

Behavioral Techniques

Goals of Behavioral Techniques

• Alter self-defeating compensatory behaviors

• Skill building (e.g., assertiveness)• Behavioral experiments designed to

weaken maladaptive beliefs

Specific Behavioral Techniques

• Role playing• Use of imagery• Reliving childhood experiences• Assisting in decision-making

Borderline Personality Disorder

Significance of BPD

• 2% of general population meet for BPD• 11% of outpatients and 19% of inpatients meet

criteria for BPD (Widiger & Francis, 1989)• Of those meeting for some personality disorder,

33% of outpatients and 63% of inpatients meet for BPD

• 70-75% of BPD patients have a history of self-injurious acts

Significance of BPD Cont.

• Estimates of suicide rates for BPD patients are approximately 10%

• 74% of BPD referred patients are women

Diagnostic Features of BPD

• Hypersensitivity to abandonment• Pattern of unstable and intense interpersonal relationships• Unstable self-image or sense of self• Marked impulsivity• Recurrent suicidal behavior• Affective instability• Chronic feelings of emptiness• Inappropriate or intense anger or difficulty controlling anger• Transient stress-related paranoid ideation or dissociative

symptoms

CBT for Borderline Personality Disorder (Linehan)

Linehan Model

B e h av io rIn s ta b ility

In te rp e rso n a lIn s ta b ility

S e lfIn s ta b ility

C o gn it iveIn s ta b ility

E m o tio n a l V u ln era b ility(A ffe c tive In sta b ility)

E m otio n R e g u la tion D ys fu nc tionIn va lid a tin g E n v iro n m e nt

Components of Emotional Dysregulation

• Emotional vulnerability– High sensitivity to emotional stimuli– Intense response to emotional stimuli– Slow return to emotional baseline once

emotional arousal has occurred

Components of Emotional Dysregulation

• Deficits in emotion modulation strategies– Ability to inhibit inappropriate behavior related to

strong negative or positive emotions– Ability to act in a way that is not mood-dependent– Ability to self-soothe any physiological arousal that the

strong emotion has induced– Ability to refocus attention in the presence of strong

emotion

Features of the Invalidating Environment

• During development, people respond to the communication of the child's preferences, thoughts, and emotions with either nonresponsiveness or more extreme negative consequences

• An invalidating environment emphasizes the inhibition of emotional expressiveness

Role of the Invalidating Environment

• Persistent discrepancies between a child’s private experience and what others in the environment respond to as her experience provide the fundamental learning environment for many of the behavioral problems associated with BPD

Consequences of the Invalidating Environment

• Child fails to learn how to label emotion or modulate emotional arousal

• Child fails to learn to tolerate distress or form realistic goals and expectations

• Child learns that extreme emotional reactions will sometimes provoke a helpful environmental response

• Child fails to learn to trust her own internal experiences and hence looks for external cues about how to think, act, and feel

Linkage of Emotional Dysregulation

and BPD Behavioral Characteristics

• The behavioral characteristics of borderline individuals (i.e., self-mutilation, suicide attempts) can be conceptualized as the effects of emotional dysregulation and maladaptive emotional regulation strategies

Linkage of Emotional Dysregulation

and BPD Behavioral Characteristics

• Emotional lability leads to unpredictable behavior and cognitive inconsistency, thus interfering with identity development

• The chaotic relationships seen with BDPs is understandable given the person’s difficulties in controlling impulsive behaviors and negative emotions

Areas of Divergence From Standard CBT

• Emphasis on acceptance and validation of behavior as it is in the moment

• DBT emphasizes the importance of balancing the technology of change with the technology of acceptance

Areas of Divergence From Standard CBT

• Emphasis on treating therapy-interfering behaviors of both client and therapist

• Emphasis on the therapeutic relationship as essential to treatment

• Emphasis on dialectic processes

Characteristics of the DBT Treatment

• Applies many standard CBT principles and techniques

• Attempts to reframe suicidal and other dysfunctional behaviors


• Adopts a problem-solving focus• Encourages exposure to fear-eliciting

stimuli


• Gives some attention to cognitive change techniques


• Emphasizes strategies for validating client's thoughts, feelings, and actions


• Emphasis on modifying current maladaptive behaviors before ameliorating long-standing interpersonal conflicts or the effects of early trauma and abuse

• Combines therapy into two conceptual components – psychosocial skills training and motivational issues

Major Modes of Treatment in DBT

• Individual psychotherapy• Group skills training• Telephone consultation• Case consultation for therapists

Specific Skill Training Modules in DBT

• Emotional regulation skills– Understanding emotions and their reactions– Observing emotions– Experiencing emotions– Reducing emotional vulnerability through

exercise and reducing alcohol/drugs


• Interpersonal effectiveness skills


• Distress tolerance skills– Distraction techniques– Self-soothing procedures– Realistically evaluating the pros and cons of

tolerating events– Acceptance strategies


• Mindfulness skills– Paying attention to the ebb and flow of

emotional experience– Paying attention to thoughts in the moment– Paying attention to action urges– Practice labeling them correctly– Practice accepting them w/o trying to

suppress them

Efficacy Data

(Linehan, 1991;1993)

CBT Treatment of Avoidant Personality Disorder

Renneberg et al (1990)

Study Overview

• 17 patients were administered an intensive 4 day group treatment program consisting of (1) group systematic desensitization; (2) Behavioral rehearsal; (3) self-image enhancement

Major Findings

20

25

30

35

40

45

50

% of patients meeting Jacobsen Criteria

ImprovedRecovered

Data from Renneberg et al (1990). Behavior Therapy, 21, 363-367.

CBT Treatment of Avoidant Personality Disorder

Alden (1989)

Design

• 4-arm randomized clinical trial (constructive strategy design)– Graduated exposure– Graduated exposure + Interpersonal skill

training– Graduated exposure + Interpersonal skill

training + Intimacy Focus– Wait-list control

Subjects

• 76 subjects (42 men, 34 women) all unmarried

• Meeting DSM-III criteria based on clinical interview

• Must score above the 75% on Millon’s AVPD scale

• No current substance abuse or psychotropic medication

Treatments

• 10 weekly group sessions (2-2.5 hour duration)

• Each group had 6-7 participants• 6 masters-level therapists (2 therapists

per group)

Results

• Patients in all three active treatments improved significantly compared to the wait-list

• There were no significant differences between the three active treatments suggesting skill training did not add to the efficacy of graduated exposure

Results Cont.

• Significant others rated the patients’ improvement as noticeable;

• Clinical significance analyses revealed that while treated patients improved 1 SD during treatment, their scores did not move into the range of a normative sample

Effectiveness of Psychotherapy for Personality Disorders:

A Quantitative Review

Perry et al (1999)

Description of Included Studies

• 15 studies examining treatments for personality disorders that included pre-to posttreatment data

• Of these only 6 were randomized studies and 9 were uncontrolled treatment studies

• 5 focused on BPD, 1 schizotypal, 1 avoidant, and 8 mixed

Description of Included Studies Cont.

• Treatment Modalities– 7 studies – psychodynamic– 4 studies – CBT– 2 Interpersonal group psychotherapy– 1 Supportive psychotherapy

Major Findings

• Drop-out rates varied considerably and averaged 21.8%

• Drop-outs were positively associated with longer treatments

• Mean pre- to posttreatment effect sizes were 1.11 for self-report measures amd 1.29 for observer-rated measures

• These did not differ for the different types of treatment

personality disorders

Documents

personality problems

personality disorders

incompetent view

definition of schemas

critical rejection

master subtitle style

constituent schemas

particular schemas