Disordered Personalities 2ed

Disorders

Personalities

David J. Robinson, M.D.

NATION^LmiTUTESOniEAm

NIH LIBRARY

AUS I 4 1999

BLDG 10, 10 CENTER DR

BETHESDA, MD 208921150

Disordered

Personalities

Second Edition

national ins ITUTES OF HEALTH

NIH LIBRARY

I 4 1999

0 CENTER DR.

20892-1150

DavidJ. Robinson, M.D., F.R.C.P.C.

Diplomute of the American Board of

Psychiatry & Neurology

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RapidPsythler Press

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Dedicated to my mentors and teachers:

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Disordered Personalities — Second Edition

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Table of Contents

Author's Foreword

Atknowledgments

Publication Notes

vi-vii

••• •

VIII-IX

X

Introduction

Diagnostic Principles 1

Theoretical Principles 25

The Biological Dimension 75

The Schizoid Personality 113

The Paranoid Personality 135

The Schizotypal Personality 161

The Histrionic Personality 185

The Antisocial Personality 209

The Borderline Personality 235

The Narcissistic Personality 265

The Avoidant Personality 287

The Dependent Personality 305

The Obsessive Personality 325

The Negativistic Personality 347

Other Personality Topics 361

Personality Changes in Later Life 381

Index 395

Disordered Personalities — Setond Edition

Author's Foreword

Disordered Personalities was my first book. I wrote it because it al¬

lowed me to combine two of my passions — teaching and humor. I am

involved in both undergraduate and postgraduate medical education

and have been increasingly aware of the need to find new ways of

teaching psychiatry. Given the information overload students face, I

have endeavored to make educational material both interesting and

comprehensible.

Throughout my studies and teaching, I have found humor to be a most

effective and enjoyable way of encouraging learning. For this reason, I

have used this as an educational enhancement in this book. Adding

levity makes concepts clearer and increases retention by adding a

positive association to the material. I feel that humor helps achieve a

sense of balance and perspective that is essential to include when

teaching clinical subjects.

Disordered Personalities was written to provide a succinct, practical

and readable overview of personality disorders at an intermediate level.

This book was designed to be used by students for course study, dur¬

ing clinical rotations and for exam review. Up to twenty-five different

aspects of each DSM-IV personality disorder are presented per chap¬

ter to give readers the ability to recognize these conditions, under¬

stand how they develop, and have an appreciation for the different

types of therapy.

The caricatures were drawn to add a visual element to the understand¬

ing of these disorders. In the illustration at the beginning of the indi¬

vidual personality chapters, the object on the table and the painting

behind the chair change to reflect aspects of the topic being pre¬

sented. Where possible, I developed a mnemonic that further reflects

features of the personality disorder it summarizes.

The illustrations and mnemonics were not included out of disrespect or

disregard for those who suffer from personality disorders. In fact, it is

quite the opposite. These conditions are among the most difficult to

teach, and I feel these added aspects aid both comprehension and

recall. Similarly, the extra humor pages at the end of the chapters were

included to add practical examples of how these conditions are mani¬

fested in everyday situations.

Rapid Psythler Press

This text has been completely overhauled, revised, and refined. New to

this edition are chapters on the biological dimension of personality

disorders, and personality changes in later life. The individual person¬

ality chapters have been expanded to include sections on interper¬

sonal psychotherapy, case examples, and review questions (with an¬

swers). Of course, more humor was added as well. All totaled, this

amounted to well over one-hundred pages of new material.

Thank you for purchasing this book and supporting Rapid Psychler

Press. Your feedback is highly valued, so please contact us if you’d

like to share your opinion on this book.

Keep Psychling!

London, Canada

February, 1999

From the moment I picked up your book until I laid it down,

I was convulsed with laughter. Someday I intend reading it.

Groucho Marx

The most wasted of days is one without laughter.

e. e. cummings

Make everything as simple as possible, but not simpler.

Albert Einstein


Rapid Psythler Staff

I am very grateful to have the time and talents of these people available

to me. Their unfailing support and enthusiasm were of crucial assis¬

tance in the preparation of this text.

• Brian & Fanny Chapman

• Monty Robinson

• Lisa Burgard

• Nicole & Mark Kennedy

• Brad Groshok

• Sam Wilson

• Dean Avola

• Gabrielle Bauer

• Dr. Donna Robinson & Dr. Robert Bauer

VIII

Acknowledgments


I am indebted to the following people for their support for the first

edition of Disordered Personalities and their assistance in furthering

my academic interests:

• Len Sperry, M.D., Ph.D.

• Alan D. Schmetzer, M.D.

• Greg Franchini, M.D.

• Paul Steinberg, M.D.

• Nikkie Cordy, M.Ed.

• John Mount, M.D.

• Harold Merskey, D.M.

• Sandra Northcott, M.D.

• Tom Norry, B.Sc.N.

• Noel Gallagher, Entertainment & Lifestyles Reporter for The

London Free Press

• The instructors at JFK University in Orinda, California

• The members of ADMSEP and AADPRT

• The instructors at other institutions who have used

Disordered Personalities as a class text

• Purchasers of the first edition of this text

Disordered Personalities — Seeond Edition

Publieation Notes

Terminology

Throughout this book, the term “patient” is used to refer to people who

are suffering and seek help. The term is further used to describe those

who bear pain without complaint or anger.

The terms “consumer" or “consumer-survivor” reflect an unfortunate

trend that is pejorative towards mental health care, labeling it as if it

were a trade or business instead of a profession. These terms are also

ambiguous, as it is not clear what is being “consumed” or “survived.”

Graphics

All of the illustrations in this book are original works of art commissioned

by Rapid Psychler Press and are a signature feature of our publications.

Rapid Psychler Press makes available an entire library of color

illustrations (including those from this book) as 35mm slides and

overhead transparencies. These images are available for viewing and

can be purchased from our website — www.psychler.com

These images from our color library may be used for presentations.

We request that you respect our copyright and do not reproduce these

images in any form for any purpose at any time.

Bolded Terms

Throughout this book, various terms appear in bolded text, which allows

for ease of identification. Most of these terms are defined in this text.

Some, however, are only mentioned because a fuller description is

beyond the scope of this book. Fuller explanations of all of the bolded

terms can be found in standard reference texts.

Introduction:


Why Study Personality Disorders?

For many involved in the mental health profession “personality disorder”

is a term that lacks comprehensibility, respectability or validity. As Tyrer

(1993) wrote, this term has historically “been imbued with the negative

qualities of degeneracy, untreatability and conflict.”

Personality disorders lack the professional consensus that exists with

the major or clinical psychiatric disorders. Difficult patients are often

given the pejorative label of a "personality disorder,” and once identified

as such, may well receive less support, empathy and tolerance from

caregivers. Frequently, this decreases the initiative to try and help

these patients. Their problems are seen as matters of personal

responsibility, given that no formal psychiatric condition exists.

Very often, reading the Personality Disorder section of a textbook

brings about the immediate identification of several friends and relatives

who fit the diagnostic criteria, and accompanying descriptions. A short

time later, readers come to fear that they themselves suffer from one or

a number of these disorders, often simultaneously. This becomes the

psychiatric equivalent of “medical student’s disease,” where one feels

afflicted by the very condition being studied.

However, the application of these concepts in clinical situations does

not readily ensue from this initial sense of familiarity. Often, despite

several assessments or lengthy hospital admissions, there is a lack of

understanding of patients’ personality styles. In case presentations or

discharge summaries, the personality assessment is often left out,

fleetingly mentioned, or recorded as “no personality.” The effect that a

personality disorder has on the treatment and outcome of a major

psychiatric disorder is considered even less still.

This omission is unfortunate because it is a disservice to patients.

Whereas many psychiatric conditions are episodic, a personality

disorder is present throughout the majority, if not all, of patients’ lives.

Perception, thinking, feeling and behavior are affected just as in the

major clinical disorders.

There are significant advantages to having a working knowledge of

the diagnosis and management of personality disorders:

• planning treatment interventions (e.g. psychotherapy, medication)

• understanding their effect on the course of major clinical conditions

• developing and maintaining effective therapeutic relationships

2

What is a Personality?

Introduttion — Diagnostit Principles

The word “personality" is used in different contexts. We hear gossip

about “TV personalities,” learn that someone we haven’t met yet has

“a nice personality,” and may refer to our favorite beer as “full of

personality.” An operational definition of the term is useful to have for

work in clinical settings.

One definition of personality is a relatively stable and enduring set of

characteristic behavioral and emotional traits. Over time, a person

will interact with others in a reasonably predictable way. However, as

the adage “don’t judge a book by its cover” warns, circumstances can

alter behavior, so that someone does something “out of character.” For

example, extreme circumstances like divorce, New Year’s Eve or the

Superbowl can bring out behavior that is atypical for that person.

Personality changes with experience,

maturity, and external demands in a

way that promotes adaptation to the

environment. It is affected by genetic

(internal), and psychosocial

(external) factors. While a discussion

on the theory of personality is beyond

the scope of this book, enumerating

some of the etiologic factors is

helpful in understanding personality

disorders.

The majority of behaviors in nonhumans are thought to be genetically

programmed. The process of natural selection influences the survival

of a species so that those having a better fit with their environment

are more likely to endure. Our distant ancestors survived because of

behaviors that sustained life and promoted reproduction. Predation,

competition, attracting a mate or helper, banding together as a group,

and avoiding overcrowding were all important adaptive strategies. One

branch of our central nervous system is geared to a flight, fright or

fight response, because these responses are essential for survival.

For all clinicians, there remains a degree of social judgment inherent

in deciding what determines a personality disorder. In different cultures,

what is considered normal varies widely, necessitating that ideas, feelings

and behaviors be understood in the context of that person’s particular

social milieu.

3


What is a Personality Disorder?

The preceding section on personality development sets the framework

for understanding disorders of personalities. When genetic endowment

is so unfavorable, early nurturing so deficient, or life experiences so

severe that emotional development suffers, a personality disorder will

often be the result.

A personality disorder is a variant or an extreme set of characteristics

that goes beyond the range found in most people. The American

Psychiatric Association defines a personality disorder as "An enduring

pattern of inner experience and behavior that deviates markedly from

the expectations ofthe individual’s culture, is pervasive and inflexible,

has an onset in adolescence or early adulthood, is stable over time,

and leads to distress or impairment."

Source: DSM-IV, 1994, p. 629

While many other definitions exist, features consistently emphasized

in defining a personality disorder are that it:

• is deeply ingrained and has an inflexible nature

• is maladaptive, especially in interpersonal contexts

• is relatively stable over time

• significantly impairs the ability of the person to function

• distresses those close to the person

Personality disorders are enduring patterns of perceiving, thinking,

feeling and behaving that remain consistent through the majority of

social situations. An essential point is that personality disorders are

egosyntonic, meaning that an individual’s behaviors do not directly

distress the person. Instead, the impact is on those with whom the

person interacts. An essential aspect of evaluating a patient’s personality

is to take into account how those close to the person are affected.

The criteria for diagnosing personality disorders are very much within

the realm of common human experience. Each one of us at times has

been: hypervigilant, destructive, suspicious, shy, bossy, vain, striving

for perfection, dramatic, afraid to be alone, fearful of rejection, purposely

late for something, too independent, too needy, critical of others,

resentful of authority, averse to criticism, bored, seductive, or

experiencing rapidly shifting emotional states. None of these behaviors

alone warrants the diagnosis of a personality disorder. Instead, clusters

of behaviors existing over a lengthy time period and interfering with a

person’s level of functioning make a diagnosis.

Introduction — Diagnostic Principles

By basing diagnostic criteria on these common qualities and behaviors,

many important questions arise:

• How many criteria are needed to make a diagnosis?

• How long do maladaptive behaviors have to be present in order to

make a diagnosis?

• What degree of severity is required for feelings, perceptions, thoughts

or behaviors to be considered diagnostic criteria?

Again, adaptation is a key point. Society has changed more rapidly

than our innate adaptive strategies. A personality disorder can be

considered as being an extreme behavior that, if present to a lesser

degree, might be beneficial to that person. Consider the following

patterns derived from social evolutionary strategies, which are either

amplified or are a poor fit for our highly individualized society:

Behavior

Suspiciousness, vigilance

towards the environment

Interest in one’s self —

"looking out for #1”

Need to be attached to others

Meticulous attention to detail,

high level of productivity

Reluctance in social situations/

Strong desire for solitude

Need to get others’ attention

Taking advantage of available

“opportunities” or bending rules

Strong desire for individuality of

style and nonconformity of thought

Personality Disorder

if Taken to an Extreme

Paranoid

Narcissistic

Dependent

Obsessive-Compulsive

Avoidant/Schizoid

Histrionic

Antisocial

Schizotypal

At the time of writing, an evolutionary or social advantage to the borderline

personality disorder is less evident.

5


HowAre Personality Disorders Diagnosed?

In 1952, the American Psychiatric Association (APA) published the

first edition of Diagnostic and Statistical Manual of Mental Disorders

(DSM). There were five categories with a total of twenty-seven personality

disorders. Diagnoses were made using a general clinical description

which was influenced by psychoanalytic concepts.

The DSM-II was introduced in 1968. In this edition the number of

personality disorders was reduced to twelve, though many from the

DSM were shifted to other categories of disorders. Again, diagnoses

were presented as descriptive paragraphs. Because of this, the DSM-

II was deemed by many to lack validity and inter-clinician reliability. It

was introduced at a time of sweeping cultural and social change and

its shortcomings necessitated significant changes for the next edition.

Introduced in 1980, the DSM-III listed specific diagnostic criteria for its

fourteen personality disorders. These were first established from the

psychiatric research done by Feighner, Robbins & Guze and later

expanded by Spitzer. Five major changes were introduced:

• descriptive features were based on presenting symptoms and not on

presumed etiologic factors (called an atheoretical approach)

• information beyond the criteria was included, such as demographic,

etiologic and prognostic variables

• discrete criteria were used (e.g. symptoms, duration, etc.)

• in response to criticism about the potential harm of labeling patients

with a psychiatric diagnosis, the APA stressed using clinical judgment

when applying the diagnostic criteria

• the concept of a multi-axial diagnosis was introduced, which fostered

a multifaceted approach towards understanding patients

Adapted from Turkat (1990)

The DSM-lll-R (R for revised) was introduced in 1987. Despite the

many advances in the DSM-III, many clinicians felt that there were

problems with the validity, accuracy and clarity of some of the criteria.

The personality disorders were now also grouped into clusters based

on their phenomenologic similarity:

Cluster A: Odd or Eccentric (“Mad”) — Paranoid, Schizoid, Schizotypal

Cluster B: Dramatic, Emotional or Erratic (“Bad") — Antisocial,

Borderline, Histrionic, Narcissistic

Cluster C: Anxious or Fearful (“Sad”) — Avoidant, Dependent,

Obsessive-Compulsive, Passive-Aggressive


The DSM-lll-R contained eleven personality disorders; three from the

DSM-III were amalgamated into a new category called personality

disorder not otherwise specified (NOS), which was used for

conditions where personality disorder was thought to be present but

the specific criteria were not met for an individual disorder.

In 1994, the DSM-IV was released, retaining the multi-axial diagnostic

approach and personality clusters listed above. The number of

personality disorders was reduced to ten. The passive-aggressive

personality disorder was felt to require further study and was moved

to Appendix B, and renamed the negativistic personality disorder.

General Diagnostic Criteria for a Personality Disorder

A. An enduring pattern of inner experience and behavior that deviates

markedly from the expectations of the individual’s culture. This pattern

is manifested in two (or more) of the following areas:

(1) cognition (i.e. ways of perceiving and interpreting self, other people,

and events)

(2) affectivity (i.e. the range, intensity, lability, and appropriateness of

emotional response)

(3) interpersonal functioning

(4) impulse control

B. The enduring pattern is inflexible and pervasive across a broad

range of personal and social situations.

C. The enduring pattern leads to clinically significant distress or

impairment in social, occupational, or other important areas of

functioning.

D. The pattern is stable and of long duration, and its onset can be

traced back at least to adolescence or early adulthood.

E. The enduring pattern is not better accounted for as a manifestation

or consequence of another mental disorder.

F. The enduring pattern is not due to the direct physiological effects of

a substance (e.g. a drug of abuse, a medication) ora general medical

condition (e.g. head trauma).

Reprinted with permission from DSM-IV.

©American Psychiatric Association, 1994


Diagnostit Points ©

The DSM-IV uses five axes to make a complete diagnostic summary:

• Axis I: Major Psychiatric Syndromes or Clinical Disorders

• Axis II: Personality Disorders and Mental Retardation

• Axis III: General Medical Conditions

• Axis IV: Psychosocial and Environmental Problems

• Axis V: Global Assessment of Functioning (GAF Score from 0-100)

The DSM also uses Axis II to record prominent personality traits and

defense mechanisms. For example, if a patient meets most but not

all of the criteria for the paranoid personality disorder, this is recorded

as “paranoid personality features.” If a personality disorder or strong

features are not evident but the patient uses a defense mechanism to

a maladaptive level, this is recorded as “frequent use of projection.”

Other official entries for coding on Axis II can be “no diagnosis” or

“diagnosis deferred.”

The paranoid, schizoid, schizotypal and antisocial personality disorders

are not diagnosed if they are coincident with certain Axis I conditions.

Exclusion criteria are not given for the other personality disorders. The

antisocial personality disorder is the only diagnosis with an age

requirement and a prerequisite diagnosis. Patients must be at least

age eighteen, and have met the criteria for the diagnosis of conduct

disorder before the age of fifteen.

The personality disorders are not diagnosed exclusive of one another,

allowing concurrent diagnoses to be made. In practice, there is usually

one disorder that is more prominent, and this is recorded as the Axis II

diagnosis, with the others listed as “features.” If two or more are equally

apparent, then all applicable diagnoses are recorded.

The residual personality diagnosis in the DSM-IV is called personality

disorder not otherwise specified (NOS). This is used when the patient

does not meet the complete criteria for a single personality disorder,

but exhibits individual diagnostic criteria from a variety of personality

disorders. Additionally, if the criteria are met for the depressive or

passive-aggressive (negativistic) personality disorders (considered

research diagnoses in the the DSM-IV), the diagnosis of personality

disorder NOS is used.

The diagnostic criteria for personality disorders in the DSM-IV are

listed in decreasing order of significance (where this is established).

Introduttion — Diagnostit Principles

The DSM-IV also lists severity and course specifiers for diagnoses:

• Mild: Few, if any, symptoms in excess of those required to make the

diagnosis are present, and symptoms result in no more than minor

impairment in social or occupational functioning.

• Moderate: Symptoms/functional impairment between mild and severe.

• Severe: Many symptoms in excess of those required to make the

diagnosis, or several symptoms that are particularly severe, are

present, or the symptoms result in marked impairment in social or

occupational functioning.

A Brief Critique of DSM-IV Axis II Construtts

The DSM has been widely criticized both for its specific content and

its general aim to be a “catalog” or “shopping list” of mental disorders.

While some detractors certainly have valid points, the manual has given

psychiatry a basis for diagnostic uniformity and an accurate means

for describing psychopathology. The specialty was in virtual disarray

prior to the DSM because diagnoses were made subjectively and there

was no standard for describing psychopathology.

The DSM continues to improve with each edition. Each of the criteria

for every diagnosis is reviewed by committees of highly respected

researchers and clinicians who make evidence-based alterations from

edition to edition (much to the dismay of those of us who must wade

through and memorize the changes).

Each personality disorder between seven and nine diagnostic criteria.

The DSM-IV doesn’t enumerate all of the possible criteria for these

disorders; it only includes those that are valid in differentiating adaptive

from nonadaptive feelings, thoughts and behaviors. Similarly, all of the

ways that a personality can go awry cannot be grouped into only ten

different conditions. Again, the personality disorders listed have survived

the scrutiny of decades of reliability and validity studies and are well

enough established to merit inclusion.

Rather than applying a “label," it is crucial to be able to accurately

diagnose psychiatric conditions. A diagnosis is a key first step in helping

patients. After establishing a diagnosis, a management plan develops,

involving investigations and treatment for biological, social and

psychological factors. Medical records are legally required to contain

a diagnosis, which is used fora variety of statistical purposes. Complete

diagnostic assessments are important for funding, research and clinical

initiatives.


What is the ICD-10?

The DSM-IV isn’t the only diagnostic system available. In 1992, the

World Health Organization (WHO) published the International

Classification of Diseases, Tenth Edition (ICD-10). It is the principal

diagnostic classification system used outside of North America.

Preparation of the DSM-IV was coordinated with Chapter V of the

ICD-10, called “Mental and Behavioural Disorders.”

DSM-IV coding and terminology are compatible with the ICD-10, which

is planned to eventually be introduced in the United States. The DSM-V

will have even greater integration with the ICD. The ICD-10 has in

common with DSM-IV the following personality disorders: paranoid,

schizoid, histrionic, and dependent. The antisocial personality is

called dissocial (dyssocial), the obsessive-compulsive is called

anankastic (anancastic) and the avoidant personality is called anxious.

There is a diagnostic category called the emotionally unstable

personality disorder with a borderline type and an impulsive type.

The latter has no clear DSM-IV analog. Narcissistic and schizotypal

personality disorders from the DSM-IV have no clear equivalent in the

ICD-10 (which may account for some cultural differences).

10


Symptom Versatility

A maxim in psychiatry is that no single symptom is exclusive to a

particular diagnosis. The personality disorders, particularly those in

the same cluster, share an overlap of symptoms:

Avoidant Personality Disorder (APD)

social isolation; avoids interpersonal contact

Schizoid Personality Disorder (SzdPD)

expression ofemotion (affect) is constricted; few friends outside family

Schizotypal Personality Disorder (SztPD)

suspiciousness orparanoid ideation

Paranoid Personality Disorder (PPD)

self-referential grandiosity (all events pertain to the person)

Narcissistic Personality Disorder (NPD)

interpersonally exploitative; lacks empathy

Antisocial Personality Disorder (ASPD)

impulsivity; failure to plan ahead; shallow expression ofemotion

Histrionic Personality Disorder (HPD)

rapidly shifting moods; affective instability

Borderline Personality Disorder (BPD)

unable to tolerate being alone; readily feels abandoned

Dependent Personality Disorder (DPD)

**

reluctance to delegate tasks; trouble with project completion

Obsessive-Compulsive Personality Disorder (OCPD)

restricted involvement in pleasurable activities; often anxious

Avoidant Personality Disorder (APD)

11


An Integrated Classification System

Clusters A, B & C listed in the previous section are based on descriptive

or phenomenological similarities. The integration of etiologic,

therapeutic, prognostic and conceptual variables provides a method

of classification based on spectrum, self and trait features.

Spectrum Disorders share a biological link to major disorders with a

spectrum of expression; they tend to have poorer prognoses.

Self Disorders cause severe dysfunction; they are often linked to

turbulent personal backgrounds and fragile sense of identity. They often

have an unstable course.

Trait Disorders exist within a context of normality; sufferers may be

subjectively distressed in social, occupational and cultural contexts.

Psychotic Disorders

Mood Disorders

Schizophrenia Delusional Disorder Depression

Spectrum Schizotypal Paranoid

Disorders

Self Schizoid Antisocial Borderline

Disorders

Trait

Disorders

Independent

Note:

Cluster A Personality Disorders have an overlap with psychotic disorders

Cluster B Personality Disorders have an overlap with mood disorders and

impulse-control disorders

Cluster C Personality Disorders have an overlap with anxiety disorders

12


Personality Change Due to a Medical Condition

Organic disorders are broadly described as those resulting from

medical disorders, the effects of medication, or drugs of abuse. It is

imperative to investigate the possibility of a personality change being

organic in nature because any psychiatric disorder can be perfectly

imitated by such conditions. In the DSM-IV, this is called personality

disorder due to a medical condition. This diagnosis is made when a

personality disturbance is due to the direct physiological effects of a

medical condition. The personality change must be persistent, and a

clear deviation from previous patterns.

When this is diagnosed, it is coded on Axis I as “Personality Change

Due to . .. (Condition).” The medical condition is specified on Axis III.

For example:

Axis I: Personality Change Due to Hypothyroidism

Axis III: Hypothyroidism

Diagnostic Criteria

A. A persistent personality disturbance that represents a change from

the individual’s previous characteristic personality pattern.

(In children, the disturbance involves a marked deviation from normal

development or a significant change in the child’s usual behavior

patterns lasting at least 1 year.)

B. There is evidence from the history, physical examination, or

laboratory findings that the disturbance is the direct physiological

consequence of a general medical condition.

C. The disturbance is not better accounted for by another mental

disorder (including Mental Disorders Due to a General Medical

Condition).

D. The disturbance does not occur exclusively during the course of a

delirium and does not meet criteria for a dementia.

E. The disturbance causes clinically significant distress or impairment

in social, occupational, or other important areas of functioning.

Specify Type:

Labile, Disinhibited, Aggressive, Apathetic, Paranoid, Other,

Combined, Unspecified



13


Personality & Culture

While the DSM-IV is prepared and published by the American

Psychiatric Association, it is used by clinicians for ethnically diverse

populations within the United States as well as in other countries. A

number of features in the DSM-IV specifically address cultural aspects:

• a section outlining cultural factors (where applicable) in the description

of the disorder that accompanies the diagnostic criteria; this is generally

included with age and gender-specific considerations

• an outline for cultural formulation which assists clinicians in more

accurately assessing the impact of an illness within the individual’s cultural

context (this appears in Appendix I)

• a glossary of culture-bound syndromes (also in Appendix I)

Personality disorder criteria in particular can be difficult to apply across

cultural situations. Concepts of self, coping mechanisms and modes

of emotional expression vary considerably between cultures. However,

the WHO has emphasized the similarity in psychiatric illnesses between

cultures and that diagnostic constructs are applicable regardless of

culture. The increasing amount of information about genetic

contributions to psychiatric disorders supports this view. Paris (1991)

reported on the WHO multi-site investigation of personality disorder

diagnoses on four continents. The findings suggest that the majority of

personality diagnoses made would be applicable in all centers.

Epidemiologic studies have consistently shown the prevalence of Axis

II conditions across populations to be in the range of 1 - 3% (for each

diagnosis). Accordingly, cultural factors have not been consistently

shown to have a dominant role in the etiology of personality disorders.

As noted above, the DSM-IV and the ICD-10 do not have a complete

overlap in their cataloging of personality disorders, suggesting that

cultural factors affect the determination of an “ideal personality.” Foulks

(1996) states that the major issue for clinicians having to make diagnoses

across cultures is differentiating between the ideal personality type,

the typical personality type and the atypical personality from the

standpoint of cultural functionality. Culture, a pervasive environmental

factor, does influence which traits are adaptive in a certain milieu.

While some of these styles may not ultimately be desirable, they assist

functionality. Individuals may have done well with their personality

characteristics in their own culture, but encountered difficulties upon

relocating to a society that does not value the expression or suppression

of certain behaviors to the same degree.

14

Specific Examples


• Reyes & Lapuz (1963) found the predominant personality style to be

histrionic (then called hysterical) in Pilipino culture. Paranoid

personality features were also frequently reported, possibly because

of widespread beliefs that supernatural forces control one’s destiny.

• Maloney (1976) reports that in many Mediterranean cultures, there

is belief in the evil eye” as well as other features of the paranoid

personality disorder: perceiving personal and threatening messages

in neutral events, expecting to be harmed by others without reason to

warrant this concern, and a widespread reluctance to share personal

information with others in case it can be used against the person.

• Canino & Canino (1993) describe indigenous healing practices among

Puerto Rican peoples involving witchcraft, magic, herbs and potions.

While these beliefs have an overlap with the schizotypal personality

disorder, a widespread cultural belief is that it is the job of each person

to perfect his or her spirit, with progress being made by successfully

dealing with life’s trials. Indigenous healers are known as espiritistas

and espiriteros, and are often more frequently sought for assistance

than are workers in traditional mental health clinics (Garrison, 1971).

• Kinzie & Leung (1993) and Kim (1993) report on some of the difficulties

in treating patients from Southeast Asia. In particular, poor compliance

with medications, concern about “saving face” by discussing only

positive things in therapy, and being late or missing appointments entirely

are common behaviors. While these actions may appear to be

narcissistic in nature, they are culturally based in that development of

trust with therapists is not as automatic as in Western cultures, and

they reflect an ambivalence towards forms of treatment that vary

(sometimes considerably) from their traditional approaches.

• Fujii, Fukushima & Yamamoto (1993) provide a description of several

cultural features in treating Japanese patients:

• delaying visits to mental health professionals in order to avoid shame and

humiliation (avoidant personality characteristics)

• excessive devotion to work, studying, and competitive pursuits (obsessivecompulsive

personality characteristics)

• belief in a form of passive love called amae, which is “to depend and presume

upon another’s benevolence” and describes a dependency-need relationship

(dependent personality characteristics)

15


How Can Psythologital Testing Help Make a Diagnosis?

The use of psychological testing,

also called psychometric

testing, provides a method for

personality assessment beyond

the criteria in the DSM-IV or ICD-

10. Testing yields valuable

diagnostic information and can

be used to monitor progress or

prognosis. Most commonly used

instruments have a standard

protocol for administration and

scoring. This helps ensure the

critical issues of reliability (the

test gives consistent results) and

validity (the test measures what

it is supposed to measure).

Inherent in the scoring is a concept of normality. Since the tables used

in these tests were assembled empirically, relatively “normal” people

were tested to provide the standardized data. Different concepts of

normality exist. The model used in statistics is the bell-shaped curve,

where some measure of behavior is plotted numerically with deviation

seen at the extreme ends. While this model lends itself nicely to numerical

interpretations, it is somewhat artificial in that aspects of a personality

or behavior cannot always be translated into a scoring system.

Many definitions of normality exist, with common themes being:

• strength of character

• flexibility/ability to adjust

• ability to learn from experience • ability to laugh and enjoy

• ability to work

• ability to love another

• ability to achieve insight

• degree of acculturation

• ability to experience pleasure without conflict

Psychological tests for personality disorders fall into two main

categories. Objective tests are structured with specific questions

yielding numerical results derived from standardized scores.

Projective tests have an ambiguous content requiring the examinees

to project something of themselves in their answers, which are neither

wrong nor right and not scored numerically. Projected answers reveal

the needs, conflicts, wishes, perceptions and defenses of those taking

the test. Interpretation is based on theories of personality development.

16

Objective Personality Tests

Introduttion — Diagnostic Principles

Minnesota Multiphasic Personality Inventory — MMPI-II

This test consists of five hundred and sixty-seven statements about

thoughts and feelings, to which the subject answers true or false.

Answers are graded on ten scales designed to separate normal

controls from people with psychiatric conditions.

MMPI-II Scales

1 Hypochondriasis 2 Depression

3 Hysteria 4 Psychopathic Deviance

5 Masculinity-Femininity 6 Paranoia

7 Psychasthenia 8 Schizophrenia

9 Hypomania 0 Social Introversion

There are also scales that report the validity of the test:

L Lie Scale F Faking Bad (Infrequency)

K Faking Good (Suppressor) ? Cannot Say Scale

Frequently, a personality assessment is based on the scores from the

two highest scales (twin peaks!). Typical elevations for the DSM-IV

personality disorders are as follows:

Cluster A

Paranoid

Schizoid

Schizotypal

Cluster B

Antisocial

Borderline

Histrionic

Narcissistic

Cluster C

Avoidant

Dependent


Elevated Scales

1,6, K

0

2, 7, 8

4,9

3,4,7

2, 3

high 4, low 0

8,0

2, 3

7, 8

Additionally, the MMPI-II may give information about patients’ clinical

state at the time of testing:

• An elevated score on 8 in borderline personality disordered patients

may signify impending deterioration

• Histrionic patients in crisis may have elevated scores on scale 2

• Violent patients may have elevated scores on scales 4, 6 & 8

17


Millon Clinical Multiaxial Inventory-ll

The MCMI-II consists of one hundred and seventy-five true or false

questions. The results are scored on scales that correspond with the

DSM-lll-R personality disorders. This inventory also contains scales

measuring validity.

Other Objective Tests

• California Personality Inventory

• State-Trait Anxiety Inventory

• Jackson Personality Inventory

• Eysenck Personality Inventory

• Beck Depression Inventory

Projective Tests

Rorschach Test

Hermann Rorschach was a Swiss psychiatrist who standardized a

set of inkblots that stimulated free association in his patients. There

are ten cards (five colored, five black & white), that are shown in a

specific sequence. Patients are asked to say what they see in the

drawings, which contain ambiguous shapes and figures that are not

based on actual images. Their responses are recorded verbatim, as

well as other parameters like number of responses and total time spent

looking at the card. Scoring takes into account factors such as shape,

color, shading, movement, etc. Interpretation is a complex task, but

useful results can be obtained regarding patients' defensive structure,

disorders of thinking, etc.

Thematic Apperception Test (TAT)

The TAT consists of thirty cards demonstrating ambiguous social

situations, to which subjects “project” their views onto the scene.

Subjects are questioned about four areas in each slide, and themes

are extracted from their answers regarding:

• the relationships between people

• the thoughts and feelings of those in the pictures

• the events leading up to the scene depicted

• the outcome of the scene/interaction

Other Common Projective Tests

• Sentence Completion Test

• Word Association

• Draw-A-Person

18

Introduction — Diagnostit Principles

Diagnostic Interviews

Psychiatric diagnoses are made on the basis of what is seen clinically.

Whereas other branches of medicine have the physical examination

and investigations, psychiatry has the interview and mental status

examination (MSE). This has prompted the use of standardized sets

of questions, often called interview schedules, to help assist with the

diagnostic assessment. These occur as structured, semistructured and

checklist schedules. Many of these diagnostic assessments require

the interviewer to be trained in administering and scoring the results,

and some can take a considerable amount of time.

• Structured Clinical Interview for DSM (SCID)

This interview contains a set of general questions for all psychiatric disorders

(Axis I & II) in the DSM-IV; a SCID-II for Axis II only is available.

• Structured Interview for DSM Personality Disorders — Revised (SIDP-R)

This schedule focuses exclusively on Axis II conditions.

• Personality Assessment Schedule (PAS)

The PAS evaluates twenty-four traits on a nine-point scale; results can be

translated into DSM-IV disorders.

• Personality Disorders Examination — Revised (PDE-R)

This assessment poses three hundred and twenty-eight questions evaluating

six key areas of functioning in the person’s life.

Whereas the above instruments assess the full range of personality

disorders, there are schedules and checklists that evaluate the

presence of single disorders or have specific areas of focus:

• Diagnostic Interview for Borderlines — Revised (DIB-R)

• Diagnostic Interview for Narcissism (DIN)

• Personality Adjective Checklist (PACL)

• Millon Personality Diagnostic Checklist (MPDC)

• Personality Disorders Questionnaire — Revised (PDQ-R)

Summary

Unlike pejorative “labels,” psychiatric diagnoses are carefully developed

constructs. Consideration must be given to organic factors such as

physical illness, substance use or medication effects before deciding

that symptoms are due to psychological causes. Clinicians must also

consider cultural factors and personality styles in deciding whether a

personality disorder exists. Personality disorders can be apparent in a

single interview, or make take a considerable amount of time, with

information supplied from collateral sources, to elucidate. Though the

DSM-IV criteria provide a sound descriptive basis, a degree of social

judgment is still required. While there is no absolute benchmark, Freud’s

idea of mental health, “to love and to work,” is a good start.

19


References

American Psychiatric Association

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition

American Psychiatric Association, Washington D C., 1994

I. A. Canino & G. J. Canino, in

Albert C. Gaw, Editor

Culture, Ethnicity & Mental Illness

American Psychiatric Press Inc., Washington, D C., 1993

M. Fauman

Study Guide to DSM-IV

American Psychiatric Press, Inc., Washington, D.C., 1994

E. F. Foulks, in

J. E. Mezzich, A. Kleinman, H. Fabrega & D. L. Parron, Editors

Culture & Psychiatric Diagnosis: A DSM-IV Perspective


J. S. Fujii, S. N. Fukushima & J. Yamamoto, in

Albert C. Gaw, Editor


American Psychiatric Press Inc., Washington, D.C., 1993

V. Garrison

Supporting Structures in a Disorganized Puerto Rican Migrant Community

70th Annual Meeting of the American Anthropological Association

New York, December, 1971

H. Kaplan & B. Sadock, Editors

Comprehensive Textbook of Psychiatry, Sixth Edition

Williams & Wilkins, Baltimore, Maryland, 1995


Synopsis of Psychiatry, Eighth Edition


J. D. Kinzie & P. K. Leung, in Albert C. Gaw, Editor



L. I. C. Kim, in Albert C. Gaw, Editor



J. Maloney

The Evil Eye

Columbia University Press, New York, 1976

T. Millon with R.D. Davis

Disorders of Personality: DSM-IV and Beyond

Wiley & Sons, Inc., New York, 1996


J. Morrison

DSM-IV Made Easy: The Clinician’s Guide to Diagnosis

The Guildford Press, New York, 1995

J. Paris

Personality Disorders, Parasuicide & Culture

Transcultural Psychiatric Research Review 28: p. 25 - 39,1991

B. Reyes & L. Lapuz

The Practice of Psychiatry in the Philippines

J. of the Philippines Coll, of Physicians 1(3): p. 161 - 165, 1963

L. Sperry

Handbook of Diagnosis & Treatment of the DSM-IV Personality Disorders

Brunner/Mazel, New York, 1995

I. Turkat

The Personality Disorders: A Psychological Approach to

Clinical Management

Pergamon Press, Elmsford, New York, 1990

P. Tyrer & G. Stein, Editors

Personality Disorders Reviewed

Gaskell/The Royal College of Psychiatrists, London, England, 1993

World Health Organization

Pocket Guide to the ICD-10 Classification of Mental & Behavioural Disorders

American Psychiatric Press Inc., London, England, 1994

Review Questions

1. Is it possible to have more than one personality disorder?

2. Are personality disorders considered “neurotic” disorders?

3. Use the following diagram to distinguish the five DSM-IV axes.

21


Answers to Review Questions

1. Yes. Multiple diagnoses are permitted on Axis II in the DSM-IV. This situation

is not that uncommon, and when it does occur, the personality disorders remain

discrete and intact, and tend to be expressed at different times. Take, for example,

a patient with both an obsessive-compulsive and a schizoid personality

disorder. He or she would at one point manifest the driven, inflexible, perfection¬

seeking characteristics of the former, and at another time demonstrate the strong

desire for solitude, anhedonia and indifference to others encompassing the latter.

In such cases, the personality characteristics most interfering with the person’s

functioning are addressed first in treatment. In some cases, there are restrictions

placed on the Axis II diagnosis; these are presented in the individual personality

chapters.

References


Diagnostic and Statistical Manual of Mental Disorders, 4th Edition

American Psychiatric Association, Washington D.C., 1994

T. Millon with R.D. Davis

Disorders of Personality: DSM-IV and Beyond


2. No, personality disorders were not considered part of the original

psychoanalytic formulation for neurotic disorders. Those with personality

disorders do not feel distressed by their behaviors (egosyntonic), and they

often see the locus of responsibility as being outside themselves. They rigidly

employ their patterns of interacting with others in spite of the repeated

difficulties they engender. Neurotic patients were seen as being quite

distressed (anxious) by their symptoms (egodystonic). There is no present

classification system involving neurotic disorders. In the DSM-IV they are

included among the anxiety disorders, somatoform disorders, sexual

disorders, dissociative disorders and dysthymic disorder.

Reference




3. From left to right:

• Axis I: Major Psychiatric Syndromes/Clinical Disorders

• Axis II: Personality Disorders/Mental Retardation/Ego Defenses

• Axis III: General Medical Conditions

• Axis IV: Psychosocial and Environmental Problems

• Axis V: Global Assessment of Functioning Scale (GAF Scale) scored from 0

to 100; there is also a Global Assessment of Relational Functioning Scale (GARF

Scale) which is also scored from 0 to 100.

Reference

American Psychiatric Association, DSM-IV, 1994

22


Parking lot of the Personality Disordered

%vn

CD

I %

ffl

%

5 am

0

ii

m

Key:

1. Paranoid

2. Narcissist

3. Dependent

4. Passive-Aggressive

5. Borderline

6. Antisocial

7. Histrionic

8. Obsessive

9. Avoidant

10. Schizoid

11. Schizotypal

s10

Cornered again!!

Largest car; prominent hood ornament

Needs other cars to feel sheltered

Angles car to take two spaces

Rams into car of ex-lover

Obstructs other cars

Parks in center of lot for dramatic effect

Perfect alignment in parking spot

Hides in corner

Can’t tolerate closeness to other cars

Intergalactic parking

23


Bistro of the Personality Disordered

Paranoid

Narcissist

Dependent

Passive-Aggressive

Borderline

Antisocial

Histrionic

Obsessive

Avoidant

Schizoid

Schizotypal

Sits with back to the wall; spies on food

preparation area when doors swing open

Expects most exclusive table without a

reservation; sends entree back to chef

While a vegetarian non-smoker, eats veal and

sits in smoking section to please date

Blows smoke into the non-smoking section

When informed her date won't leave his wife, she

throws a drink on him, and for good measure, stuffs

a Cornish hen on his head

Sucker punches the waiter, and in the resulting

confusion, steals the tip left by the Narcissist

Does an interpretive belly dance near the

jukebox in the center of the restaurant

Visits other tables polishing the crystal, aligning

cutlery and giving etiquette tips

Gives tips for service from take-out counter

Orders home delivery; ingests food through a

straw sticking out of mail slot

Eats from a fondue cauldron with gardening

equipment and a ginsu knife set

By Dr. Deborah Wear-Finkle & Dr. David J. Robinson

24

Introduttion:

Theoretical Principles


25


Theoretital Printiples

This chapter provides a introduction to the theoretical principles and

concepts contained in the individual personality chapters that follow.

The first section provides a brief introduction to personality

development. This is a diverse field which encompasses many theories

and active areas of research that are beyond the scope of this book.

Following this, sections on ego psychology and ego defenses are

presented to give an appreciation of where and how personality

disorders are thought to develop. Defense mechanisms are crucial to

understanding the interpersonal behavior exhibited by those with

personality disorders. Defenses that are discussed in the later chapters

are introduced here by means of a definition and illustration. These

concepts can prove to be a challenge when learning about personality

disorders, so the extra dimension of a caricature has been added.

Following the ego defenses is a section introducing the major

psychodynamic principles. These key concepts form the building

blocks of many types of psychotherapy and are relevant to all

interactions with patients. Attachment theory and object relations

theory are also outlined to help understand the Psychodynamic

Aspects section in the individual personality disorder chapters.

Next, the tenets of cognitive, group and interpersonal psychotherapy

are presented. Psychotherapy, which is the major form of treatment

of personality disorders, can be defined as:

Treatment by communication for any form of mental illnesses, behavioral

maladaptations, and/or other problems that are of an emotional nature, in which

a trained person deliberately establishes a professional relationship with a patient

for the purpose of:

• removing, modifying, or reducing existing symptoms

• attenuating or reversing disturbed patterns of behavior

• promoting positive personality growth and development

(Campbell, 1996)

Inherent in this definition is the application of a set of theoretical principles

to the person’s difficulties. This provides the roadmap the therapist will

use to guide the therapy.

The chapter following this one presents an introduction to the genetic

aspects of personality (e.g. temperament) and the rationale for using

medications (psychopharmacology) in treating personality disorders.

26

Introduction — Theoretical Principles

Recent advances in neuro- and biological psychiatry have renewed

interest in genetic and neonatal factors. Biogenetic factors that can

provide a more descriptive classification system are continually sought.

This approach is fueled by a growing understanding of the genetics of

major psychiatric conditions, and the view that some of the personality

disorders may be attenuated forms of these conditions.

Innate characteristics or tendencies can be reinforced or extinguished

by relationships early in life. Whatever the genetic contributions, social

and psychological influences have an impact from the moment of birth.

Early disruptive experiences with caregivers are strong influences for

later personality disorders, though curiously not everyone exposed to

potentially “pathogenic” situations develops a disorder. Genetic

endowment and experience dynamically interact to shape personality.

Overall, genetic endowment sets a range of possibilities and, within

that range, developmental experiences influence the outcome.

Many different theories exist on what goes awry in the development

of personality disorders. Still, an unifying, all-encompassing explanation

remains elusive. Some people, despite the best-intentioned parents

and a privileged upbringing, develop severe personality disorders.

Others, despite disadvantage and abuse, emerge as well-adjusted

people making meaningful contributions to society. This chapter

presents the bases for the most common approaches to understanding

and treating personality disorders.

The ancient Greeks considered personality to be a mix of four

temperaments, too much of which resulted in the following symptoms:

• yellow bile — “choleric” — which causes irritability and anxiety

• black bile — “melancholic” — which causes depression

• mucus — “phlegmatic” — which causes apathy

• blood — “sanguine” — which causes optimism or hypomania

It’s unfortunate that things had to get more complicated than this.

However, treatment needed to improve — bleeding was the remedy for

excessive optimism and purgatives were given for melancholy.

Personality development is theoretically based, and the variables are

often too complex to establish an exact science. Many classification

systems offer explanations for various stages of personality development.

Among the most famous are those of: Margaret Mahler, Jean Piaget,

Erik Erikson, John Bowlby and Sigmund Freud.

27


Life Cytle Stages

The Life Cycle represents stages from birth to death. There are three

assumptions about the progress through these stages.

1. Stages are completed in their given sequence.

2. Development proceeds only when an earlier stage is completed.

3. Each stage has a dominant feature, and various personality

difficulties can be caused by arrested development at this stage,

also know as fixation.

Margaret Mahler

Birth to 4 weeks: Normal Autistic Phase

Feature: Main task is to achieve equilibrium with the environment

4 weeks to 4 months: Normal Symbiotic Phase

Feature: Social smile

4 to 10 months: Separation Individuation — Phase I, Differentiation

Feature: Stranger anxiety (development of recognition memory)

10 to 16 months: Separation Individuation — Phase II, Practicing

Feature: Separation anxiety

16 to 24 months: Separation Individuation — Phase III, Rapprochement

Feature: The child wants to be soothed by mother, but may be unable to

accept her help

24 to 36 months: Separation Individuation — Phase IV,

Consolidation and Object Constancy

Feature: Able to cope with mother’s absence; finds substitutes for her

Jean Piaget

Birth to 2 years: Sensorimotor Phase

Schemata (patterns of behavior) dictate actions; the environment is mastered

through assimilation (taking in new experiences through one’s own knowledge

system) and accommodation (adjusting one’s system of knowledge to the

demands of the environment); object permanence is achieved by two years

2 to 7 years: Preoperational Phase

Feature: Uses symbolic functions; egocentrism; animism; magical thinking

7 to 11 years: Concrete Operations

Feature: Logical thinking emerges; able to see things from another’s point of

view; laws of conservation are understood

11 years to Adolescence: Formal (Abstract) Phase

Feature: Hypothetico-deductive reasoning used; able to understand

philosophical nature of ideas; more flexible thinking becomes possible

28


Erik Erikson

Birth to 1 year: Basic Trust versus Basic Mistrust

Feature. Consistency of experience provided by caretaker is crucial

I to 3 years: Autonomy versus Shame & Doubt

Feature. Learns to walk, feed self and talk during this phase; firmness of

caretaker, boundaries and guidelines are necessary before autonomy

3 to 5 years: Initiative versus Guilt

Feature: Mimics adult world; Oedipal struggles occur at this age, with

resolution via social identification

6 to 11 years: Industry versus Inferiority

Feature: Busy with building, creating, accomplishing; abilities in relation to

peers increase in importance

II years through Adolescence: Identity versus Role Diffusion

Feature: Preoccupied with hero worship and appearance; group identity

develops

21 to 40 years: Intimacy versus Isolation

Feature: Finding love and work are the key tasks

40 to 65 years: Generativity versus Stagnation

Feature: Guiding children/new generation prevents stagnation

Over 65 years: Integrity versus Despair

Feature: Satisfaction with accumulated productivity and accomplishments

John Bowlby

Birth to 12 weeks: Phase I

• Olfactory and auditory stimuli used to discriminate between people

• Initiates innate attachment behavior to any person — smiling, babbling,

reaching and grasping, which increase the time spent close to a caregiver

• Tracks movement with eyes; stops crying in the presence of a person

12 weeks to 6 months: Phase II

Feature: increased intensity towards the primary attachment figure

6 months into Second Year: Phase III

Feature: Attachment to mother more solid, uses her as a base from which to

explore; stranger anxiety towards others

2 years and beyond: Phase IV

Feature: Growing independence from mother; obtains sense of objects being

persistent in time and space; observation of adult behavior

29


Sigmund Freud

Birth to 1 year: Oral Stage

• Main site of tension and gratification is the mouth, including lips and tongue

• More aggressive with the presence of teeth after six months

1 to 3 years: Anal Stage

• Acquires voluntary sphincter control; anus and perineal area become the

major area of interest

3 years to 5 years: Phallic-Oedipal Stage

• Genital stimulation of interest; masturbation is common

• Intense preoccupation with castration anxiety

• In Freud’s theory, penis envy is seen in girls at this stage

• Oedipus Complex (desire to have sex with and marry opposite-sex

parent and dispose of or destroy same-sex parent)

5 to 11 years: Latency Stage

• Superego forms, the last part of the psychic apparatus (explained later)

• The id is present at birth and the ego develops as the child becomes

aware of the external world

• Sexual drives channeled into socially acceptable avenues

• Quiescence of sexual drive as the oedipal complex is resolved

11 to 13 years: Genital Stage

• Final psychosexual stage

• Biologically capable of orgasm and able to experience true intimacy

Freud shows Erickson that he has transcended stagnation.

30

What is Ego Psythology?

Introduition — Theoretical Printiples

In the early 1900’s, Freud published the Interpretation ofDreams and

developed his topographical theory which divided the mind into the

conscious, unconscious and preconscious. The unconscious contained

wishes seeking fulfillment that were closely related to instinctual drives,

specifically to sexual and aggressive urges. A type of thinking called

primary process was associated with the unconscious. Primary

process is not bound by logic, permits contradictions to coexist, contains

no negatives, has no regard for time, and is highly symbolized. This is

seen in dreams, psychosis and children’s thinking.

The preconscious was an agency of the mind that developed over

time and was involved in the censorship of wishes and desires. It

facilitated bi-directional access between the conscious and uncon¬

scious. The preconscious and conscious mind use secondary

process thinking, which is logical and deals with the demands of

external reality. Secondary process is the goal-directed, day-to-day

type of thinking used by adults.

Over time, Freud encountered resistance to his therapeutic interven¬

tions. Fie observed that patients defended themselves against the

recollection of painful memories. In the topographical model, the

preconscious was accessible to consciousness. Clearly, there was

an unconscious aspect of the mind responsible for repressing

memories. Freud incorporated his findings into his structural theory,

introduced with the publication of The Ego and the Id in 1923. This

theory postulated a tripartite structure containing the id, ego and

31


Present from birth, the id is completely unconscious and seeks gratifi¬

cation of instinctual (mainly sexual and aggressive) drives. The superego

forms via the process of identification with the same-sex parent at the

resolution of the oedipal conflict. It suppresses instinctual aims, serves

as the moral conscience in dictating what should not be done, and as

the ego ideal, dictates what should be done. The superego is largely

unconscious, but has a conscious element.

The ego is the mediator between the id and superego; and between

the person and reality. The ego has both conscious and unconscious

elements. The following are considered the conscious roles of the ego:

• Perception (sense of reality)

• Reality Testing (adaptation to reality)

• Motor control

• Intuition

• Memory

• Affect (visibly expressed emotion)

• Thinking (the ego uses secondary process) and Learning

• Control of instinctual drives (delay of immediate gratification)

• Synthetic functions (assimilation, creation, coordination)

• Language and Comprehension

The fundamental concept in ego psychology is one of conflict amongst

these three agencies. The id, ego and superego battle for expression

and discharge of sexual and aggressive drives. This conflict produces

anxiety, specifically called signal anxiety. This anxiety alerts the ego

that a defense mechanism is required, which is an unconscious role

of the ego. The events can be conceptualized as follows:

The id seeks expression of an impulse

*

The superego prohibits the impulse from being expressed

*

This conflict produces signal anxiety

An ego defense is unconsciously recruited to decrease the anxiety

Repression is the first defense used; others follow if required

A character trait or neurotic symptom is formed,

based in part on which other ego defenses are used

32

Introduction — Theoretital Principles

The consequence of an ego defense can be thought of as a compromise

which allows expression of the impulse in a disguised form. Such

compromise formations can be part of adaptive mental functioning but,

when pathological, are considered neurotic symptoms. Everyone, normal

or neurotic, employs a repertoire of defense mechanisms in varying

degrees. All defenses protect the ego from the instinctual drives of the

id and are unconscious processes.

Freud directed most of his attention to repression, which he

considered the primary ego defense. Repression is defined as expelling

and withholding an idea or feeling from conscious awareness. He

thought other defenses were used only when repression failed to

diminish the anxiety. Freud’s daughter, Anna, expanded the total to

nine in her 1936 book, The Ego and the Mechanisms of Defense.

Since then, many more defense mechanisms have been identified.

Akin to the theories of life cycle development, there is a progression

in the use of ego defenses with maturity.

George Vaillant catalogued defenses into four categories: narcissistic,

immature, neurotic and mature. Fuller explanations of these defenses

can be found in reference texts. The key defenses found in personality

disorders are discussed in the individual chapters.

Narcissistic Defenses

Denial

Distortion

Idealization

Projection

Projective Identification

Splitting

Neurotic Defenses

Controlling

Displacement

Dissociation

Externalization

Inhibition

Intellectualization

Isolation

Rationalization

Reaction Formation

Repression

Sexualization

Undoing

Mature Defenses

Altruism

Anticipation

Asceticism

Humor

Sublimation

Suppression

Immature Defenses

Acting Out

Blocking

Hypochondriasis

Identification

Introjection

Passive-Aggression

Regression

Schizoid Fantasy

Somatization

33


Mnemonic for Ego Defenses

“BUD HAS PRICE”

Blocking

Undoing

Denial, Displacement, Dissociation, Distortion

Hypochondriasis, Humor

Acting Out, Altruism, Anticipation, Asceticism

Schizoid Fantasy, Sexualization, Somatization, Sublimation

Suppression

Passive-Aggression, Projection, Projective Identification

Rationalization, Reaction Formation, Regression, Repression

Idealization, Identification, Inhibition, Intelluctualization, Introjection,

Isolation

Controlling

Externalization

From the book:

Psychiatric Mnemonics &

Clinical Guides, 2nd Ed.

ISBN 0-9682094-1-6


© Rapid Psychler Press, 1998

34

Introduttion — Theoretical Principles

Ego Defenses in Personality Disorders

An understanding of defensive mechanisms is essential for recognizing

and treating Axis II disorders. “Understanding the defenses of another

person allows us to empathize rather than condemn, to understand

rather than dismiss.” (Vaillant, 1992)

Personalities become disordered by the maladaptive use of ego

defenses, both in terms of which defenses are used, and the extent to

which they are used. A more detailed account of these defenses is

contained in the following individual chapters, where they are explained

in the context of the personality disorder to which they apply.

The major defenses used with the different personality disorders are

as follows:

Antisocial

Avoidant

Borderline

Dependent

Histrionic

Narcissistic

Obsessive-

Compulsive

Paranoid

Schizoid

Schizotypal

Acting Out, Controlling, Dissociation,


Inhibition, Isolation, Displacement, Projection

Splitting, Distortion, Acting Out, Dissociation,


Idealization, Reaction Formation, Projective

Identification, Inhibition, Somatization, Regression

Sexualization, Repression, Denial, Regression,

Dissociation

Idealization/Devaluation, Projection, Identification

Intellectualization, Undoing, Displacement,

Isolation of Affect, Rationalization

Projection, Projective Identification, Denial, Splitting,

Reaction Formation

Schizoid Fantasy, Intellectualization, Introjection,

Projection, Idealization Devaluation

Projection, Denial, Distortion, Idealization,

Schizoid Fantasy

35


Ego Defenses Illustrated

Repression is considered to be the principal ego defense and therefore

receives the largest drawing. This defense involves an active process

of excluding distressing material from conscious awareness, which

Freud thought was integral to the formation of psychological symptoms.

The “distressing material” can be further defined as consisting of an

instinctual impulse, an idea, and the accompanying emotion or affect.

For an example, let’s get oedipal. A boy may consciously be aware of

hating his father, an idea and emotion which are both too upsetting to

bear. If the idea reenters consciousness, it be altered so that rather

than the father being hated, a substitute is used such as another

authority figure. In this way, what is forgotten is not forgotten, and the

object of the strong feelings is symbolically linked to the original conflict.

Primary

repression

refers to stopping

an idea or affect

before it reaches

consciousness.

Secondary

repression

removes from

consciousness

what was once

experienced.

Suppression is

the conscious

avoidance of

attending to an

impulse or conflict.

For example,

primary repression

would involve not

reading this page in

the first place.

Secondary repression would be reading it and then forgetting what

was presented. Suppression would be consciously avoiding this book

because it reminds you of an unpleasant event (like an examination).

36

Introduttion — Theoretital Principles

Acting Out

Acting out involves the expression of unconscious impulses through

behavior in order to avoid experiencing the accompanying painful affect.

The action provides partial gratification of the wish rather than the

prohibition against it. For example, as a patient in psychotherapy nears

the end of treatment, unconscious fears of abandonment stemming

from previous relationships arise. The

patient may then “act out” by taking an

overdose rather than dealing with the

pain of feeling rejected. The action here

serves as a substitute for remembering

and is an unrecognized (unconscious)

repetition of earlier behavior. Acting out

entails more than a single thought or

behavior. The term is properly used to

describe an inappropriate response to

a current situation as if it were the

original one causing the conflict. The

term is often improperly used to

describe conscious, impulsive behavior.

This is more appropriately called acting

up or misbehaving, as the fellow on

the right is illustrating.

37


Controlling

Controlling is the unconscious

manipulation of events, people

or objects in the environment to

serve an inner need, such as

reducing tension or lessening

the anxiety accompanying a

conflict or conflicted wish.

Dissociation is the sudden and drastic alteration of an aspect of

consciousness, identity or behavior. It is a temporary state which allows

the person to avoid emotional distress.

Identification

In this defense mechanism,

patients adopt some, many or

all of the characteristics of

another peson as their own. As

an example, this mechanism is

familiar in the marketing of

sports equipment in that the

buyer feels an identification with

the professionals who use the

same brand(s), which lasts until

the first use of the item(s).

38


Displacement transfers the emotion attached to a conflicted wish or

relationship to one where expression is permitted, more acceptable, or

at least less forbidden. Common examples are kicking the dog or

shooting the messenger. The target of the discharge remains

symbolically linked to the original source of the conflict.

Introjection

This defense involves internalizing the image or qualities of a person.

39

Distortion

This involves

altering one’s

perception of the

environment by

replacing reality

with a more

acceptable version

in order to suit inner

needs.

The degree of

distortion can be

mild or can be so

severe that

psychosis develops.


Idealization/Devaluation

In idealization,

exceedingly positive

qualities (e.g.

beauty, strength,

skill) are ascribed to

another person.

Typically, the object

of the idealization

demonstrates the

desirable qualities

to some extent, and

is someone who can

provide comfort,

assistance,

empathy, etc., but

not to the

(unrealistic) level

desired by the

patient. If such

wishes are met to a certain extent, this only serves to increase

expectations, which

escalate to the point

where the idealized

person cannot possibly

meet them.

Inevitably,

disappointment results,

whereby the idealized

person is devalued far

out of proportion to the

actual “failure.” An

example of this is the hero

worship lavished on

movie stars or athletes.

They can do no wrong

until they snub you for an

autograph or don’t reply

to your tenth fan letter, at

which point they plummet

beneath contempt.

40


Inhibition

Inhibition is an unconscious confinement or restraining of instinctual

impulses. Here, the superego prevents the expression of an impulse

from the id. Inhibition has also been described as a conscious

mechanism which serves the similar purpose of helping avoid expression

of the conflicted wish, which would cause problems with the superego

(conscience) and/or other people.

Intellectualization

This defense involves the

extreme or exclusive use

of “thinking” to deal with

emotional issues. This has

also been referred to as a

“thinking compulsion.”

Attention is focused on

external matters,

inanimate objects or

irrelevant details to avoid

intimacy. Expression of

emotion is restricted or

absent. This is present in

an unempathic “just deal

with it” attitude, and is a

component of brooding where events are continually rehashed in a

distant, abstract, emotionally barren fashion.

41


Isolation of Affect

This defense, which is also simply called isolation, involves the

separation of an idea and its accompanying affect. The affect is

subsequently kept out of conscious awareness. The idea, stripped of

its emotional charge, is more easily dealt with on a conscious level.

Passive-Aggression

Passive-aggressive behavior refers to the expression of hostile feelings

in a non-confrontational

manner. Examples are

lateness, procrastination,

telling partial truths and

acts of omission rather

than commission that

obstruct others. The

passive and aggressive

elements are expressed

simultaneously.

This term was applied to

a discrete personality

disorder in the DSM-lll-

R, and was deleted

presumably because

these forms of behavior

are so common they can’t properly be considered a disorder.

42


Projection involves the casting out or “projecting” onto others the thoughts

or feelings that a person cannot tolerate as being his or her own. In the

example above, the man with the glasses blames his wife for having an

affair with the elderly gentleman, when he himself has been harboring

yearnings for another woman. This can also be summed up as, “a

good defense starts with a good offense.” By blaming others for their

sentiments and actions, the focus stays off the person doing the

accusing.

Splitting

This defense

divides

external

objects into

all-good or

a I I - b a d

categories.

Ambivalence

towards the

external object is not possible. Rapid shifts between these categories is

also seen, with little to no recall of the previous view or awareness of

the self-contradictory switch. Splitting can be directed towards a single

person, group of people, institutions, etc. Often only a minor or symbolic

event produces a shift in the split.

43


Projective identification is a difficult defense to conceptualize. A quick

analogy is that of a self-fulfilling prophecy. Here, unwanted aspects of

the self are “projected" onto others, and in a way that somehow applies

to them. In the illustration below, the patient can’t tolerate feelings of

being unlikable, so via projection, the therapist is accused of hating

her. This projection is “reasonable” because some patients are difficult

to work with, and in this instance there may have been an initial reaction

that felt like rejection to the patient. The patient then exerts interpersonal

pressure on the therapist to think and feel in a way that is in accordance

with the projection. Finally, once this projection is “processed” by the

therapist, it is reinternalized by the patient, and in this case, she makes

herself into a difficult patient. This defense is effective in making others

feel what the patient is experiencing.

44


Rationalization is the process of covering up unreasonable or

unacceptable acts and ideas with seemingly reasonable explanations.

Justification is provided for beliefs or behaviors that would otherwise

appear illogical, irrational or immoral.

Reaction

Formation

In this defense,

unacceptable

wishes are

transformed into

their complete

opposite. This

has also been

called reversal

formation, and

can be thought of

as socializing the

infantile urges

that persist on an

unconscious

level.

45

Regression involves the return to a previous (earlier) level of functioning

which can serve the purpose of conflict avoidance. It is easier to find

gratification at earlier stages of development, and it entails fewer

responsibilities. Regression can be seen to an extent in many inpatients

who because of illness cannot maintain their usual level of function,

and have fewer expectations placed on them while in hospital.

Schizoid

Fantasy

Fantasy is used

as a escape

and as a means

of gratification

whereby other

people are not

required for

emotional

fulfillment. The

retreat into

fantasy itself

acts as a means

of distancing

others.

46


Sexualization

Here, objects, situations and people are colored with sexual overtones

that were either not there initially, or if present were subtle. This can

help lessen anxiety by reducing everything to a base level, or assigning

a common element to unknown or uncomfortable situations.

Somatization

In this defense, psychological difficulties become expressed as physical

complaints. There is also a major psychiatric (Axis I) condition called

somatization disorder. Somatization is considered a form of regression

because expressing somatic problems verbally is a step in development.

Some family

situations and

cultures can

encourage

somatization in

that little

attention is

paid to

emotional

concerns,

thereby

facilitating

expression

instead in

physical terms.

47


Undoing

Undoing is an action instead of a psychological mechanism. The

behavior is linked to the conflict, and is carried out to prevent or reverse

the consequences that are anticipated from the impulse. Undoing can

be realistically or magically associated with the conflict and serves to

reduce anxiety and control the underlying impulse.

Denial

In this defense reality is simply ignored. Painful affects or memories

are avoided by the disavowal of sensory input. Denial can be a primitive

defense, but

it also has

adaptive

elements

and can be

useful in

coping with

serious

conditions or

traumatic

events.

48

Mature Ego Defenses


The preceding section is not a comprehensive presentation of ego

defenses, but an introduction to those that are relevant later in this

book. Everyone uses defense mechanisms to some extent because

there are elements which assist in ego functioning. For example, some

patients with terminal illnesses fare better with a moderate amount of

denial regarding their medical condition. Regression is an essential

ingredient in creativity, and the term regression in service of the ego

refers to instances where it is beneficial to allow one’s self to enjoy a

less demanding situation or experience. Mature ego defenses allow the

expression of impulses in socially acceptable ways.

Sublimation

This defense allows

the channeling of

aggressive impulses

towards a modified

outlet. Sports,

particularly those

involving body

contact, are an

example of

sublimated urges.

Anticipation

Anticipation involves the

postponement ofwishes

or impulses until they

can be more

appropriately

expressed. Discomfort

may result from

deferring action, but

satisfaction is achieved

from avoiding

unpleasant outcomes.

49


Attachment Theory & Object Relations Theory

As discussed, Ego Psychology proposes that sexual and aggressive

drives are innate, or primary, and relationships with people are

secondary. Here, the most important task is to discharge the tension

generated by these drives. Attachment theory and object relations

theory postulate that human drives are geared towards seeking

relationships instead of discharging primal urges. In these theories,

tension emerges in the context of frustrated relationships.

What is Attachment Theory?

The central concept in Attachment Theory is that close, positive

attachments are a fundamental human need. This theory posits that

the quality of early attachments to caregivers largely determines the

success of future relationships. Deprivation of early attachments, with

the loss, or threatened loss, of positive attachments to caregivers

creates a vulnerability resulting in adverse psychological reactions.

The outcome of these reactions can be a diverse array of emotional

conditions, including personality disorders.

A diagrammatic representation of the Causation of Psychological

Symptoms according to attachment theory appears on the next page.

If the innate need for close attachment is satisfied by pleasurable

interpersonal relationships (PIRs), normal growth and development

occur. If these needs are frustrated by disturbed interpersonal

relationships (DIRs), an inevitable drop in self-esteem is followed by

various consequences.

Withdrawing, or the flight response, involves:

• building interpersonal walls to diminish emotional pain

• developing work habits that compensate for other deficiencies, or

finding a structured “institutional” workplace as a substitute

• regressing to the need for earlier pleasures that don’t require other

people (these are often “oral” habits like smoking or drinking alcohol)

The fight response is one of aggression. Anger is a source of energy

that, if not used constructively, may be used against the self, causing

the emergence of suicidal feelings. Anger and hostility directed at others

bring about a potent sense of guilt. Accompanying this sense of guilt is

its unconscious analog — the fear of, or need for, punishment.

A third response is a creative effort, which involves learning how to

deal with DIRs in more adaptive ways.


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51


What is Object Relations Theory?

The word object in this theory is an unfortunate substitute for person.

Freud focused his attention on the subject who possessed the drives.

Object, in this context, referred to the person at whom the drive was

aimed. Object relations theory developed from the contributions of a

number of theorists, each with his or her own perspective. Some of the

key names associated with object relations theory are: Melanie Klein,

W.R.D. Fairbairn, Margaret Mahler, Otto Kernberg and Heinz Kohut.

Freud laid some of the groundwork for the development of this theory,

and in many ways object relations theory is a refinement and reshaping

of his ideas. There is no unified object relations theory. Each of the

contributors listed above had a particular focus, though there is a

common thread of agreement.

Central to an understanding of object relations theory is that interpersonal

contact becomes internalized as a representation of that relationship.

For example, at an early developmental stage, it is not the mother who is

internalized, but the whole relationship with her. This process is called

introjection. In object relations theory, an understanding of people and

what motivates them stems from an awareness of how relationships are

internalized and transformed into a sense of self or self-image.

52

Introduttion — Theoretital Printiples

Object relations theory postulates that the most important relationship

is with an early caregiver, most often the mother. The sense of alternating

gratification and deprivation occupies so much of the life of an infant

that this relationship becomes a template for subsequent relationships.

Consider the following interactions in a hungry infant:

Positive experience of mother:

Attentive caregiver

Positive emotional experience:

Satiated with milk

Positive sense of self:

Loved and cared for

Negative experience of mother:

Neglectful caregiver

Negative emotional experience:

Persistent hunger

Negative sense of self:

Frustrated and angry

These two sets of interactions are introjected as the good object

and bad object, partitioning or splitting the inner world of a child into

good and bad experiences. It is important to note that what is introjected

is the experience of the relationship, not necessarily the actual

relationship. For example, a loving mother attending to other

responsibilities might still be experienced as the bad object. Over time,

this influences the sense of self, or sense of being.

The notion of conflict in object relations is viewed as the clash between

the internalized representations of feelings, self and objects.

From this point on, the various contributors focused on different

applications of this theory — defense mechanisms (especially splitting

and projective identification), individual disorders (narcissistic and

borderline in particular) and parameters affecting development.

An individual may find a substitute in order to compensate for deficient

attachments. As a means of understanding substitution as symptom,

Steinberg (1995) has divided activities into three groups:

Direct Oral or Genital Somatic Satisfaction

• overindulgence in sex, food or alcohol/drug abuse

Narcissistic Satisfactions

• acquisition of fame/notoriety, money or power

Investment in “Institutions”

• excessive devotion to work, social causes, groups, or recreational

activities; close attachments to animals, plants or inanimate objects

53


Deficient attachment early in life influences our style of relating as

adults. Early relationships are internalized as a negative self-image

and negative view of others. This has a very strong influence on how

we relate to others and to whom we relate. These early relationships

tend to get repeated (a process called repetition compulsion).

The internalized image influences what is expected in future relationships

and how others are perceived. Internalized objects are projected onto

others. With a personality disorder comes an inability to realistically

evaluate others. This is most obvious when individuals expect someone

to behave a certain way when very little is known about that person.

This process is called transference and is explained in the next section.

Object Relations Tidbits

• Object Relations considers the substance of the human psyche to be

made of concerns about relationships, not discharging drives.

•Thefocus in Freud’s

theory was on the

father. By causing

castration anxiety in

boys and penis envy

in girls, the father

determines the

success of the

oedipal complex or

stage. In object

relations, the focus is

pre-oedipal and

centers on the

relationship with the

mother. This places

critical developmental

issues in the first

year of life instead of

in the fifth or sixth

year when oedipal

issues are thought to

emerge.

54

Basit Psychodynamic Principles


There are some time-honored principles that form the basis of

psychodynamic theory and give it a unique perspective on diagnosing

and treating personality disorders. As introduced earlier, the presence

of the unconscious is an integral part of this theoretical perspective.

Dreams and Freudian slips (parapraxes) are the two most common

ways the unconscious is accessed. Symptoms and behaviors are

visible extensions of unconscious processes that defend against

repressed wishes and feelings.

Experiences in childhood are considered crucial in the formation of

the adult personality. It is in these early years that the repetitive

interactions with family members are of etiologic significance in

personality disorders. Early patterns of relating to others persist into

adult life; in a sense, the past is repeating itself. This was aptly put by

William Wordsworth as “the child is the father of the man.”

Transference

In therapy, the process of transference involves a patient experiencing

the therapist as a significant person from his or her (the patient’s)

past. Feelings, thoughts and wishes that are projected onto the

therapist stem from a previous significant relationship. In this way, the

current therapeutic relationship is a repetition of the past. Properly

handled, transference is fertile ground for learning in psychotherapy.

Two key points characterize transference:

• the relationship is re-enacted in therapy, not just remembered; this

becomes more obvious when one focuses on the process of the

sessions with patients instead of only on the content

• the reaction to the therapist is inappropriate and anachronistic

Transference in not limited to therapy. It can be said that all

relationships are a combination of the real relationship and transference

reactions. Early attachments and internal representations of caregivers

are so firmly held that they color future interactions. In this way,

transference guides the relationships that people pursue. The

unconscious influences behavior to a larger extent than is often

appreciated. We seek out the type of relationship(s) with which we

are already familiar, which is the principle of psychic determinism.

However, people are not passive victims of their unconscious mental

processes. There is room for choice and conscious intention in bringing

about change, which is one of the goals in psychotherapy.

55


Countertransference

Harry Stack Sullivan said “we are all much more human than

otherwise.” Just as patients exhibit transference in their relationships

with therapists, the converse also happens. Therapists are (usually)

human beings who will, to some degree, unconsciously experience

the patient as someone from the past. While many definitions of

countertransference exist, Kernberg (1965) summed it up as “the

therapist’s total, conscious emotional reaction to the patient.” Whereas

a patient’s transference is grounds for observation and interpretation,

countertransference is not openly discussed in therapy. Constant

internal scrutiny on the therapists’ part is required to be aware of

countertransference reactions. Though it can be tempting to act on

such feelings, doing so only repeats the kind of relationship patients

have experienced, rather than giving them the chance to learn about it.

Instead, countertransference can be used diagnostically and

therapeutically. It gives a firsthand awareness of how patients interact

with others. Links (1996) lists countertransference reactions as a key

step in recognizing personality disorders:

•Isa symptom disorder present?

• Why is the patient seeking help?

• How does the patient make me feel?

56

Resistance


At some point in treatment, almost every patient exhibits a tendency

to oppose therapeutic efforts. Change is often accompanied by distress

because there is an internal drive to preserve the psychic status quo.

Whereas ego defenses are unconscious and inferred, resistance can

be conscious, preconscious or unconscious and is openly observed.

It can take many forms: lateness or absence from sessions, prolonged

silence, digression to irrelevant material, personal questions about

the therapist, “forgetting” the content of past sessions, avoidance or

failure to arrange payment, non-compliance, etc.

Resistance is a self-protective mechanism against experiencing strong

emotions. As therapy progresses, these “unacceptable” feelings

become less repressed and some type of resistance accompanies

their expression. Just as countertransference is used therapeutically,

resistance also provides important information. A psychodynamic

approach provides an opportunity to discover what the resistance is

concealing and what is being reenacted in therapy. Though the term

resistance suggests that it is an impediment, understanding resistance

is a large component of psychotherapeutic treatment.

Since personality disorders are interpersonal in nature, it follows that

interpersonal, “talking” treatments are the prime therapeutic modality.

By understanding the processes of transference, countertransference

and resistance, the therapeutic relationship can be used to increase

the awareness of how past relationships (object relations) affect current

relationships, thus encouraging conscious decisions about changing

maladaptive patterns of interpersonal behavior.

57


What is Cognitive Therapy?

A cognition is a verbal or visual representation that comes into

consciousness when one is confronted with a situation. Specifically, it

is what one thinks in the situation and not about the situation. This type

of therapy was developed by Aaron Beck and is based on his

observation that “an individual’s affect and behavior are largely

determined by the way in which he or she structures the world.” Beck

originally developed this approach for use in depressive disorders. He

found that the style of thinking depressed patients exhibited reinforced

a negative view of themselves, the world and their future (the cognitive

triad of depression). Cognitive techniques are now available for many

conditions, including personality disorders.

Cognitive therapy is short-term, structured and interactive. It has a

“here and now” focus and is geared to solving current problems. The

assumptions on which cognitive therapy is based are as follows:

Cognitions represent a synthesis of internal and external stimuli

Individuals structure situations based on their cognitions

Emotional and behavioral changes are caused by cognitions

Cognitive therapy elicits an awareness of “cognitive distortions”

Correction of these distortions leads to improved functioning

Adjusting the

“cogs” in

Cognitive

Therapy.

58

Basic Concepts


The genesis of a personality disorder, and some Axis I disorders, is

biased information processing, called a schema. In essence, those

with personality disorders think differently than those who aren’t af¬

fected. The way that information is synthesized forms the type of dis¬

order manifested (e.g. anxious people interpret the world as threaten¬

ing, depressed people visualize hopelessness, etc.). Both genetic and

environmental contributions predispose patients to interpret experi¬

ences in an altered way, which can initiate the disorder.

Basic Strategies

The process of cognitive therapy involves an agreement between

patient and therapist to explore and modify dysfunctional beliefs, called

collaborative empiricism.

The next step involves the elucidation of certain themes that run

through a patient’s misperceptions. Like psychodynamic therapies, con¬

nections are made to previous experiences, so the development of

the disorder can be understood. This is called guided discovery.

Patients keep a diary of their negative thoughts or automatic as¬

sumptions. This becomes the focus of the therapy session. These

conclusions are constantly evaluated, subjected to scrutiny and reality

testing, and then refined. The initial goal of cognitive therapy is to have

these automatic assumptions become more neutral or benign so that

emotional and behavioral reactions are lessened.

Socratic questioning guides the patient and therapist to understand

the problem and examine the consequences of maintaining maladap¬

tive thoughts and behaviors. When patients see the illogical or false

aspects of their beliefs, they are encouraged to alter them in a more,

adaptive and reasoned way. A cognitive shift occurs when patients

gain a more realistic and reasoned approach to processing informa¬

tion. This is facilitated by the exploration of maladaptive assumptions,

testing their validity (reality testing) and altering them when alternative

explanations or contradictory evidence are presented.

At the beginning of each session, the therapist sets the agenda, checks

and assigns homework, and introduces new skills. Behavioral techniques

are practical interventions designed to change maladaptive strategies,

such as: scheduling activities, graded task assignments, rehearsal, selfreliance

training, role playing and diversion techniques.

59


Some Cognitive Distortions

Arbitrary inference: drawing a specific conclusion without supporting

evidence, or in the face of contradictory evidence

Selective abstraction: seeing a situation in terms of a single detail

and ignoring other possibilities

Overgeneralization: developing a "rule” after a small or isolated num¬

ber of incidents and applying it broadly and to unrelated situations

Personalization/Excessive Responsibility/Self-Reference: attribut¬

ing external events to one’s self without evidence supporting the con¬

nection

Magnification/Minimization: seeing something as being much more

or much less significant than it is in reality

Dichotomous Thinking: seeing experiences as being all good or all

bad; a complete success or an utter failure

Catastrophizing: using a small setback as evidence of gross failure

Assuming temporal causality: seeing an artificial or coincidental

connection between events

Course of Cognitive Therapy Sessions

Early:

• initiate relationship

• elicit information

• define problem, generate list, and discuss expectations

• explain the type of therapy

• assign homework — recognize the connection between feel¬

ings and behavior

(e.g. count certain thoughts, record automatic thoughts)

Mid:

Later:

• focus on patterns of thinking

• make connections between thoughts, emotions and behavior

• challenge thoughts that interfere with functioning; progress

towards altering the underlying assumptions

• the patient takes a more active approach to homework

• time-limited; 10-25 sessions, can go on for several months

• date of termination is discussed in the first session

• with the instillation of a new approach to thinking about

difficulties, patients learn to “become their own therapist”

60

Introduttion — Theoretical Prindples

What is Croup Therapy?

Group therapy is an effective form of treatment for many disorders.

Virtually any type of individual therapy is possible in a group setting:

supportive, cognitive-behavioral, interpersonal, analytically oriented or

educational. Groups can be set up on an inpatient or outpatient basis,

be open or closed to new members, be time-limited or open-ended,

and have heterogeneous or homogeneous compositions.

Group therapy is an efficient treatment modality. In an age where the

resources for therapy are under greater scrutiny, groups are gaining

popularity and, in some cases, are an economic necessity.

While some personality-disordered patients do well in a group setting,

others do not. It is important to keep in mind that within a given

diagnosis, there is a range of functioning that should be considered

when determining suitability for group therapy.

Group therapy is different from The Bob Newhart Show or the movie

Color of Night. A group has an identified leader or therapist who uses

strategic interventions and interactions between members to facilitate

change. Unlike individual therapy, a group provides opportunities for

immediate feedback from peers. Also, the group functions as a micro¬

society and is perhaps a more “normal” setting in which to view patients’

interactions. This is valuable, because it allows the therapist and the

patient to observe transference reactions to a wider variety of people.

Groups conducted for personality disorders are generally ongoing and

open to new members. Ideally, a group has eight to ten members.

Sessions are ninety minutes to two hours, once or twice per week.

Socialization outside the group is discouraged, as is participation in

concurrent therapy not involving (or not known to) the group therapist.

The theoretical basis for treating personality disorders in groups is

usually analytical. There are several powerful therapeutic factors

operative in group therapy settings:

• Cohesion

• Altruism

• Universality

• Acceptance

• Socialization

• Catharsis

• Identification

• Validation by other group members

• Corrective emotional/familial experiences

• Learning from group members

• Internalization

• Instillation of hope

• Existential factors

• Imitation of other members

61


Interventions in group therapy are the same as in individual

psychodynamic psychotherapy, though they can be initiated by

members as well as the therapist(s):

• Confrontation — calling attention to a trait that the person was

previously unable to see; confrontations do not address motivation,

they are made to point out the behavior; the group situation is

particularly effective at bringing about a change in those confronted.

• Clarification — group members become adept at noticing repeating

patterns in sessions; clarification brings particular actions into focus.

• Interpretation — interpretations are designed to make unconscious

processes conscious, thereby revealing underlying motivations or

conflicts; they help the patient attach a significance to events, feelings,

behaviors, motivations and conflicts.

Group psychotherapy provides an opportunity for interpretations to be

made on a group-as-a-whole and an individual basis.

Peer interpretations can be particularly valuable, as members

frequently have less difficulty learning about themselves with input

from other group members. However, peer interpretations have a

higher chance of being incorrect, poorly timed, or somehow skewed.

In general, groups function more smoothly when members direct their

attention to confrontation and clarification, leaving the more delicate

matter of interpretation to the group leader.

62


What is Interpersonal Therapy?

Interpersonal therapy (IPT) focuses on the interactions between the

patient and significant others. In IPT, is it assumed that personality

disorders result from disordered relationships. The central aim in therapy

is to elucidate and alter the inadequate, inappropriate and self-defeating

means of communicating with current family members, the family of

origin, present romantic partners and friends.

As with other theories, there

is no single approach to IPT.

Harry Stack Sullivan is

widely regarded as the

pioneer in examining the

effect of relationships on

functioning. In his view, an

infant is fundamentally

sociable, with a basic need

for both emotional and

physical contact. Stack

Sullivan sought to make

connections between a patient’s perceptions of early experiences and

current character traits. He sought to elicit interpersonal distortions

and unwarranted preconceptions through active interviewing. His

countertransference reactions, speculative interpretations and other

provocative means were used in the interview to get a sense of a patient’s

interpersonal style.

IPT was originally developed as a short-term treatment for depression

by Gerald Klerman and Myrna Weissman. There have been other

theorists involved in adapting it for personality disorders: Timothy Leary,

Lorna Benjamin, Donald Kieslerand Jerry Wiggins.

Benjamin (1993) has presented a

comprehensive model that takes into

consideration behavioral, intrapsychic and

social factors. She calls this the Structural

Analysis of Social Behavior (SASB),

providing hypotheses about personality traits

and their social origins. Like other

interpersonal theorists, she has developed

a circumplex, or an organizational circle of

personality traits (the example shown is not from Benjamin’s work).

63


Treatment (interpersonal change) comes about in IPT as a result of

several interventions (listed sequentially):

increased collaboration between patient and therapist

making links between past and current relationships,

and the effects the former have on the latter

4'

preventing the repetition of self-defeating patterns of interaction

4

motivating patients to abandon destructive patterns

4

facilitating the learning of new ways of interacting

Another facet of IPT is being aware of what patients with personality

disorders hope to accomplish in relationships (prototypic wishes):

Antisocial:

Avoidant.

Borderline:

Dependent:

Histrionic:

Narcissistic:

Paranoid.

Obsessive-

Compulsive:

Schizoid:

Schizotypal:

No one gave me anything but grief, so I seek to take

charge and get what I want.

I feel ashamed of the way I am and get embarrassed

by my awkwardness, but I do yearn for acceptance.

Being alone means I can be violated again, which I

am still angry about, but don’t you dare leave me.

Anything you want to do is fine, just include me.

Tell me I’m wonderful and you’ll always adore me.

Am I not the best you’ve ever seen? You should be in

awe of my talents, connections and power.

You will exploit me as soon as I let down my guard.

If I show you how perfectly I can do things, then you’ll

want me around to improve things for you.

Please leave me alone, I am uncomfortable with you.

Convention has hurt/bored me. There are other ways

of explaining what goes on — let’s find them.

A unique facet of IPT is learning the social consequences of expressing

affect, neediness or illness. For example, a central theme in borderline

personality disorder is abandonment and the white-hot anger that ensues

when there is even the possibility of being left alone. For example, a

borderline personality-disordered patient is faced with having a spouse

leave on a business trip that he or she cannot attend. The feeling of

panic becomes overwhelming and anger is used to coerce the spouse

into providing the desperately needed nurturing. The patient needs to

learn that the anger only serves to distance the spouse and may lead to

real abandonment, and that there are more effective ways of seeking

reassurance about being loved than forcing others into a certain role.

64

Integrating Therapeutic Strategies


Intrapersonal

FJerceptiori

Interpersonal

Society/

Environment

*

*

Occupational

Functioning

*

Social

Functioning

All psychiatric disorders can be considered in terms of aberrations of

perception, affective state, cognition and behavior. By definition, these

conditions impact on a individual’s ability to function at work and in

relationships (again, using Freud’s test of mental health as being “to

work and to love”).

In addition to this general scheme, there are specific aspects that

apply to personality disorders:

• The ego defenses employed are either primitive or used to an

exaggerated extent; however, psychotic defenses are not used (i.e.

personality disorders are not considered psychotic disorders).

• In order to successfully treat patients with moderate-to-severe

personality disorders, it is often necessary to intervene at as many

“entry points” in the above scheme as possible.

65


Summary

Millon (1996) includes an important proviso with regard to various theories

and treatments of personality disorders:

Concepts are not reality. They are not inevitable and true representations of

the objective world. The conceptual language of a theory is an optional tool

utilized to organize observable experience in a logical manner, (p. 11)

Many theories exist on the etiology and treatment of personality

disorders. Initial approaches stemmed from psychoanalytic concepts

(called psychodynamic psychotherapy). While this theory certainly

has its merits, it has deficits as well. Recent theories have led to more

humanistic, relationship-based therapies, many with structured, timelimited

approaches which are increasingly important in today’s climate

of managed care and limited resources.

Based on the diagram on the previous page, there are several places

where interventions can be made. A simplified view is as follows:

• perception

• thinking

• feeling

• behaving

• social functioning

• occupational functioning

psychoactive medication

cognitive therapy

psychodynamic psychotherapy

behavior therapy

group & interpersonal therapy

skills training

Accordingly, these are the types of therapy outlined in this book. It is

important to note that the above divisions are artificial. For example, a

patient’s feelings are as important in cognitive therapy as his or her

thoughts are in psychodynamic psychotherapy. One of the functions of

the above scheme is to show that changing one facet affects the whole

system. The ultimate goals of treatment are: symptom reduction,

improvement in social and occupational functioning, and effecting a

change in the way a person responds to the environment (e.g. thinking

differently, acting differently, feeling differently, etc.). Treatment

approaches vary in terms of which aspects are deemed important. Some

focus on past events, some on the here-and-now vicissitudes of the

relationship with the therapist; some on conscious thoughts and others

on unconscious motivation. While no type of therapy is clearly “better”

than than any other, successful therapy depends on the skill of the

practitioner and on the application of the type(s) of treatment(s) that

address the needs of the patient. Facility with several approaches is

helpful, as combined treatments are often necessary.

66


Referentes


Diagnostic and Statistical Manual of Mental Disorders, Fourth

Edition


A. Beck, A. Freeman & Associates

Cognitive Therapy of Personality Disorders


L. S. Benjamin

Interpersonal Diagnosis and Treatment of Personality

Disorders


R. Campbell

Psychiatric Dictionary, Seventh Edition

Oxford University Press, New York, 1996

J. Derksen

Personality Disorders: Clinical & Social Perspectives

Wiley & Sons, New York, 1995

G. Gabbard

Psychodynamic Psychiatry in Clinical Practice: The DSM-IV Ed.


W. N. Goldstein

A Primer for Beginning Psychotherapy








O. Kernberg

Notes on Countertransference

J. of the American Psychoanalytic Assoc. 13: p. 38 - 56, 1965

67


P. S. Links, Editor

Clinical Assessment and Management of

Severe Personality Disorders


W. J. Livesley, Editor

The DSM-IV Personality Disorders


T. Millon with R. D. Davis

Disorders of Personality: DSM-IV and Beyond, Second Edition

Wiley & Sons, Inc, New York, 1996

J. Mount

Causation of Psychological Symptoms

Personal Communication, 1995 Revision

R. W. Pies

Clinical Manual of Psychiatric Diagnosis and Treatment


J. S. Rutan & W. N. Stone

Psychodynamic Group Psychotherapy, Second Edition


L. Sperry

Handbook of Diagnosis and Treatment of the DSM-IV Personality

Disorders


P. Steinberg

The Psychodynamic Formulation

Personal Communication, 1995

G. Vaillant

Ego Mechanisms of Defense


J. E. Young

Cognitive Therapy for Personality Disorders:

A Schema Focused Approach, Revised Edition

Practitioner’s Resource Press, Sarasota, FL, 1994

Review Questions

Introduction — Theoretical Printiples

1. Match the following statements to the corresponding theoretical

approach:

a) “You feel sad every time you see an elderly man with a pocket

watch.

b) “You have been feeling anxious about ending your current

relationship, which has caused you to sleep and eat poorly. Also, you

tell me that your concentration has been poor and you’ve been

preoccupied by thoughts of guilt.”

c) “You appear to have an innate tendency to not be able to suppress

your urges, and this has been a large factor in your substance use

and legal difficulties.”

d) “Your repressed wish to defy authority manifests itself as

procrastination when you have a deadline assigned by your boss.”

e) “You were admired for your good looks and talent, which became

the focus for your self concept. In this way you continue to expect that

your attractiveness will give you leverage with others.

f) “You view the world as a hostile place where the law of the jungle

applies — do unto others before they do unto you."

g) “Regardless of how you are feeling at a particular moment, try

greeting your husband with a smile and a hug.”

1. Cognitive Therapy 2. Psychoanalytic Psychotherapy

3. Behavior Therapy 4. Interpersonal Psychotherapy

5. A Biophysical Approach 6. Social Skills Training

7. A Phenomenologic Approach

2. Match the cognitive distortion with the ego defense that it most

closely resembles:

Magnification

Minimization

Dichotomous Thinking

Selective Abstraction

Splitting

Intellectualization

Denial

Distortion

3. Which are not considered therapeutic factors in group therapy?

a) One member telling the others how he or she solved a problem.

b) Empowering insightful members as co-therapists.

c) The group telling a chronically late member how upset they are at

his or her behavior.

d) The group pitching in to help a member move from one apartment

to another.

69


Answers to Review Questions:

1. f — Cognitive Therapy

d — Psychoanalytic Psychotherapy

a — Behavior Therapy

e — Interpersonal Psychotherapy

c — A Biophysical Approach

g — Social Skills Training

b — A Phenomenologic Approach

• Social skills and biological aspects of personality are described in

the next chapter

• Phenomenology is the study of happenings and events, and seeks

to classify illnesses by the symptoms subjectively experienced and

consciously reported. This is a method of classification and does not

infer cause.

References

R. Campbell

Psychiatric Dictionary, Seventh Edition





2. Magnification — Distortion

Minimization — Denial

Dichotomous Thinking — Splitting

Selective Abstraction — Intellectualization

3. Option a is imitation, which is the conscious mimicking of another

person. This can be a powerful and helpful aspect of group therapy

(when it is unconscious, it is called identification). Option c is

confrontation, which is also a therapeutic factor. The other options

are not considered therapeutic, but do occur in group therapy. Generally,

members who attempt to become “co-therapists” are not participating

in the group process, regardless of how accurate their comments are.

This behavior is dealt with by the group leader. Contact outside group

sessions is generally discouraged because not all members can

participate (losing the group-as-a-whole experience), and schisms or

allegiances form between members, which impairs progress.

Reference

J. S. Rutan & W. N. Stone

Psychodynamic Group Psychotherapy, Second Edition


70

Why Did the Chitken Really Cross the Road?


Paranoid Personality

Schizotypal Personality

Schizoid Personality

Antisocial Personality

Borderline

Histrionic

To commit an act of unprovoked

aggression.

To embark on a new astral plane.

This was the only kind of trip society

would let it take.

If you saw me coming, you’d cross

the road too!

It wanted to take out its revenge on

Colonel Sanders.

No one would notice if it just stood

there.

Narcissistic I know that chicken, I helped her

achieve stardom.

Obsessive Personality

Avoidant

Dependent

It was the logical next step in avian

evolution.

The chicken crossed the road and

that’s good enough for me.

It was facing the road less traveled,

and that was too much for this chicken.

71


The Mutation of Ego Defenses

In his structural theory of the mind, Freud divided the psychic apparatus

into the id, ego and superego. The ego, being the “middle child” in this

arrangement, was set up to get nailed from both sides. Strategy dictates

that a strong offense starts with a strong defense. Freud appreciated

the need for defense mechanisms for the ego, and duly noted

repression to be the mother of all defenses. A further cataloging of

ego defenses was provided by his daughter Anna, and Valiant1 efforts

have led to several more. Just as Freud’s Drive Theory was overrun by

Objectionable Relations Theory2 and Selfish Psychology3, ego

defenses have had to mutate to adjust to contemporary demands.

Narcississy Defenses

Old: Primitive Idealization New: American Expressization

Explanation: The ultimate expression of “plasticity," they allow the ego

to function autonomously from the superego until the end of the month.

Old: Projective Identification New: Primate Identification

Explanation: Used by over-socialized egos (primarily male) to seek

psychic equilibrium through the imitation of primate behavior.

Old: Denial

New: Alibido

Explanation: An amalgamation of two other defenses, alibi and libido,

with the first usually covering up the actions of the second.

Premature Defenses

Old: Acting Out

New: Acting

Explanation: This allows the ego to make the most of the “as if

personality by assuming identities of fictitious characters. Combined

with relocation, this can be a lucrative defense.

Old: Regression

New: Digression

Explanation: The spontaneous use of irrelevant and dated material in

a rambling and verbose style, thus ensuring complacency in others.

Old: Passive Aggression New: Passe Aggression

Explanation: Here, the ego becomes embroiled in the social milieu

and struggles of a prior decade in order to avoid facing the demands

of the current one. Some decades (particularly the 1960’s) seem

heavily favored for use with this defense.

72

Post-Mature Defenses


Old: Controlling

New: Remote Controlling

Explanation: The ego is now able to achieve remarkable control over

the external environment with this new defense. Not only is it effective

with electrical devices, it can cause marked changes in humans as

well.

Old: Displacement

New: Relocation

Explanation: This defense allows the ego to displace itself across

municipal, county and federal lines as a way of avoiding confrontation.

It may be that egos using this defense cluster geographically (e.g.

Hollywood).

Old: Isolation

New: Insulation

Explanation: An evolved defense that now gives the ego materials

with which to perform the isolating. The use of urea-formaldehyde

insulation was one of the early misapplications of this defense.

Old: Humor

Explanation: No comment.

Victor Mature Defenses

New: Humor

Old: Altruism

New: Trumanism

Explanation: Plainly stated, this enables the ego to have hard cash,

as well as responsibility, seek a final resting place on a desk.

Old: Suppression

New: Supper-ession

Explanation: The (usually unilateral) decision to postpone attention to

a conscious impulse, at least until after dinner.

References

1 Valiant, Prince George: The Hierarchy of Ego Defenses

Journal of Medieval Psychology: Round Table Press, New England

2 Maggie, Melanie and Bill

Driven to Detraction: Objectionable Relations Theory

British School Publishers: Grate Britain

3 Kohutek, Heinz

From Lilliputian to Kohutian: The Advancement of Self Through

Selfish Psychology

Chapter 1: Heinz 57 Manual of Therapeutic Interventions

Mirror on the Wall Press: New York

73


Personalities 'R Us Corporate Structure

Senior Management

President

Narcissist

Vice-President

Paranoid

Personnel

Borderline

Middle Management

Advertising

Histrionic

Legal Department

Antisocial

Research

Schizotypal

Customer Service

Passive-Aggressive

Workforce (with preferred hours)

Dependent

Whenever Told

Obsessive

Day & Night

Schizoid

Nights Only

Avoidant

Undesirable Shifts

74

Introduttion:

The Biologieal Dimension


75


What Does the Term "Psythosomatit" Mean?

Despite the relatively recent use of the term psychosomatic, the con¬

cept of unity and a reciprocal relationship between the health of the

mind and the health of the body has existed since antiquity. Ancient

societies appreciated the presence of a cause-and-effect relationship

between mind and body. Illnesses were deemed to involve social and

emotional factors and often thought to have magical or religious origins.

Accordingly, efforts to treat diseases were largely based on such be¬

liefs and on the faith that the afflicted person had in the spiritual healer.

The power invested by society in such shamans, as well as their inter¬

personal qualities, were the curative factors in these relationships.

PSYCHOSOMATIC

Psychosomatic medicine

is concerned “holistically”

with the whole patient —

the effects of the mind on

the body and vice versa.

PSYCHE

The study of the psyche be¬

came divided — the “mind” by

philosophers and the “soul” by

theologians. The emotional

aspects of illness (both caus¬

ing and resulting from physical

illnesses) are difficult to sub¬

stantiate objectively, and are

seen as unscientific because

of the high degree of variabil¬

ity from person to person

SOMA

Virchow, the founder of mod¬

ern pathology, stated that

“disease has its origin in dis¬

ease of the cell” in that:

• subcellular components

are affected by disease,

altering cellular function and

eventually structure

• tissue and organ changes

are observable on a micro¬

scopic and macroscopic level

76

Introduction — The Biological Dimension

With the disintegration of ancient Greek and Roman civilizations, the

concept of illness was viewed as resulting from personal, societal or spiri¬

tual causes. Religious causes in particular (i.e. sinning) were consid¬

ered the dominant factor in the etiology of illness. Until the Renaissance,

religious figures were the ones principally involved in treating sickness.

Eventually, the advances made in other scientific fields led to the dis¬

covery that certain illnesses had demonstrable organic findings. Autop¬

sies revealed that tissue and organ changes, rather than those in the

spiritual realm, caused or were associated with diseases. The use of

the microscope detected pathological changes on a cellular level. This

started an era where the causes for illnesses were elucidated, the patho¬

logical findings correlated and remedies sought — which shifted

medicine’s focus to treating the illness instead of the patient.

Freud, a neurologist by training, worked with Charcot in Paris. This gave

him first-hand experience with hysteria, a condition in which Charcot

was especially interested. Freud observed that hypnotic suggestion could

cause hysterical (physical) manifestations, which started him thinking

about hysteria having a psychological origin. He was instrumental in link¬

ing hypnosis and neurology, and ultimately psychology to neurophysi¬

ology.

The terms psychosomatic and psychosomatic medicine still carry

considerable ambiguity. Lipowski (1984) traced the historical uses of

these terms, and offers the following definitions:

• psychosomatic — refers to the inseparability and interdependence of psycho¬

social and biologic (physiologic) aspects of humankind

• psychosomatic medicine — refers to the discipline concerned with: a) the

study of the correlations of psychological functions, normal or pathologic, and

of the interplay of biologic and psychosocial factors in the development, course,

and outcome of diseases; and b) advocacy of a holistic (or biopsychosocial)

approach to patient care and application of methods derived from behavioral sci¬

ences to the prevention and treatment of human morbidity

Lipowski stresses that there have been two enduring aspects of psy¬

chosomatic medicine:

• the holistic conception — refers to the treatment of the whole patient by focus¬

ing on emotional/psychological factors in addition to the somatic/physiologic (this

is contained in the definition of psychosomatic)

• the psychogenic conception — refers to the mental or psychological etiology

of an illness


The Biopsythosotial Model

As an application of psychosomatic principles, Engel (1967,1977) pub¬

lished an integrated approach to understanding the multifactorial influ¬

ences on the causation and course of illnesses. A balanced and

comprehensive view of the etiology (also called a formulation) and treat¬

ment of illnesses can be made using this model:

Predisposing

Precipitating

Perpetuating

Protective

Some of these factors are intuitively obvious. Physical illnesses, by defi¬

nition, involve biological aberrations. For example, cirrhosis or

Alzheimer’s Disease show characteristic pathologic findings in the liver

and brain cells, respectively. However, there are psychosocial factors

involved in medical illnesses, such as the issue of stress (Type A per¬

sonalities) in heart disease or emotional upset in psoriasis flare-ups.

Psychiatric disorders are still often referred to as “functional” in that no

“organic” impairment has been consistently demonstrated. Nevertheless,

there are biological bases for some mental illnesses, ranging from con¬

ditions which are clearly genetically based (e.g. psychosis in Wilson’s

Disease, an inherited defect in copper metabolism) to those that are

more speculative, such depression following a head injury. Many Axis I

conditions are now being found to have genetic associations (e.g. genes

associated with bipolar mood disorder are thought to be on chromo¬

somes 5, 11 and X). There are also physical findings associated with

many major psychiatric disorders, for example:

• eye pursuit movement abnormalities in schizophrenia

• endocrine and sleep abnormalities in depression

• metabolic irregularities in certain brain regions in patients with obses¬

sive-compulsive disorder

• the majority of patients presenting with a conversion disorder go on

to develop bona fide neurologic disorders within several years of the

onset of their psychiatric symptoms

78


The Biopsythosotial Management Plan

A management plan for psychiatric conditions is included below and on

the following pages. While this is a comprehensive plan designed to ad¬

dress the salient parameters for Axis I conditions, many of these fac¬

tors apply to patients with severe personality disorders (who are

frequently hospitalized) and to patients who have personality changes

induced by physical illnesses, substance use or the side effects of medi¬

cations or other treatments.

Biological

Social

Investigations

• Admission physical exam

• Diagnostic tests:

Routine: hematologic and clinical chemistry

admission/screening bloodwork

Toxicology: serum medication levels; urine

screen forsubstances of abuse

Special assays

• Diagnostic investigations: CXR, EKG

• Neuro-imaging: CT, MRI scans

• EEG

• Consultations to other medical/surgical specialties

• Special tests:

hypothalamic/pituitary/adrenal axis testing

(DST, TRH stimulation test, GH response)

sleep studies

• Collateral history:

friends and family members

primary care physician

community psychiatrist

other clinics, programs or hospitals

• Activities of Daily Living (ADL) assessment

• Referral to members of multidisciplinary team

social worker

occupational therapist

physiotherapist

dietician

clergy

nurse clinician

Psychological • Personality and Intelligence tests

• Cognitive screening tests (e.g. Mini-Mental State

Exam, Clock Drawing, etc.)

• Neuropsychological test batteries

• Structured interviews/diagnostic testing

79


Treatment — Short Term

Biological

Social

Psychological

• Psychopharmacology

antidepressants

antiparkinsonian agents

antipsychotics

anxiolytics

mood stabilizers

psychostimulants

sedative/hypnotics

others

•ECT

• Other psychiatric treatments

• Somatic illnesses

medications

physical treatments

• Detoxification from medications or substances

• Environmental

level ofobservation

passes

attire (pajamas or street clothes)

seclusion rooms

mechanical restraints

objects to assist with orientation

• Social services

assistance with housing, finances, etc.

• Education and focus/support groups

• Occupational therapy

• Family meetings

• Administrative

voluntary/involuntary status

rights/legal advice

duty to warn/duty to protect others

treatment contracts

informing work/school ofabsence

obtaining consent ifpatient incapable

• Advice/Reality Therapy

• Behavior Therapy/Modification

• Cognitive Therapy

• Group Therapy

• Milieu Therapy

• Recreation Therapy

• Stress Management/Coping Skills

• Other therapies with a shorter-term focus


Treatment — Longer Term

Biological

Social

Psychological

• Reduction/optimization of dosage

• Depot antipsychotic medications

• Monitoring vulnerable organ systems

• Serum level monitoring

• Adjunct/augmentation/combination treatments

• Reducing factors affecting efficacy of medication

nicotine

caffeine

liver enzyme inducers

others

• Health teaching and lifestyle changes

‘Vocational rehabilitation

• Religious guidance

• Community supports and organizations

• Discharge planning

transfer to another facility

housing considerations

case manager

• Liaison with general practitioner

• Psychotherapy

continuation ofinpatient therapy

outpatient treatment

• Match various types of therapies to needs and

attainable goals for the patient

• Skills Training

Comprehensive Management Parameters

Investigations

Short-Term

Treatment

Longer-Term

Treatment

81


Biology and Personality

The concordance rate for schizophrenia in monozygotic (identical) twins

is about fifty percent. Put another way, when one twin develops this ill¬

ness, the other will only do so half the time. This condition exists as a

paradigm in psychiatry for conditions where biological and psychoso¬

cial influences are equally important.

Loehlin (1982) has shown that personality traits (not disorders) also have

heritability on the order of fifty percent. Thus, biochemical forces in the

form of hormones, neurotransmitters and many other compounds exert

an important effect on mental processes. In order to further examine

the biological dimension of personality, temperament and character must

be differentiated:

Temperament

Temperament is the genetic or

constitutional contribution to

personality. It refers to an

individual’s inherited disposition

to feel, act, and think in specific,

restricted ways.

Character

Character is derived from the

Greek word for “engraving.” It

refers to the distinctive qualities

of a person that are learned or

develop through socialization

and experience.

Personality

Personality is considered a blend of

temperamental and characterological factors.

Temperament and character can be differentiated by the two long-term

memory systems in the human brain, procedural and declarative:

Procedural

• involves the cortico-striatal re¬

gions of the brain

• preverbal (presemantic) pro¬

cessing of perceptions

• visuospatial and emotional as¬

pects are stored here

• can operate independently of

declarative memory

• called “knowing how” memory

• unconscious/instinctive

Declarative

• involves the cortico-limbic-diencephalic

regions of the brain

• experiences are represented

as words, images and symbols

• these memories are factual;

can be consciously retrieved, ex¬

pressed verbally and lead to in¬

tentional action

• called “knowing what” memory

• conscious/uses reason


Character development, covered in the previous chapter, is concerned

with learned psychosocial influences, socialization and formation of

basic beliefs and concept of self. Character is often referred to in

terms of Freud’s psychosexual stages (oral, anal, etc.) or in terms of

which ego defense mechanisms are thought to be operative. Character

is considered to be linked to declarative memory and temperament

with procedural memory, where it is processed on an unconscious,

preconceptual level. Temperamental factors are considered heritable

and are manifested before significant learning occurs. Chess & Thomas

(1986), Sigvardsson (1987) and Kagan (1988) have shown that

temperamental traits range from moderately to substantially predictive

of behavior/personality style later in life.

Establishing core temperamental factors is a subject of intense research

and debate. Chess & Thomas (1986) identified nine “autonomic”

reactions in the behaviors of infants:

• activity level — degree of motor behavior

• adaptability — facility with which behavior is modified to match

changes in the environment

• approach or withdrawal — quality of the response to new stimuli

• attention span and persistence — length of time engaged in an

activity and degree of continuation when faced with obstacles

• distractibility — degree to which extraneous stimuli divert attention

• intensity of reaction — degree to which emotions are expressed

• quality of mood — degree of socially engaging behavior

• rhythmicity — stability of cyclical behaviors, such as sleeping, eating,

elimination, etc.

• threshold of responsiveness — the minimum level of stimulation

required to evoke a reaction

Most other authors identify between three and seven temperamental

factors, with five-factor models being the most popular. Eysenck &

Eysenck (1976) identify three dimensions of temperament: neuroticism,

extraversion-introversion and psychoticism (or tough-mindedness).

Instead of psychoticism, Tellengen (1985) suggested constraint and

Costa & McCrae (1992) openness to experience. Conscientiousness

and agreeableness are also frequently included in five-factor models.

Cloninger (1987) identified three dimensions to temperament: novelty

seeking, harm avoidance and reward dependence, and then added

persistence as the fourth quality in Cloninger (1993). Costello (1996)

added aggressiveness and behavioral inhibition to this list.

83


Among the theories contributing to the understanding of temperament,

Cloninger’s (1987) is the most germane to this book. He argues that

while the DSM-IV considers the five different axes, it has the following

shortcomings regarding personality disorders:

• often more than one diagnosis is applicable

• there is an arbitrary division between style and disorder

• the behaviors listed in the diagnostic criteria, in general, are socially

undesirable, so defensiveness and minimization are common

The last point is particularly cogent. Even among individuals with some

insight into the effects of their actions, it can be difficult to get clear

enough information to make a diagnosis. Because these disorders are

egosyntonic, and the locus of responsibility is often seen as being

outside of the person, researchers continually seek more direct, stand¬

ardized methods of assessment applicable across cultures.

Cloninger sought temperamental factors that would prove to be

biologically independent, span the range from adaptive to pathological,

and have an application to current diagnostic nosology. For example,

the factors involved in the Millon Multiaxial Clinical Inventory are:

“negativistic-avoidant," “asocial-avoidant,” and “paranoid,” which do

not exist on a continuum with adaptive traits. The Eysencks’ criteria do

not correspond with either DSM-IV or ICD-10 diagnostic criteria.

Furthermore, Gray (1982) demonstrated that sedative medications such

as alcohol or benzodiazepines reduce both neuroticism and introversion,

suggesting that they are not biologically independent.

Most inventories are able to explain personality variation with the use of

three variables. Those delineated by Cloninger (1987) are:

• harm avoidance — an inherited response to inhibit behavior leading

to punishment, novel situations or frustration

• novelty seeking — a genetic tendency involving exploratory activity

leading to exhilaration or other rewards, or behavior that will avoid

drudgery, monotony or punishment

• reward dependence — the constitutional tendency to respond to

rewarding situations and to maintain behaviors that continue gratifica¬

tion or bring relief from punishment

Cloninger also suggested that the above sequence represents a

phylogeny of temperamental factors in that harm avoidance is a basic

quality in all animals. With more evolved species comes novelty seek¬

ing and then reward dependence, which maintains key behaviors.


These temperamental factors can be illustrated as follows:

Novelty Seeking

behavior activation

for unfamiliar

situations

Behavior

Inhibition

leads to passively

avoidant behavior

Reward

Dependence

conditions

behavior

Cloninger went on to develop detailed descriptions for each of these

three dimensions, which he scored on a seven-point scale:

-3 (severely low)

-2 (moderately low)

-1 (mildly low)

0 (average) 68.2% 95.4% 99.7%

+1 (mildly high)

+2 (moderately high)

+3 (severely high)

Cloninger’s rating system corresponds with standard scores on a

gaussian distribution. He was able to demonstrate that these three

dimensions are independent, allowing for a flexible and integrated pattern

of response to varying conditions of novelty, reward and punishment.

Cloninger set up a grid with high and low aspects of each dimension.

Then, personality characteristics were derived from the blending or


overlap of the intersecting temperament dimensions (e.g. impulsivity is

a blend of high novelty seeking and low harm avoidance).

High Novelty Seeking

Impulsive

Conflicted

Low Harm Avoidance

High Harm Avoidance

Buoyant

Rigid

Low Novelty Seeking

High Novelty Seeking

Opportunistic

Vain

Reward Independence

Reward Dependence

Modest

Authoritarian

Low Novelty Seeking

Reward Dependence

Impressionable

Submissive

Low Harm Avoidance

High Harm Avoidance

Imperturbable

Alienated

Reward Independence

86


Personality characteristics/behaviors can then be correlated with DSM-

IV diagnoses by amalgamating the corners or intersections of the pre¬

ceding three diagrams:

• Antisocial Personality Disorder

Impulsive, Opportunistic, Imperturbable

Novelty Seeking — high, Harm Avoidance — low, Reward Dependence — low

• Dependent Personality Disorder & Avoidant Personality Disorder

Rigid, Authoritarian, Submissive

Novelty Seeking — low, Harm Avoidance — high, Reward Dependence — high

• Histrionic Personality Disorder, Borderline Personality Disorder &

Narcissistic Personality Disorder

Impulsive, Vain, Impressionable

Novelty Seeking — high, Harm Avoidance — low, Reward Dependence — high

• Obsessive-Compulsive Personality Disorder

Rigid, Modest, Alienated

Novelty Seeking — low, Harm Avoidance — high, Reward Dependence — low

• Schizoid Personality Disorder

Buoyant, Modest, Imperturbable

Novelty Seeking — low, Harm Avoidance — low, Reward Dependence — low

• Schizotypal Personality Disorder

Buoyant, Authoritarian, Impressionable

Novelty Seeking — low, Harm Avoidance — low, Reward Dependence — high

This scheme does an impressive job of categorizing DSM-IV personal¬

ity disorders with only three temperament characteristics, though it

has clear limitations. First of all, with only three variables, a maximum

of eight disorders can be described. In Cloninger’s article, he included

two conditions that were not presented here because they are not in

the DSM-IV (the passive-aggressive and explosive personality disorders).

No formulation was provided for the schizotypal or paranoid

personality disorders, which he felt best classified as variants of

psychotic disorders. Finally, this scheme is not able to clearly

differentiate between some of the disorders that fall in the same cluster

(such as the avoidant and dependent personalities from Cluster C).

Cloninger’s article used descriptions of up to seven characteristics for

each of the interactions (corners) between the temperament dimen¬

sions (this was not done here because of space limitations).

87


Revising this three-factor model, Cloninger (1993) established persist¬

ence as a fourth temperamental factor, defined as perseverance despite

frustration and fatigue. It was initially formulated as an aspect of reward

dependence, but emerged as a distinct factor.

In order to develop a model that made distinctions between personality

disorders and that also distinguished such disorders from Axis I

disorders, Cloninger derived a seven-factor model using the above

four dimensions of temperament and three dimensions of character:

• self-directedness — the intentional drive of an individual to commit

to a goal or value and to regulate or adapt behavior in accordance with

achieving this aim

• cooperativeness — acceptance of other people and willingness to

assist them in achieving their goals without selfish domination

• self-transcendence — seeing the unity or totality of a situation and

one’s part in its evolution; spirituality and a union with nature

Cloninger found that common to all the personality disorders were low

degrees of self-directedness and cooperation, though these were not

helpful in distinguishing between disorders. Self-transcendence was

not as sensitive in establishing the presence of a personality disorder,

but was helpful in distinguishing schizotypal (high transcendence)

from schizoid (low transcendence) personality disorder.

An instrument called the Temperament & Character Inventory (TCI)

was developed to test the validity of these constructs. This is a selfreport,

true-false questionnaire consisting of 226 items: 107 questions

relating to the four temperament dimensions and 119 measuring the

three character dimensions. The results support the above-described

dimensions, and an application of the seven-factor model for diagnosing

personality disorders is presented in Svrakic (1993).

Akin to the hierarchy of temperamental factors, the three character

factors can be considered as a progression in development, as follows:

• self-directedness — identification as an individual

• cooperativeness — identification as part of a society

• self-transcendence — identification as part of a larger order

Cloninger concludes by speculating that there are genetic factors that

are as important in character development as they are in temperament.

This can help explain the variation seen between individuals who persist

with maladaptive behaviors and those who are able to change them.

88

Introduetion — The Biological Dimension

Addressing Temperament in Treatment

The work of Cloninger and others has provided convincing evidence to

support the hypothesis that personality development may be hierarchical,

and may consist of temperament and character dimensions, which are

thought to involve different memory systems.

Temperament is most strongly influenced by genetic determinants, while

character is shaped more by experience. Character can be considered

a rational, cognitive or schema-based dimension. In contrast,

temperament involves processes that are more automated, such as

perception and habits.

The main goals in treatment are:

• symptom reduction

• improvement in social and occupational functioning

• effecting a change in the way a person responds to the environment

The last point can be subdivided into treatments specifically targeting

either character or temperament dimensions.

Many psychotherapies focus specifically on aspects of character. For

example, Cloninger’s three character factors are addressed by the

following types of therapy:

• self-directedness — psychodynamic psychotherapy, cognitive therapy

• cooperativeness — interpersonal psychotherapy, Rogerian counseling

• self-transcendence — Jungian analysis, meditation

Sperry (1995) and Freeman & Davison (1997), among others, herald

a paradigm shift in the treatment of personality disorders toward a

focus on both character and temperament dimensions. Furthermore,

dysregulation in temperament and coping skills may well need to be

addressed before dimensions of character can be treated.

For example, patients with moderate to severe borderline personality

disorders manifest many of the following behaviors:

• self-mutilation, suicidal gestures and attempts

• shoplifting and other impulsive acts

• substance abuse and other self-damaging acts

• intense but brief relationships which can include promiscuity

• pervasive moodiness with abrupt shifts in emotional state that lack

clear precipitants

89


Such patients manifest dysregulation of temperamental factors more

prominently than dysregulation of character. While both aspects require

treatment, temperamental factors would impair or prohibit therapy aimed

only at dimensions of character. Specifically, these patients need to

curb their tendency to action (impulsivity), control their emotional “roller

coasters” (unmodulated affect) and become aware of how their behavior

affects others. Put another way, they must first stop “acting out” their

difficulties before deeper issues (e.g. neglect, abuse, trauma) can be

dealt with.

A simplified way of delineating treatment is that psychodynamic and

cognitive therapies address character dimensions and behavioral

therapies (skills training) are geared towards temperament dimensions.

A list of treatments for temperamental dysregulation is as follows:

• emotional expression aspects

too much

Anger Management Training

Anxiety Management Training

Distress Tolerance Training

Emotional Regulation Training

Impulse Control Training

Sensitivity Reduction Training

too little

Empathy Training

identification

Emotion Awareness Training

• behavioral aspects

Self Management Training

• relational aspects

Interpersonal/Social Skills Training

Assertiveness Training

Role Playing

• perceptual/cognitive aspects

Cognitive Awareness Training

Problem Solving Skills

Symptom Management Training

Thought Stopping

90


Personality Disorders as Milder Forms of Major

Psythiatrit Disorders

A major area of research in psychobiology involves conceptualizing

personality disorders as being on a continuum with Axis I disorders,

which is called the dimensional model. A useful analogy is that of

someone being heterozygous for a single gene disease — often called

mendelian diseases — such as Huntington’s disease or cystic fibrosis.

Those who have a mixture of one affected and one unaffected gene

may show an illness to a lesser extent (forme fruste) or not at all.

As described, major psychiatric disorders can be illustrated as distur¬

bances in four key areas of function:

«-

Society/

Environment

*

Cognition *

Occupational

Functioning

Social

Functioning

This scheme is helpful in conceptualizing the basic aberration in an

illness. For example, schizophrenia can be considered primarily an

illness of perception/cognition, which is commonly expressed by

symptoms such as delusions, hallucinations and abnormal speech.

However, there are also characteristic changes in affective state

(flattening of emotional responses) and behavior (disorganized or

catatonic) that are key elements of this condition.

91


Combining the cognitive and perceptual aspects into one domain allows

the derivation of the central scheme for major psychiatric disorders:

Abnormal Findings

Form of Thought

• flight of ideas

• loosening of

assocations

• derailment

• blocking

Content of Thought

• delusions

• overvalued ideas

Perception

• hallucinations

• illusions

• depersonalization

• derealization

Abnormal Findings

Affect is defined as

the visible, external

or objective

manifestions of

emotional state;

it refers to the

observation of

momentary changes

in emotions.

Mood refers to the

subjective, internal

emotional state; it is

the pervasive tone

displayed over time;

it is described by

the patient.

Abnormal Findings

There are many

aberrations of

behavior that are

seen in Axis I

disorders (e.g. tics,

compulsions,

catatonia, etc.).

For the purpose of

this presentation, a

disorder of behavior

can be considered an

extreme along the

continuum of being

either too prone or

too inhibited to act in

everyday situations.

Axis I Conditions

• schizophrenia

• delusional disorder

Axis I Conditions

• mania (mood too

high)

• depression (mood

too low)

Axis I Conditions

• impulse-control

disorders (deficit in

behavioral inhibition)

•anxiety disorders

(excess of

behavioral inhibition)

If the degree of severity of the symptoms of Axis I conditions is lessened,

there is an overlap with the core features of personality disorder clusters

as follows:

• Schizophrenia/Psychotic Disorders — Cluster A: odd, eccentric,

socially detached

• Mood Disorders/Impulse Control Disorders — Cluster B: transient

shifts in emotional state are more related to affect than mood; aggressive

actions and impulsivity are characteristic of some of these disorders

• Anxiety Disorders — Cluster C: avoidance of potentially aversive

consequences; low tolerance for anxiety; overly constrained behavior

92


The Mental Status Examination (MSE)

The previous section highlights the need to perform a mental status

examination on all patients regardless of the diagnosis. The MSE is the

part of the interview where cognitive functions are tested and inquiries

are made about the symptoms of psychiatric conditions. It is a set of

standardized observations and questions that evaluate perception,

thinking, feeling, and behavior. The MSE records only the observed

behavior, cognitive abilities and inner experiences expressed during the

interview. A mnemonic for the MSE is as follows:

“ABC STAMP LICKER”*

Appearance

Behavior

Cooperation

Speech

Thought — form and content

Affect — visible moment-to-moment variation in emotion

Mood — subjective emotional tone throughout the interview

Perception — in all sensory modalities

Level of consciousness

Insight & Judgment

Cognitive functioning & Sensorium

Orientation

Memory

Attention & Concentration

Reading & Writing

Knowledge base

Endings — suicidal and/or homicidal ideation

Reliability of the information supplied

Typical MSE findings for each personality disorder are included in the

individual chapters.

* From the book:

Psychiatric Mnemonics & Clinical Guides, Second Edition


© Rapid Psychler Press, 1998

ISBN 0-9682094-1-6, softcover, 160 pages

93


Rationale hr the Use of Psythotropit Meditation

Based on the presentation up to this point, there are three main as¬

pects of personality disorders that provide the basis for using

psychotropic medication:

• the dimensional model with Axis I Disorders

• alteration of genetic/temperamental factors

• concomitant Axis I & Axis II Disorders

The Dimensional Model

In the dimensional model discussed earlier, the association between

the personality disorder clusters and the corresponding Axis I disorders

is more than theoretical. Siever (1991) listed a number of physical

findings (biological markers) common to both major psychiatric and

personality disorders:

Cognitive/

Perception

• eye movement (tracking) abnormalities

• impaired task performance

• neurotransmitter abnormalities

• anatomic changes

• brain electrical abnormalities

Impulsivity/

Aggression

• impaired task performance

• neurotransmitter response to stimulation

• electrical changes in skin conductivity

Emotional

Instability

• sleep architecture changes

• neurotransmitter response to stimulation

mAnxietv/

lAlwlyi

■Inhibition

■ l l 1 1 w l 11 V1 1

R

• autonomic response (heart rate)

• orienting responses

• physical response to stimulation

Not all of the above biological findings are present in patients with either

major psychiatric or personality disorders, but there is enough of an

overlap to give credence to the dimensional model. Given that there are

effective pharmacologic treatments for many of the Axis I conditions, an

argument can be made to treat the shared, underlying biological/genetic

mechanisms in personality disorders with the same medications.

94


Another view based on the dimensional model considers symptoms

common to both Axis I and Axis II conditions. Symptom-focused

treatment extracts component symptoms from the patient's presenting

complaints. These personality symptoms are then treated

pharmacologically according to the recommended management for

major psychiatric disorders. For example:

Each ofthe features common to these disorders is amenable to treatment

(to a greater or lesser extent) with medication. This approach seeks to

extract symptoms related to genetic, structural or neurochemical

changes (in essence, the biological from biopsychosocial

amalgamation) and treat them pharmacologically. Features such as

disturbances in interpersonal relationships, limited insight and poor

judgment are not treatable by medication. A partial list of symptoms

that are amenable to pharmacologic intervention is as follows:

Symptom

• anhedonia/dysphoria

• anxiety

• impulsivity/ADHD

• insomnia

• mood swings

• perceptual disturbances

• substance abuse

Medication Category

antidepressants

anxiolytics

mood stabilizers, stimulants

sedative/hypnotics

mood stabilizers, antidepressants

antipsychotics

naltrexone, disulfiram

Further symptom elucidation and specific medication strategies will be

presented in the individual personality chapters.

95


Genetic/Temperamental Factors

The initial three temperamental factors presented in Cloninger (1987)

can be related to the action of a key neurotransmitter:

Principal

Neurotransmitter

Dopamine

Dopaminergic tracts

in the brain receive

input from several

areas and then

project to the

forebrain where

they are involved in

behavioral

activation.

Dopamine release

is enhanced by

amphetamine and

cocaine use, and is

considered an

integral part of the

brain’s “reward

system.”

Principal

Neurotransmitter

Serotonin

Serotonergic tracts

are mainly in the

rostral and caudal

raphe nuclei. They

project to three main

areas in the brain:

• basal ganglia

(movement)

• limbic system

(emotion)

• cerebral cortex

(cognition and many

other functions)

Serotonin has been

linked to violent and

suicidal behavior.

Principal

Neurotransmitter

Norepinephrine

Noradrenergic cells

arise from the locus

ceruleus and project

to the hypothalamus

and limbic system.

Norepinephrine is

thought to be a key

factor in learning

and some memory

functions. In this

capacity, it prevents

the forgetting of

behaviors that were

previously

rewarded. It has

many connections

to serotonergic

neurons.

While this presentation may be reductionistic, it is useful in linking

some of the key neurotransmitters involved in psychiatric disorders to

genetically based behavior. Cloninger (1987) provides a more elegant

explanation of this association, as do Bates & Wachs (1994).

Coexisting Axis I & Axis II Disorders

Personality-disordered patients are more likely to develop Axis I disorders

than the general population. Mood, anxiety and substance-related

disorders are common comorbid conditions. Major psychiatric

disorders complicate the treatment of personality disorders and vice

versa. Ascribing symptoms to one particular condition can be difficult,

if not impossible, to sort out. Features such as age of onset, chronicity

and severity of symptoms are not generally helpful in distinguishing

personality disorders from major psychiatric conditions.

96


A personality disorder, which may well be the priority for treatment, is

often overlooked when an Axis I disorder coexists. Assigning a sepa¬

rate axis for personality disorders (starting with the DSM-III) helped

highlight the need to consider this situation.

Axis I and II disorders can have a reciprocal effect on each other. For

example, a patient with a dependent personality disorder can quite

foreseeably become depressed when a relationship ends. Conversely,

a lifetime of suffering from a condition such as agoraphobia could

quite reasonably be seen as causing aberrations in personality devel¬

opment that would fall into the “dependent” realm.

In general, a coexisting personality disorder has the following effects on

major mental illnesses:

• earlier age of onset

• worsening of the course (including suicide attempts)

• poorer and less predictable response to treatment

• higher rate of recurrence/relapse of the illness

• lowered compliance with treatment for either condition

• the personality disorder often improves with treatment of the Axis I

disorder

The symptoms of a personality disorder may need to be addressed first

if they interfere with the treatment of other conditions. For example, the

socially controlling behavior exhibited in narcissitic personality disor¬

der can negatively influence participation in group therapy for sub¬

stance abuse. In some illnesses (e.g. schizophrenia), some personal¬

ity disorders are excluded from consideration because the effect of

the illness is so severe that aberrant personality formation is presumed

to occur as a matter of course. Hogg (1990) investigated the preva¬

lence of personality disorders at the onset of schizophrenia and found

that over half the patients had personality disorders, the most common

being schizotypal (21%), and then borderline and antisocial (15% each).

Substance use disorders present a “chicken or egg” dilemma about

cause and effect. Vaillant (1983) asserted that maladaptive interper¬

sonal characteristics arise from alcoholism. Others have argued that

patients who abuse alcohol are more likely to have a pre-existing anti¬

social or borderline personality disorder (which often affects recov¬

ery). For example, in non-personality disordered patients, a “socially

positive milieu” (e.g. a party) increases the chance of relapse, while in

patients with borderline personality disorder, a negative event (e.g. an

argument) is more likely to trigger the resumption of consumption.

97


Selection ofMeditation

The following two brief cases will be used to illustrate the delineation of

target symptoms for treatment with medication:

Case 1

A forty-year-old female news reporter has been paired with the same

male camera operator for several years. Although their contact was

exclusively work related, she felt a growing closeness and, given that

they were both unattached during this interval, hoped that a relation¬

ship would start. When he announced his engagement to another

woman, she accused him of leading her on and wasting her most

“eligible” years. She threw her microphone at him and complained to

the station manager that the quality of his work had deteriorated to the

point that she could no longer work with him.

Case 2

Norman is a fifty-year-old male systems administrator who works for a

company with offices across the nation. While the caliber of his work

was satisfactory, he was frequently transferred, at either his own or his

supervisor’s suggestion. This happened so often than his reputation

usually preceded him. Upon starting at yet another new office, some

mischievous co-workers altered the lettering on his cubicle to the name

"Nomad,” which upset him greatly. He became constantly on the alert

for other practical jokes and refused to join his colleagues for lunch so

he wouldn’t have to leave his desk unattended.

The following target symptoms can be extracted from these histories:

Psychosocial

Temperamental

Case 1 limited insight affective instability

poorjudgment

impulsivity

Case 2 interpersonal difficulties suspiciousness

rejection sensitivity

social withdrawal

Dividing presenting symptoms into psychosocial/character and biologi¬

cal/temperamental characteristics helps focus treatment interventions.

There is a small but growing number of studies showing that patients

with personality disorders have different neuroendocrine responses than

controls (Siever, 1992; Steinberg, 1994) and on this basis may warrant

a trial of medication in addition to psychotherapy and skills training to

address the temperament dimension.

98


Expanding on the work of Siever & Davis (1991), the selection of medi¬

cations can be made according to the following scheme:

Dimension

of Pathology

Personality

Cluster

Associated

Neurotransmitter

Category of

Medication

Cognitive-

Perceptual

A Dopamine Neuroleptics

Impulsivity-

Aggression

B

(ASPD, BPD)

Serotonin

Selective

Serotonin

Reuptake

Inhibitors

(SSRIs)

Affective

Instability

B

Cholinergic/

Noradrenergic

Tricyclic Anti¬

depressants

(TCAs);

Monoamine

Oxidase

Inhibitors

(MAOIs)

Anxiety-

Inhibition

C Biogenic Amines Benzo¬

diazepines

SSRIs,

MAOIs

• Neuroleptics, also called antipsychotic medications, are principally

used for the acute and prophylactic treatment of psychotic disorders.

There are over ten different classes of these medications; however, a

popular distinction is made between “traditional” and “novel” agents

based on their mode of action. Traditional agents block the action of

dopamine at dopamine type 2 (D2) receptors. Novel or atypical agents,

also referred to as serotonin-dopamine antagonists (SDA), each

have a unique profile of receptor subtype affinities.

• Mood stabilizers include of lithium and anticonvulsant medications.

The principal indications for these agents are the acute and chronic

treatment of mood disorders; however, there are a considerable (and

growing) number of other indications for these medications. Mood sta¬

bilizers are especially useful in treating bipolar disorders but have also

been found helpful for unipolar (major) depression. Not all anticonvulsants

have uses in psychiatric disorders — the two currently in greatest use

are carbamazepine and valproate (divalproex).

99


• Antidepressant medications also encompass a wide range of differ¬

ent chemical categories and have a considerable number of uses be¬

yond treating depression. Tricyclic antidepressants (TCAs) and

monoamine oxidase inhibitors (MAOIs) were the first two categories.

Other agents have modifications to the tricyclic structure and are known

as heterocyclic antidepressants (HCAs). Selective serotonin reuptake

inhibitors (SSRIs) and the newest agents (from various categories)

have been increasingly used in the treatment of personality disorders.

• Sedative/Hypnotics are also called anxiolytics and “sleeping pills,”

respectively. The anti-anxiety agents are dominated by the group called

the benzodiazepines, of which the most common is diazepam (Valium®).

Some benzodiazepines, as well as other medications that have less of

a chance of causing dependence (addiction), are also indicated for

treating insomnia.

• Other medications used in treating personality disorders include stimu¬

lants, anticholinergic agents and opiate antagonists. Many case

reports have been published advocating the use of certain agents and

combinations of medications.

Medication Points ®

• One of the many intriguing aspects of psychopharmacology is the

multitude of uses not only for categories of medications, but for indi¬

vidual agents. For example, aside from mood disorders, antidepres¬

sants are useful for treating chronic pain, sexual dysfunction, premen¬

strual syndrome, some “organic” syndromes and eating disorders, and

for enuresis, sleepwalking and night terrors in children. Lithium is use¬

ful as a mood stabilizer and antidepressant, as well as for decreasing

aggression and in the treatment of cluster headaches.

• Where possible, it is best to avoid medications that have a high

potential for lethality in overdose or addiction, or become dangerous in

combination with other medications or with substances of abuse. The

TCAs are the most worrisome because they can cause a cardiac rhythm

disturbance, which is usually the terminal event in a lethal overdose.

• As the severity of a personality disorder increases, higher doses or

combinations of medications may be required.

Specific treatment strategies are presented in the individual personality

chapters.

limitations in the Use ofMeditation


Overall, there is a paucity of methodologically sound studies showing

the clear efficacy of medications in the treatment of personality disor¬

ders. In summary, no specific pharmacologic intervention has been

consistently shown to be effective for a specific personality disorder or

a particular constellation of symptoms. Borderline personality disor¬

der has been the focus of the majority of reports, with the schizotypal

personality disorder being the second most studied condition, due to

its presumed genetic association to schizophrenia.

The relative lack of controlled studies is not necessarily a reason to

avoid using medication. Studies showing the unequivocal effective¬

ness of many types of psychotherapy are still awaited, as is a clear

rationale for choosing a particular type of psychotherapy for an indi¬

vidual patient. A considerable clinical lore (anecdotes and case re¬

ports) has developed regarding the response of individual patients. At

this point in time, there is no reliable way of knowing which patients will

predictably respond to particular medications. Further, a significant

placebo effect is operative in the treatment of personality disorders.

Published reports, studies and texts contain a wide range of attitudes

toward the use of medications in Axis II conditions. Many caution against

the widespread use of pharmacologic agents, and none advocate us¬

ing medication without some form of concurrent psychotherapy.

The rationale for using medications in the treatment of personality disor¬

ders is based on two main areas of research:

• the dimensional model, where personality disorders are considered to

be on a continuum with Axis I disorders (which have well-established

pharmacologic treatments); the more closely the symptoms of a per¬

sonality disorder resemble those of an Axis I condition, the more likely

the response to medication

• relating specific psychopathology to the action of specific neurotrans¬

mitters, as in the work of Cloninger (1987) and Siever & Davis (1991); in

this view, symptoms are not grouped into DSM-IV diagnoses, but in¬

stead according to which neurotransmitter is putatively linked to the

dysfunctional behavior. In other words, rather than saying “antidepres¬

sants are useful for patients with borderline personality disorders” this

approach would be expressed by a statement such as “patients with

reduced impulse control may benefit from a trial of mood stabilizing

medication."

101


WhatAbout "Chemical Imbalances"

The term “chemical imbalance” has become a popular explanation for

many mental and emotional disorders. While perceptions, cognitions,

emotions and behaviors are chemically mediated events (via neurotrans¬

mitters), the term lacks specificity and does little to indicate the source

of the imbalance. While “genetics” or “stress” are common explana¬

tions for the onset of chemical imbalances, this places too little empha¬

sis on elucidating psychosocial precipitants for DIRs, and does not

foster introspection or the development of insight. Keeping a

biopsychosocial perspective keeps a balanc^£urbs the temptation to

look for simple explanations and quick fixes to life’s problems.

Special Considerations

Timing and Introduction of Medication

It is generally advisable to discuss the possibility of using medication at

the outset of treatment. Patients can be told that certain symptoms

may be more amenable to medical treatment, may be treated faster

pharmacologically, or that complications can arise during psychotherapy

(e.g. depression) that will require medication.

It is important to avoid the perception that medication is being given as

a last resort. The successful use of medication is influenced by the

therapist’s confidence in these agents and the way they are intro¬

duced into treatment. If a referral for medication is made because of

an impasse in therapy, pessimism about the efficacy can come from

either the therapist or the prescriber. Similarly, at times of crisis, con¬

siderable pressure can be put on prescribers to “do something.” Be¬

cause medications can be switched, increased or decreased quickly,

this often becomes the desired (or at least easiest) intervention. Be¬

cause most crises are interpersonal in nature, adjusting medication is

unlikely to be effective and can deleteriously affect treatment. Wher¬

ever possible, it is best to define specific symptoms or symptom com¬

plexes as the target of medication and not deviate from this when inter¬

personal storms arise.

It also important to explain the role and limitations of medications. For

example, many agents have a delayed onset of action, have predict¬

able side effects and be substituted with another agent if the person

doesn’t respond. Silk (1996) provides a comprehensive guide to the

use of medications in patients with personality disorders.

102

Medication as an Entity


In general, patients with personality disorders can be seen as being

fixed at a less-developed level of functioning. Akin to children using

teddy bears as symbolic reminders of their parents (transitional ob¬

jects), patients can come

Patient

to view the pill or tablet

as a symbolic reminder

oftheir therapist. Patients

Prescriber A k Medication may see^ medication in

order to receive a tan¬

gible item and/or some¬

thing that will remind them

of the therapist between

sessions.

Patients may begin to speak about their medication as a kind of talis¬

man. The pill or tablet can be seen as a dependable ally that is there for

the patient night and day. A strong attachment can develop toward

certain medications or dosages, and for this reason considerable re¬

sistance can develop to stopping the prescription even when there is

little biochemical benefit in continuing the medication.

Separate Providers

In situations where the therapist does not have prescribing privileges,

medications will need to be provided by someone else, usually a psy¬

chiatrist or family doctor. Even among psychiatrists, many choose to

treat patients with either psychotherapy or pharmacotherapy and refer

patients elsewhere for the other type of treatment.

This sets up a four-way interaction, with each dimension having its

own transferences:

Patient

103


In such instances, mutual respect for each other’s abilities and com¬

munication between the two professionals is essential. For example, a

psychotherapist may see pharmacotherapy as a blunt instrument with

which to treat patients, while a biologically oriented psychiatrist may

see psychotherapy as an inefficient means of treatment. Having a work¬

ing knowledge of each field and being appraised of the limitations of

each specialty helps keep these disparate forms of treatment in per¬

spective. Ultimately, the goal is the well-being of the patient, which is

assisted by respecting professional differences.

In some cases, treatment with medication promotes a faster resolution

of symptoms than with psychotherapy. This situation can create a spe¬

cial challenge. The patient may feel symptomatically better, for ex¬

ample, after a few doses of anxiolytic medication or a few weeks of

taking an antidepressant, and not wish to return to psychotherapy.

Even short-term, structured therapies last at least several weeks and

may cause a period of initial worsening as patients become increas¬

ingly aware of the effects of their actions and of the maladaptive nature

of their interpersonal styles. On the other hand, a patient who suffers

severe side effects may develop a strong bias against ever using psy¬

chiatric medications again.

In these situations, it is most helpful if gains and setbacks are not

immediately ascribed to one particular person or intervention. Lasting

gains in treatment are slow and almost always accompanied by set¬

backs. Complicating this is the notion of a “cure” and of the ideal

endpoints of treatment. A complete personality make over is not realis¬

tic. Instead, more attainable goals are:

• fostering an awareness of dysfunctional patterns (increasing insight)

• increasing adaptive behaviors (improving judgment)

• promoting more effective coping strategies and relationships (chang¬

ing behavior)

• double-checking one’s perception of events

• decreasing symptoms

Some patients, particularly those who externalize the locus of their dif¬

ficulties (NPD, ASPD), may well feel that the medication has “accom¬

plished everything” and not wish to participate in a fuller treatment

program despite the urging of everyone else involved.

A detailed discussion of negotiating the therapist-prescriber split is

provided in Koenigsberg (1993) and Woodward (1993).

104

Introduftion — The Biologital Dimension

Summary

Innate, biological factors influence the range of adaptation or plasticity

of character development. Psychobiologists seek to find the underly¬

ing neurophysiologic mechanisms through which enduring patterns of

interacting with the environment are mediated. This has important im¬

plications for the identification, understanding and treatment of Axis II

conditions. Psychobiology has gained a firm foothold from studies show¬

ing the heritability of the antisocial, borderline and schizotypal person¬

ality disorders in particular. Temperamental factors are deemed to play

a role in the strength of innate drives and to influence the development

of particular ego defenses, affecting whether (and which) personality

disorders develop. The interplay of between three and seven tempera¬

mental/character factors provides a convincing basis for continued

research.

Aberrations in four key areas offunctioning are common to both person¬

ality disorders and major clinical disorders:

• cognitive/perceptual organization

• affective regulation

• impulse control

• anxiety modulation

A comprehensive management program takes into account biological,

psychological and social factors. While personality disorders are not

treatable by medication alone, in severe cases, psychotherapy alone

is often not a sufficient treatment either.

Because of the lack of literature showing the predictable response of

patients with certain disorders to specific medications, each patient, in

essence, is an “n of 1” trial. The presence of symptoms at a certain

level of severity can warrant a trial of medication, but this needs to be

evaluated on an individual basis. Many medications can provide at

least partial symptom relief.

While specific strategies will be outlined in the individual personality

chapters, due consideration must be given to the “process” of prescrib¬

ing medication as well as the actual drug and dosage. What the patient

is told, when the medication is introduced, the therapist and prescriber’s

attitude, and the significance of the medication to the patient are all

important factors in determining the success of pharmacologic interven¬

tions. In addition to medication, skills training can be utilized to modify

temperamental or constitutional factors.

105


References

J. E. Bates & T. D. Wachs

Temperament: Individual Differences at the Interface of Biology

& Behavior

American Psychological Association, Washington D.C., 1994

S. Chess & A. Thomas

Temperament in Clinical Practice


C. R. Cloninger

A Systematic Method for Clinical Description and Classification

of Personality Variants

Archives of General Psychiatry 44: p. 573 - 588, 1987

C. R. Cloninger, D. M. Svrakic & T.R. Przybeck

A Psychobiological Model of Temperament and Character


P. T. Costa & R. R. McCrae

Four Ways Five Factors are Basic

Pers. Individual Diff., 13: p. 652 - 665, 1992

C. Costello, Editor

Personality Characteristics of the Personality Disordered


J. A. Gray

The Neuropsychology of Anxiety


G. L. Engel

The Concept of Psychosomatic Disorder

J. Psychosom. Res. 11: p. 3 - 9, 1967

G. L. Engel

The Need for a New Medical Model: A Challenge for Biomedi¬

cine

Science 196: p. 129 -136, 1977

H. J. Eysenck & S.B. Eysenck

Manual of the EPQ (Eysenck Personality Inventory)

Educational and Industrial Testing Service, San Diego, 1976

106


A. Freeman & M. Davison

Short-Term Therapy for the Long-Term Patient, in

L. Vandecreek, S. Knappy & T. Jackson, Editors

Innovations in Clinical Practice, Volume 15

Professional Resource Press, Sarasota, FL, 1997

B. Hogg, H. J. Jackson, R. P. Rudd et al

Diagnosing Personality Disorders in Recent-Onset

Schizophrenia

J. Nerv. Ment. Dis. 178: p. 194 - 199, 1990

S.Joseph

Personality Disorders: New Symptom-Focused Drug Therapy

The Haworth Medical Press, New York, 1997

J. Kagan, J. S. Resnick, N. Snidman, J. Gibbons & M. O. Johnson

Childhood Derivatives of Inhibition and Lack of Inhibition to the

Unfamiliar

Child Dev. 59: p. 1580- 1589, 1988

H. W. Koenigsberg, in

J. M. Oldham, M. B. Riba & A. Tasman, Editors

American Psychiatric Press Review of Psychiatry, Volume 12

American Psychiatric Press, Inc., Washington D.C., 1993

Z. J. Lipowski

What Does the Word “Psychosomatic” Really Mean? A Historical

and Semantic Inquiry

Psychosomatic Medicine 46: p. 153-171,1984

J. C. Loehlin

Are Personality Traits Differentially Heritable?

Behav. Genet. 12: p. 417 -428, 1982

L. J. Siever & K. L. Davis

A Psychobiological Perspective on Personality Disorders

American Journal of Psychiatry 148(12): p. 1647 - 1658, 1991

L. J. Siever, E. F. Corcarro & R. L. Trestman

The Growth Hormone Response to Clonidine in Acute and

Remitted Depressed Male Patients

Neuropsychopharmacology 6: p. 165 - 177, 1992

107


K. R. Silk, in

P. S. Links, Editor

Clinical Assessment and Management of Severe Personality

Disorders


S. Sigvardsson, M. Bohman & C. R. Cloninger

Structure and Stability of Childhood Personality: Prediction of

Later Social Adjustment

J. Child Psychol. Psychiatry 28: p. 929 - 946, 1987

L. Sperry

Handbook of Diagnosis & Treatment of DSM-IV Personality

Disorders


B. J. Steinberg, R. L. Trestman & L. J. Siever, in

K. R. Silk, Editor

Biological and Neurobehavioral Studies of Borderline Personal¬

ity Disorder


D. M. Svrakic, C. Whitehead, T. R. Przybeck & C. R. Cloninger

Differential Diagnosis of Personality Disorders by the Seven-

Factor Model of Temperament and Character

Archives of General Psychiatry 50: p. 991 -999,1993

A. Tellengen, in

A. H. Tuma & J. Maser, Editors

Anxiety and the Anxiety Disorders

Lawrence Erlbaum Associates, Hillsdale, N.J., 1985

B. Woodward, K. S. Duckworth & T. G. Gutheil, in

J. M. Oldham, M. B. Riba & A. Tasman, Editors

American Psychiatric Press Review of Psychiatry, Volume 12


G. E. Vaillant

The Natural History of Alcoholism: Causes, Patterns and Paths

to Recovery

Harvard University Press, Cambridge, MA, 1983

108


Review Questions

1. Below are the criteria for the borderline personality disorder.

Which ones reflect dimensions of temperament?

a. frantic efforts to avoid real or imagined abandonment; note: do not

include suicidal or self-mutilating behavior covered in criterion e

b. a pattern of unstable and intense interpersonal relationships charac¬

terized by alternating between extremes of idealization and devaluation

c. identity disturbance: markedly and persistently unstable self-image

or sense of self

d. impulsivity in at least two areas that are potentially self-damaging

(e.g., spending, sex, substance abuse, reckless driving, binge eating);

note: do not include suicidal or self-mutilating behavior covered in crite¬

rion e

e. recurrent suicidal behavior, gestures, or threats, or self-mutilating

behavior

f. affective instability due to a marked reactivity of mood (e.g., intense

episodic dysphoria, irritability, or anxiety usually lasting a few hours

and only rarely more than a few days)

g. chronic feelings of emptiness

h. inappropriate, intense anger or difficulty controlling anger (e.g., fre¬

quent displays of temper, constant anger, recurrent physical fights)

i. transient, stress-related paranoid ideation or severe dissociative symp¬

toms

Reprinted with permission from DSM-IV


2. Which of the statements regarding the use of medication in treating

personality disorders is/are correct?

a. medications can significantly alter interpersonal functioning

b. instituting medications at the time of a crisis will maximize their

effectiveness and assist with compliance

c. psychotropic medications pose little risk of fatality in overdose

d. there are clear-cut indications for certain medications to be used

e. while some medications have a variety of indications, it is better to

use a different medication for each target symptom

f. introducing medication at a time when progress in psychotherapy is

slow is a good way to motivate patients to improve

109



1. Recall that temperament reflects inborn, constitutional behaviors (state)

while character reflects learned behaviors (traits). The following four

are dimensions of temperament:

d. impulsivity in areas that are potentially self damaging

e. recurrent suicidal threats, gestures or behavior

f. marked reactivity of mood causing affective instability

h. inappropriate, intense anger; difficulty controlling anger

2. a. False. Medications do not alter interpersonal functioning. Their

use is for target symptoms and will not improve how patients relate to

those close to them.

b. False. While instituting medications at the time of a crisis is a com¬

mon and acceptable practice, it can lead to difficulties in treatment. For

example, patients may feel that something was being withheld from

them until the need arose or that they were not able to control the

situation alone. A more helpful practice is to introduce medication in a

planned manner for specific target symptoms, which allows a more ac¬

curate evalution of their effectiveness.

c. False. Psychotropic medications do pose an appreciable risk of

fatality in overdose. The most lethal are the tricyclic antidepressants

which can be fatal if less than a week’s supply is taken. Neuroleptics,

MAOIs and lithium all pose risks in overdose and certainly can cause

fatalities. Medications are considerably more lethal if taken in combi¬

nation, or with alcohol or street drugs.

d. False. There are guidelines given for which medications may be

most helpful for disturbances in particular areas of functioning. There

is a scant literature showing the effectiveness of using medications

with personality-disorderded patients, and most of the reports focus on

borderline or schizotypal personalities.

e. False. It is usually preferable to use one medication at a time. Using

a variety is called polypharmacy, which increases the chance of a

drug-drug interaction and lessens the effectiveness of individual medi¬

cations. Using two or more medications simultaneously also impairs an

evaluation of the effectiveness of a single agent.

f. False. Medications are not a way to help therapy gain momentum.

Interpretation of resistance, exploration of transference issues or re¬

questing a consult from a colleague are more effective means.

110


Nag-B-Gone®

tri-caffeinated-primadonna-adnauseate-turbonagging-hydrazine

a proprietary brand attitude suppressant

Supplied as:

• Nag-B-Gone Regular Strength — 250mg tablets

• Nag-B-Gone Extra Strength — 500mg tablets

• Nag-B-Gone STAT — 750mg IM blow dart form

• Nag-B-Gone PMS — 5g long-acting IM form — monthly injection

• Nag-B-Gone EverFlow — 50 g/L intravenous formulation

Indications:

For the reduction of attitude, grandiosity and pomposity in all settings;

alleviates demonstrations of superiority and rampant indignation.

Action:

Temporarily deadens attitudinal receptors in the superior portion of the

locus narcissisticus in the dominant frontal lobe.

Alternate Forms

WhineAway®

A mild attitude suppressant in a pleasant-tasting cappuccino-flavored

liquid form for those who can’t stop talking long enough to take the

tablets. Also practical for surreptitious introduction into colleagues’

coffee mugs.

DeFlato®

An attitude suppressant in aerosol form with two delivery modes:

• wide setting works as an antiperspirant

• narrow setting delivers an effective dose across conference rooms

Flock-Off®

A triple-strength formulation available in suppository form. For use in

extreme cases, such as meetings composed of multitudes of the indi¬

viduals listed above (e.g. Narcissists Anonymous).

Narciss-Fix-AII®

An experimental community-based formulation suitable for inclusion in

water supply; government approval is pending for endemic areas.

Ill


If You Love Something, Set It Free ...

Antisocial Personality

Schizoid Personality

Dependent Personality

Obsessive-Comp. Personality

Narcissistic Personality

Histrionic Personality

Paranoid Personality

Schizotypal Personality

If it doesn’t come back to you, hunt it down

and kill it.

So, what’s the problem?

And walk right back in the door.

By spending a requisite amount of

time apart, an emotion may occur.

Take this opportunity . . . please.

A complete make-over is clearly

required to rekindle this romance.

While this person is gone, place bugs in

the phones, hidden cameras on all levels,

and hire a team of private investigators.

Get your fortune read before returning.

112

The Sthizoid Personality


113


Biographical Information

Name:

G. 0. Solo

Occupation:

Toll booth collector between

1 and 7 a.m.

Appearance:

Stove-pipe pants, and a circa

1970’s ultra-wide tie

Relationship with animals: Brings “best friend” to session

Favorite Songs:

Alone Again, Naturally; Solitaire

Motto: Through email 1 will prevail

At the Therapist's Office

Before Session:

Waiting Room Reading:

During Session:

Fantasies Involve:

Relationship with Therapist:

Behavior During Session:

Brings to Session:

Gets first appointment to avoid

seeing others in the waiting room

Reads Statistics Quarterly in

the hallway

Plays Hide & Seek; only won’t seek

Liaison with philosophy course

instructor

Asks to play Dungeons &

Dragons

Teeters on edge (of chair and

sanity)

Collection of mail-order catalogs

Mnemonic for Diagnostic Criteria

"SIR SAFE"

Solitary lifestyle

Indifferent to praise and criticism

Relationships of little to no interest

Sexual experiences are not of interest

Activities preferred are almost always solitary

Friendships are few

Emotionally cold and detached

114

Introduttion

The Sehizoid Personality

Schizoid means “representing splitting or cleaving.” This personality

disorder is characterized by detachment from others, a restricted range

of emotional expression and a lack of interest in activities. Some of

the key names associated with this disorder are:

• Hoch (1910) — described a large percentage of schizophrenic

patients as having a “shut-in” personality — reticent, seclusive and

living in a world of fantasy — which was present before, and remained

after, the florid signs and symptoms of a psychotic episode.

• Bleuler (1924) — used the term “schizoidie” to describe an apparent

indifference to relationships or experiencing pleasure.

• Kraepelin (1920’s) — made the comparison to an autistic personality,

which he considered an attenuated form of schizophrenia.

• Kretschmer (1925) — identified two types of schizoid personalities:

• overly sensitive — resembling the avoidant personality disorder

• insensitive — which forms the basis of the current understanding

• Fairbairn & Guntrip (1969) — made contributions to the description

and understanding of this disorder; however, some of their work is

more relevant to the schizotypal personality.

The schizoid personality disorder (SzdPD) is characterized by social

isolation extending even to family members. Emotional and physical

intimacy are not desired. Men seem to marry rarely. Women may, if

aggressively pursued by someone comfortable with the (usually

considerable) emotional distance. Schizoid patients prefer solitary

pursuits, often with a degree of intellectual abstraction — computers,

mathematics, astronomy, electronics, etc. They come across as bland,

distant people lacking social graces. Their restricted affect does not

inspire others to engage them in conversation or pursue relationships.

SzdPD was first clearly defined in the DSM-III and its criteria expanded

from three to seven in the DSM-lll-R. Schizoid and schizotypal represent

personality disorders consistent with the negative and positive

symptoms (respectively) of schizophrenia (see the Differential

Diagnosis Section).

Because they are not distressed by isolation, schizoid patients rarely

seek attention because of their style of interacting with others.

Commonly, an acute stressor or the urging of a family member brings

these patients in for help. Schizoid patients have an increased risk of

suffering from certain Axis I disorders — depression, dysthymia and

anxiety disorders (especially phobic disorders).

115


Media Examples

Schizoid characters are generally not flamboyant enough to play a leading

role in TV shows, movies or fictional bestsellers. They are typically

cast as recluses, loners, outcasts or hermits. Roles as scientists,

inventors, computer wizards and musicians are also common depictions.

Typically, these characters are removed from society and care only

for their work. A schizoid-like quality is an essential ingredient in

heroism. Examples like the lone gunslinger who rides in from nowhere,

takes out the bad guys, and then heads off into the sunset after refusing

gracious invitations to stay in the town enhance the mystique of such

characters. Here is a list of notable examples:

• Sherlock Holmes — The famous Victorian detective embodies many

schizoid elements. He craves contact with no one and is distant even

with Dr. Watson, his aide and confidant. When not involved in an active

case, Holmes almost exclusively immerses himself in scientific and

research pursuits that enhance his skills as a detective.

• The Net — Sandra Bullock portrays a computer whiz who declines a

dinner invitation in favor of ordering a pizza via an online connection.

Later, she plans her first vacation in six years. As the plot thickens,

she has almost no one to turn to for help, because she doesn’t know

her neighbors or have any contacts at the company that employs her.

• Flesh and Bone — Dennis Quaid gives a good performance as a

schizoid vending machine owner. He travels from town to town

absorbed only in replenishing stock until he’s forced into interacting

with Meg Ryan (he eventually has to — they’re married in real life).

• Batman — While Bruce Wayne has many fine qualities that do not

imply a personality disorder, he remains isolated, choosing to perfect

his physical skills and secret weapons. In many instances he resists

attempts to divulge his identity as Batman, or share his troubled past.

• The Professional — This movie casts Jean Reno as Leon, an

assassin. Because of his occupation, he would surely be considered

an antisocial personality, he leads an isolated, nomadic existence that

is reminiscent of a schizoid personality.

Other schizoid personalities can be seen in the following movies:

• Mad Max

• Thief

• Shane

• Many of Clint Eastwood’s Westerns

116

The Schizoid Personality

Interview Considerations

Schizoid patients will seem at best modestly cooperative when

interviewed. A lack of emotional (affective) response pervades the time

spent speaking with them. Often responses are limited to a word or two,

leaving the impression of indifference to significant or even catastrophic

events.

It is difficult to use a “strategy” to draw out people who are so detached.

Often, general, open-ended questions are used at the beginning of an

interview to develop rapport. Schizoid patients’ clipped responses may

give the impression that they are upset, but this is an unlikely situation.

Because they radiate little to no emotional warmth, it is difficult to use

empathy to make a connection. Their feelings are related in such a

detached manner that they sound artificial or rehearsed.

Open-ended questions often do not evoke the desired response.

Encouragement to provide more information, even on topics that interest

these patients, rarely succeeds. If a history cannot be obtained using

open-ended questions, a closed-ended, structured “laundry list” of

questions may be necessary. Schizoid patients are unlikely to be

affected by even a barrage of questions. Mention of an emotional state,

in particular, requires closer scrutiny. For example, schizoid patients

may exist in a state of “depression” that does not correspond with the

symptoms of a major depressive episode. Due to the difficulties n

establishing rapport and obtaining sufficient information, collateral social

history is invaluable in making this diagnosis.

Sthizoid Themes

• Prefers to do things alone

• Why bother? Who cares?

• Withdrawn and reclusive

• Works below potential

• Observer, not a participant

• Lacks interests and hobbies

• No apparent desire to pursue

• Deficient motivation

• Goes “through the motions”

• May show considerable creativity

• Aloof, distant and cold

• Humorless

• Constricted emotions

relationships

Prattite Point ©

In some psychiatric literature, and in particular psychoanalytic writing,

the term “schizoid” may refer to schizoid, schizotypal and/or avoidant

personalities. These three diagnoses were introduced as separate

disorders in the DSM-lll.

117


Etiology

Biological: SzdPD has a debatable link to schizophrenia. Some studies

consider it a personality variant consistent with the negative symptoms

of schizophrenia. Other studies suggest that the schizotypal personality

disorder has a stronger association with, and a similar outcome to,

schizophrenia.

If there is a genetic component, neuroanatomic and neurochemical

aberrations may serve as a marker. To date, a number have been

postulated but not confirmed (e.g. autonomic hyperactivity, deficits in

the reticular formation, congenital aplasia in the limbic system, etc.).

Temperamental factors include hyper-reactivity, a tendency towards

being easily overstimulated, anhedonia and aversion to others.

Introversion is a highly heritable trait; pupillary dilatation, elevated heart

rate and elevated urinary catecholamines accompany the behavioral

signs. Families of patients with schizoid personalities have a higher

prevalence of schizophrenia, and both schizotypal and avoidant

personality disorders than the general population.

Psychosocial: There is split (pun intended) in what is considered a

“schizoidogenic” family milieu. The most obvious family history involves

cold, distant, inadequate or even neglectful caregivers. Children raised

in such a setting experience relationships as painful and unrewarding.

However, the other extreme may also contribute to the etiology of this

disorder. Parents who are overinvolved and overinvested (and perhaps

overdrawn) may foster an emotional withdrawal in their children. A

common finding is that of a seductive mother who transgressed

boundaries, and an impatient, critical father. Bateson coined the term

double bind (the psychiatric equivalent of a Catch-22) to describe

confusing and contradictory interactions. This no-win situation may

facilitate retreat into a fantasy state.

It is important to keep cultural factors in mind with this diagnosis. For

example, a Scandinavian will very likely seem more reserved than

someone from the Mediterranean. Even within a given culture, a rural

versus urban environment can foster different social behaviors in people.

Analytic observations generally hold that men suffer more from disorders

characterized by excessive isolation, and women from disorders

involving excessive attachment (e.g. dependent personality disorder,

depression).

118


Epidemiology

Estimates of prevalence range from 0.5 to 7%. By its very nature SzdPD

is difficult to measure accurately. There appears to be a higher

prevalence in males.

Ego Defenses

SzdPD is notable for the absence of common defenses, especially in

higher-functioning individuals. The primary defense used in this disorder

is appropriately named schizoid fantasy, a withdrawal into an inner

world of imagination. The next most common defense is

intellectualization, the excessive use of intellectual processes to avoid

experiencing or expressing emotion. Other defenses used to a lesser

extent are:

• projection — also see the Paranoid Personality Chapter

• introjection — internalizing the qualities of an important person

• idealization & devaluation — also described in the Borderline

Personality Chapter

DSM-IV Diagnostic Criteria

A. A pervasive pattern of detachment from social relationships and a

restricted range of expression of emotions in interpersonal settings,

beginning by early adulthood and present in a variety of contexts, as

indicated by four (or more) of the following:

(1) neither desires nor enjoys close relationships, including being part

of a family

(2) almost always chooses solitary activities

(3) has little, if any, interest in having sexual experiences with another

person

(4) takes pleasure in few, if any, activities

(5) lacks close friends or confidants other than first-degree relatives

(6) appears indifferent to the praise or criticism of others

(7) shows emotional coldness, detachment, or flattened affectivity

B. Does not occur exclusively during the course of Schizophrenia, a

Mood Disorder With Psychotic Features, another Psychotic Disorder,

or a Pervasive Developmental Disorder and is not due to the direct

physiological effects of a general medical condition.



119


Differential Diagnosis

Schizoid is one of five “schizo” terms occurring in psychiatry. In order

to explain the differential diagnosis of this disorder, an understanding

of these terms is necessary.

Schizophrenia: Literally, a splitting of the mind, or “schism,” between

perception, thinking, feeling and behavior. Clinical features include

delusions, hallucinations, disorganized speech and behavior, and

negative symptoms (described on the next page).

Schizophreniform Disorder: This condition is identical to schizophre¬

nia except that the duration is not long enough (greater than one month

but less than six months) to qualify for a diagnosis of schizophrenia.

The deterioration in social and occupational function is usually less

marked than in schizophrenia.

Schizoaffective Disorder: Describes the presence of:

• a mood disorder (major depressive, manic or mixed episode)

concurrent with the symptoms of schizophrenia listed above, with

• at least a two-week period where delusions or hallucinations are

present without prominent mood symptoms, and where

• mood symptoms (depression, mania or a mixed episode) are present

for a substantial part of the total illness

Schizotypal Personality Disorder: This is a short form for “schizo¬

phrenic genotype” and is a Cluster A personality disorder.

The differentiation of SzdPD from schizophrenia is not difficult during

the acute or psychotic phase of the latter. The presence of positive

symptoms and a clear decline in functioning are not features of SzdPD.

It may be more difficult to distinguish this personality disorder from

the residual or prodromal phases of schizophrenia.

Schizoid patients do not have the same severity of symptoms or the

decline in function seen in a major depressive episode. There is little

overlap between mania ora mixed mood episode and this personality

disorder. However, micropsychotic episodes lasting minutes to hours

can occur in SzdPD.

The continued use of street drugs or alcohol can cause schizoid-like

characteristics. The presence of a schizoid personality disorder prior

to the onset of schizophrenia is usually a poor prognostic feature.

120


Schizophreniform

Disorder

lesser in time course

and severity than

schizophrenia

Schizophrenia

consists of:

positive

symptoms,

which are

added to the

clinical

presentation

negative

symptoms,

which are

absent from

the clinical

presentation

Schizoaffective

Disorder

• combination of

mood and

psychotic

symptoms

Positive Symptoms

Hallucinations

• can occur in any sensory modality,

usually auditory or visual

• when auditory, can be a running

commentary on actions

Delusions

• bizarre themes (things that cannot

possibly happen)

Odd Behavior

• appearance, attire, social actions

• stereotyped movements

Formal Thought Disorder

• tangential/circumstantial pattern

• illogical/incoherent

• insertion or withdrawal of thoughts

• thoughts being outwardly broadcast

Inappropriate Affect

• blunted/silly/not in keeping with the

situation

Schizotypal

Personality

Disorder

Negative Symptoms

Affective Flattening

• unchanging emotional response

• little change in vocal inflection

• few spontaneous movements

Alogia

• poverty of speech

• poverty of content of speech

Avolition/Apathy

• poor grooming & hygiene

• physical anergia

• deficient interest & motivation

Anhedonia/Asociality

• few recreational interests

• no relationships/intimacy

• derives no pleasure from activities

Attentional Deficits

• inattentive to social cues/situations

• deficits may be found on the men¬

tal status exam

\

Schizoid

ersonalil

Disorder

121


Other Diagnostit Considerations

Autism (markedly impaired development of social interaction and

communication and a restricted repertoire of activities and interests),

and Asperger’s disorder (similar to autism but without the delays in

language, cognitive development or adaptive behavior), are examples

of the pervasive developmental disorders mentioned in the diagnostic

criteria. Generally, patients with these disorders have stereotyped

behaviors and demonstrate more impaired social interactions than is

seen in SzdPD. Frequently, patients with SzdPD have an associated

avoidant and/or schizotypal personality disorder.

Mental Status Examination

Appearance:

Behavior:

Cooperation:

Affect:

Speech:

Thought

Content:

Thought

Form:

Perception:

Insight &

Judgment:

Suicide/

Homicide:

None characteristic; usually inattentive to trends;

clothes are functional, not fashionable; may appear

to be socially inept

Edgy, anxious; fidgety; clumsy; stilted; ill at ease;

few facial expressions; little animation

Cooperative, but little personal information revealed

Restricted range, flat, withdrawn; may be

dysphoric

Goal directed but lacks detail; intonation rarely

changes; monotonous; may be slow

Little to no elaboration on any topic; one-word

answers; seemingly unaffected by material usually

laden with emotion; may be aware of having a lack of

interest in people or significant events; may have

ideas of reference (an event pertains to them

specifically, such as a radio or television broadcast)

No characteristic abnormality; rarely have actual

thought blocking; answer readily, just sparsely

No characteristic abnormality

Intact; not bothered by lack of interest; tend to be

pessimistic and underestimate their abilities

Need to consider this in conjunction with any

Axis I disorder; not likely to be dangerous to

others or themselves; isolation from relationships

tends to minimize DIRs as precipitants for

seeking help

122


Psythodynamit Aspetts

Melanie Klein hypothesized that an infant in about the third or fourth

month of life passes through a paranoid-schizoid position. Here,

the infant splits off (the schizoid part) libido from aggression that is

then projected (the paranoid part) onto the mother, leaving the infant

in fear of maternal persecution. At about six months, this progresses

to the depressive position which involves a fear of destroying the

loved object, and via reparation, the infant acts towards the mother as

if to repair the damage inflicted by this fantasy. Remember, this is just

a theory. However, to Klein’s credit, later in life schizoid patients often

struggle with basic safety concerns (the paranoid aspect) and have

split off their desires (the schizoid aspect) to the point that they become

spectators rather than participants in their own lives.

To schizoid patients, the world looms with the potential for consuming,

engulfing, or absorbing them. The usual appetitive drives (sex, food,

etc.) are not experienced as coming from within, but instead as coming

from the external world. In fact, the body habitus of many schizoid

patients tends to be thin (a link to anorexia nervosa has been

proposed), accentuating their withdrawal from sustenance. Emotional

expression causes anxiety ranging from outright fear to deep

ambivalence. When overwhelmed, these patients hide, either literally

or defensively.

The retreat into fantasy as a coping mechanism happens reflexively

in a wide variety of situations. Fantasies may contain violent themes

and be manifested by an interest in sordid movies and literature: horror

films, true crime books, heavy metal music, bondage magazines,

games with omnipotent or destructive roles for players, etc. The hunger

fueling these interests is usually well defended. Schizoid personalities

usually seem pleasant, low-key and even transparent.

It would be a mistake, however, to assume that no emotional

experiences occur within these patients. Schizoid patients can be in

touch with emotions on a level of genuineness not often seen.

Difficulties may stem from a lack of validation of emotional and intuitive

experiences, not their complete absence. Schizoid patients perceive

what others ignore, and may feel out of place with those oblivious to

what is so apparent to them. Social practices may appear so contrived

that it seems fraudulent to participate. A detached, sarcastic and faintly

contemptuous attitude helps fend off a world they perceive as

overcontrolling and overintrusive.

123


Psythodynamit Therapy

Schizoid characters may be unfairly thought of as lower functioning

across a spectrum of behaviors (social, career, interpersonal, etc.)

due to the presumed connection to schizophrenia, and in particular,

to the negative symptoms of that illness. It is important to keep in

mind that this diagnosis can be applicable at any level of functioning

— from a withdrawn, chronically hospitalized patient to a reclusive

and highly creative artist. It is common for these people to be drawn to

intellectual pursuits often removed from direct contact with others:

philosophy, theoretical sciences, mathematics, theological studies,

computers and creative arts. The overall level of functioning is not

exclusively related to the level of occupational functioning.

Although the interpersonal dynamics mentioned above keep patients

from entering relationships and seeking professional help, the

constraints of psychotherapy may well be appealing. The customary

boundaries of time limits, the professional office setting, ethical

restrictions against social and sexual relationships, and a clearly

outlined therapeutic contract can all decrease fears of engulfment.

Frequently, a crisis may precipitate the initial visit — an Axis I disorder

(depression, anxiety), dysphoria over a loss, or the wish for a limited

social life (they often long for unattainable sexual partners while

ignoring available ones). Interpersonal difficulties are revealed early

in therapy. Though experiencing emotional pain, patients may not be

able to clearly express themselves, leaving awkward pauses. It is

critical early on to create an atmosphere .of patience, respect and

safety. Avoid probing too deeply or pressing for immediate disclosure.

By letting patients share what they want to, in the way they want to,

and at the speed they want to, a trusting relationship has a chance to

develop.

In a noncritical atmosphere, their highly tuned perceptual abilities

become more apparent and provide fertile ground for the therapeutic

process to continue. Regardless of how bizarre or incomprehensible

internal experiences seem, being able to express them in an intimate

and supportive atmosphere is a prime therapeutic factor.

As therapy proceeds, the defensive withdrawal into fantasy can be

addressed. Imagination can be reframed as a talent, rather than an

immutable barrier. A key factor that promotes self-esteem is the

encouragement of self-expression through creative activity.

124


Schizoid patients frequently need reassurance that they are not deviant

or grotesque to others. Here, confirmation of their sensitivity and

uniqueness can be valuable. This can be accomplished by

communicating that their inner world is not only comprehensible, but

that they have unique gifts. This can be aided by the use of artistic or

literary examples, depending on the erudition of the therapist.

In his book Solitude, Anthony Storr emphasizes that many of the world’s

great thinkers lived alone for the majority of their lives. Descartes,

Newton, Locke, Pascal, Spinoza, Kant, Leibnitz, Schopenhauer,

Nietzsche, Kierkegaard and Wittgenstein are just a few examples. Even

among notably creative individuals who did marry, there is an almost

universal observation that their work was carried out in solitude.

We must reserve a little back-shop, all our own, entirely free, wherein

to establish our true liberty and principal retreat and solitude.

Montaigne

As therapy proceeds, patients hopefully internalize the experience of

being accepted without being engulfed or dominated. Eventually,

increased self-esteem engenders the idea that being misunderstood

may well be due to the limitations of others, not to a deficiency on the

patient’s part. Once this idea has taken hold, practical gains outside

therapy may start taking place: friendships, membership in group

activities, creative endeavors, etc.

The main feature contrasting SzdPD with the avoidant personality

disorder is that schizoid patients appear not to desire close relation¬

ships. However, attachment theory postulates that relationships are a

fundamental human need. In schizoid patients, early experiences have

walled off the desire to form relationships.

McWilliams outlines helpful techniques to draw patients out:

• support taking risks in the direction of initiating relationships

• be playful or humorous in ways lacking in the patient’s past

• respond with attitudes that counteract the tendency of just “going

through the motions” of emotionally connecting to others

• a more responsive therapeutic style may make the patient’s trans¬

ference more accessible to interpretation; the patient needs the

therapist’s active participation as a warm and empathic person

Adapted from McWilliams (1994)

125


Transference and Countertransferente Reactions

Schizoid patients generally are appreciative and cooperative within

the boundaries of a therapeutic relationship. Countertransference can

involve boredom, impatience, derision and giving a prematurely

negative prognosis. Patients can be seen as resisting a process that

requires disclosure on their part. It may be tempting to “get to the heart

of the matter,” finish patients' sentences, or become amused by their

maladroit mannerisms.

Later, there may be an unwitting tendency to form an emotional world,

or cocoon, within therapy. This is enhanced when patients express the

feeling of being special or unique, but have no other relationships.

Under such circumstances, therapy can appear to become a solution

for a schizoid patient instead of a catalyst for growth outside the office.

This is more likely to happen in two situations:

• the therapist colludes with a patient’s sense of helplessness and fragility

by seeking to protect him or her from the harsh world

• with patients who are creatively gifted, therapists may find themselves

in the role of agent or advocate — sometimes taking on a parental role

(the parent the patient never had) — to promote special talents

Suggested Therapeutic Techniques

• Don’t rush the patient into early disclosure; be patient; avoid using

too many open-ended techniques at the outset

• Provide structure; initial sessions may need to be spread out

• Be aware of your office setup; locate your chair comfortably away

from patients; respect the need for physical and emotional distance

• These patients usually disregard convention — keep an open mind

• Try to understand the latent or symbolic content of their speech

• Consider social skills training to increase assertiveness

Pharmacotherapy

The rationale for the use of medication for SzdPD is based on the

overlap of personality characteristics with the negative symptoms of

schizophrenia and with depression. Target symptoms are as follows:

• apathy/decreased motivation

• decreased libido

• seclusiveness/social withdrawal

• blunted affective responses

• anhedonia

126


Another condition closely resembling SzdPD is the simple deteriorative

disorder, previously called simple schizophrenia. This appears in

DSM-IV in Appendix B and is a disorder undergoing further study. The

essential criteria of this disorder are:

• marked decline in social or occupational functioning

• limited social interaction

• the onset and gradual worsening of negative symptoms

Newer (also called novel or atypical) antipsychotics improve negative

or deficit symptoms to a far greater degree than do traditional agents.

At the time of writing, six novel antispychotic agents are available:

clozapine, olanzapine, risperidone, quetiapine, sertindole and

ziprasidone. Clozapine carries the risk of potentially fatal side effects

and would be the least likely from this group to be used. These

medications have target dosages for schizophrenia which are likely

excessive for treating SzdPD.

Because there is also an overlap with symptoms of depression,

antidepressant medications may provide some benefit. While any

antidepressant may be efficacious, the SSRIs in particular may be

helpful when features of anxiety present. While anxiety is not a frequent

initial symptom, it can become more pronounced as patients make

attempts to become more socially involved. Anxiolytic medication

(usually benzodiazepines) and hypnotic medication may also be

required in these circumstances.

Group Therapy

Some schizoid patients are suited to the group process. Meeting with

a consistent group of people is an important step in beginning to value

relationships and developing a social network. Social learning, such

as the deciphering of facial expressions, gestures and verbal cues, is

a common early therapeutic gain.

At times, schizoid patients can be accused of passively drawing

attention to themselves by remaining silent. Their manner can also be

reminiscent of a co-therapist, and both these situations can draw ire

from the more attention-seeking members of a group. If a therapist

experiences countertransference difficulties with silence, he or she

may covertly encourage group members to “gang up" on withdrawn

patients. Forcing patients to contribute too early to a group situation

can be countertherapeutic because it is a repetition of earlier

interpersonal trauma.

127


Cognitive Therapy

Basic Cognitive Assumptions:

• “Relationships are just trouble.”

• “I’m a social outcast.”

• “Nothing excites me.”

• “Life is a lot easier without involving others.”

• “It is better to walk softly, and walk away.”

Adapted from Beck, Freeman & Associates (1990)

Cognitive therapy with schizoid patients is a test of perseverance for

the therapist. Because thoughts are linked to feelings, and since these

patients express few feelings, it takes considerable time to generate

something to examine. Additionally, the indifference expressed towards

others removes a useful catalyst for change. Frequently these patients

enter therapy because of anxiety or depression. While they are under¬

going cognitive therapy for these conditions, interventions can be made

toward correcting their isolated lifestyle:

• paying more attention to positive emotional details

• using limited self-disclosure to develop a rudimentary relationship

• incorporating social skills training and assertiveness training

• adding booster sessions to help prevent relapse

Interpersonal Therapy

Benjamin (1993) hypothesizes the following factors are operative in

the development of SzdPD:

• Growing up in an atmosphere that was orderly, detached and

regimented. Assistance was given to achieving basic goals such as

education and functional independence, but there were no particular

wishes or implicit agendas contributed by the parents, such as continuing

in a family business or excelling in a certain area.

• As children, they were tolerated but not cherished. The emotional

tone of the household was flat with little warmth or interest expressed.

The majority of the guidance would have been towards developing

solitary interests rather than engaging in play or other social situations.

Schizoid patients expect nothing from others, and in turn do not seek

to contribute anything. They are not prone to experiencing either pain

or pleasure, and are considered to be passively detached from others.

Their principal interpersonal strategies are to ignore and become walled

offfrom others. Self-neglect is also considered to be a major aspect.

128


They may be capable of filling expected roles but do so without becom¬

ing emotionally involved. For example, if married, bonding through inti¬

macy (especially sexual) is not desired. “Socialized, but not sociable” is

an apt description. Patients lack an awareness of social cues, which

contributes to their indifference to the approval or criticism of others,

and their general obliviousness to interpersonal situations.

Benjamin casts doubt on the validity of this diagnosis. While fitting into

her theoretical formulation of personality disorders, she had not seen

such a patient by the time her book was published. Accordingly, she

has no recommendations for interpersonal therapy with schizoid patients.

Case Example

Mr. Solo has been employed as a toll booth operator for several years.

While he has taken and passed many courses at a community college,

he doesn’t mind working at a job for which he is overqualified. He has

several interests in life: exploring the internet, fantasy/science fiction

books and studying the writings of German philosophers. The college

courses he takes generally further his understanding of these areas.

He will take other courses, but checks to see how the course is graded

before enrolling. He specifically avoids courses involving oral

presentations or group work.

He enjoys working night shifts because it gives him time to think about

what he's learned that day. He avidly maintains his homepage, which

is a tribute/introduction to some of the great thinkers. At some point, he

is considering writing a book discussing the historical significance of

philosophy and its relation to the Industrial Revolution.

When asked about himself, he quickly changes the discussion to an

area in which he has some expertise, but offers little of a personal

nature. The person he admires the most is Immanuel Kant due to the

widespread influence of his ideas. He has no close friends and has no

wishes for a relationship. He will occasionally see a movie with one of

his co-workers, who himself is rather withdrawn and doesn’t say much

or try to arrange their outings more than a few times per year.

Course

SzdPD appears to be a stable condition. Little is known about the

incidence of schizophrenia in patients and their first-degree relatives

overtime.

129


Referentes



Edition

American Psychiatric Association, Washington, D.C., 1994




L. S. Benjamin

Interpersonal Diagnosis & Treatment of Personality Disorders


G. Gabbard

Psychodynamic Psychiatry in Clinical Practice: The DSM-IV

Edition



Comprehensive Group Psychotherapy, Third Edition

Williams & Wilkins, Baltimore, 1993




N. McWilliams

Psychoanalytic Diagnosis


E. Othmer & S. Othmer

The Clinical Interview Using DSM-IV


R. Pies

Clinical Manual of Psychiatric Diagnosis & Treatment


A. Storr

Solitude

Collins Publishing Group, Great Britain, 1988

130


You’re just about to do computer battle with Zorgon for control of the

thirteenth level of the CyberEmpire when the doorbell rings.

You’ve avoided your neighbors for twelve years, so why would

they pick today to meet you?

And after all you’ve done to ensure your privacy — working nights,

eating take-out food, and choosing a basement apartment at the end

of the hallway. You can run, but you’ll just have to meet them tired.

Have no fear!! Eau D’Hermit is here!!

An antiperspirant foul enough to keep everyone away.

131


Shopping by Diagnosis

Area/Activity in Store

Check Out

• Exact-change cashier

• Uses cash register nearest the exit

(for a faster getaway)

• Enters line-up at cashier with an empty

cart and then sends children to get items

• Insists on starting new diet right in the

store — won’t pay for book or food until

results are seen

Parking Lot

• Has items delivered directly to car

• Remains in car, scans surroundings

with a periscope before exiting

• Visits only on CustomerAppreciation Day

• Greets shoppers and introduces self

as “Wal” from Wal-Mart

Diagnosis


Antisocial

Passive-Aggressive

Schizotypal

Schizoid

Paranoid

Avoidant

Narcissist

132

Review Questions


1. How can attachment theory be used to explain the underlying

dynamics of the schizoid personality disorder?

2. Which of the following descriptions are consistent with the schizoid

personality disorder?

a. seclusive; indifferent to world events; prefers to engage in long-term

daydreaming

b. deficient ambition; absent-minded; not interested in responsibilities

related to work or school

c. self-centered; lack of disclosure; numerous minor physical com¬

plaints

d. devoid of humor; restrained; moralistic

e. shut-in, suspicious, incapable of discussion; “comfortably dull”

f. colorless, shy, indifferent; interpersonal imperceptiveness

133



1. Recall that the central concept in attachment theory is that close,

positive attachments are a fundamental human need. This is difficult to

reconcile with the schizoid personality disorder, where relationships

are not sought and the need to relate affectionately with others is not a

motivating factor. Attachment theory would explain SzdPD on the basis

of deprived early attachments. Presumably, behavioral factors such as

modeling were important in encouraging withdrawal from social activi¬

ties. Identification with a withdrawn parent is another important factor.

The emotional gratification that others get from relationships schizoid

patients appear to get from objects (items) and abstract ideas. Indi¬

vidual pursuits such as collecting things is common, as are academic

studies. Developing an intricate fantasy life to accompany the activities

appears to satisfy their need for attachment.

2. All are features of schizoid personalities. The first four are taken from

historical concepts of the disorder, initially described by Hoch (1910)

and later subdivided by Farrar (1927). In order, they are: a. asocial

b. backward c. neurotic d. precocious.

Choice e is part of Bleuler’s (1924) formulation of the schizoid person¬

ality disorder. The last option is part of Millon’s (1996) presentation of

the current DSM-IV construct of this disorder.

References

E. Bleuler

Textbook of Psychiatry

Macmillan, New York, 1924

C. F. Farrar, in

D. Henderson & R. F. Gillespie

A Textbook of Psychiatry

Oxford Publishers, London, 1927

A. Hoch

Constitutional Factors in the Dementia Praecox Group

Review of Psychiatry & Neurology 8: p. 463 - 475, 1910

T. Millon, with R. D. Davis


Wiley & Sons Inc., New York, 1996

134

The Paranoid Personality




Name:

Occupation:

Appearance:

Relationship with animals:

Favorite Song:

Motto:

Perry Noyd

Full-time movie projectionist

Wears glasses with rear-view

mirrors

Doubts even his dog’s fidelity

I Spy theme song

In vigilance I trust


Before Session:


During Session:

Fantasies Involve:



Brings to Session:

Checks to see if he was followed

Authenticates therapist’s diploma

Questions partner’s fidelity

Demanding a full explanation of

therapist’s jokes

Questions therapist’s fidelity

Complains about the lack of warmth

in office

Scrapbook of injustice collection


"HEAD FUG"

Hidden meanings read into others’ remarks and actions

Exploitation expected from others

Attacks on his or her character are perceived

Doubts the loyalty of others

Fidelity of partner doubted

Unjustified suspicions about others

Grudges are held for lengthy periods of time

136

Introduttion


The paranoid personality disorder (PPD) is characterized by a

generalized, unwarranted suspiciousness and the tendency to

misinterpret the actions of others as threatening or deliberately harmful.

Paranoia is an ancient term, preceding even Hippocrates. Literally

translated from Greek it means “a mind beside itself and was originally

used to describe insanity. Over time, it has been inconsistently applied

to a diverse number of conditions.

Some of the key names associated with the concept of paranoia are:

• Heinroth (1818) — reintroduced use of the term in its current form.

• Kahlbaum (1863) — used the term to designate a group of disorders

that remained essentially stable over time.

•Adolf Meyer (1910’s) — first used the term Paranoid Pers. Disorder.

• Kraepelin (1915) — described a pseudoquerulous type of personality

that predisposed patients to delusional thinking.

• Freud (1911) — in his analysis of the jurist Daniel Paul Schreber

(who suffered from paranoid schizophrenia), thought the core conflict

in paranoia was a homosexual wish; for Schreber, this consciously

unacceptable (denial) wish was transformed (reaction formation) into

a male companion hating him (projection); thus, he was only aware of

feeling persecuted. Freud introduced the defense mechanism of

projection in 1894 (how did you celebrate its centennial?)

• Melanie Klein (1952) — in developing object relations theory, she

proposed a paranoid-schizoid position, in which destructive thoughts

and feelings are split off (schizoid part) from the ego and projected

outwards (paranoid part) as a means of separating intrapsychic

representations of good (nurturing mother) and bad (depriving mother).

Due to the long-standing use of the term paranoia, it has become a

diagnostic category in almost all classification systems. The paranoid

personality disorder was included in the DSM-I and in each edition

since. The ICD-10 also contains a diagnostic category for paranoid

personalities, with a broader definition than in the DSM-IV. Other features

that have historically been part of the description of PPD are:

hypersensitivity to criticism, disproportionate reaction to setbacks and

the aggressive pursuit of individual rights (when such rights are not

being threatened).

PPD has been hypothesized to be part of the schizophrenic spectrum

of disorders and has also been linked to the delusional disorders.

137


Media Examples

Paranoid personalities are frequently cast in “us versus them”

situations. As main characters, they garner audience support for their

battles, usually against authority figures. An element of heroism is

involved when the underdog triumphs against oppression. Frequent

portrayals are characters such as private investigators or police officers

who prepare to do battle with the “forces of evil.”

• The Caine Mutiny — Humphrey Bogart plays a classic paranoid

personality as Captain Queeg. Soon after taking command of the ship,

he becomes increasingly suspicious of others. He becomes ruthless

when he believes he is being humiliated by some of his men. The

court martial scene in particular is an excellent illustration of this disorder.

• Doctor Strangelove — this movie is virtually a study in paranoia.

Even the character names — Jack D. Ripper, T. J. “King” Kong,

Ambassador de Sadesky, Lothar Zogg, and Premier Kissoff— have

a sinister ring to them. We see the clearly paranoid General Jack D.

Ripper ordering his bomber squadron to launch a nuclear attack on

Russia. Later, we learn his motivation for doing so — fluoridation of

water — which he perceives to be a communist plot to destroy his

precious bodily fluids. As Strangelove, Peter Sellers demonstrates

the suspiciousness, lack of humor and grandiosity seen in this disorder.

• Guilty by Suspicion — paranoia is exemplified by the menacing

committee driven to eradicate communism at the time of the McCarthy

witch hunts.

• Invasion of the Body Snatchers — deals with a paranoid theme

(Capgras Syndrome — replacement of a close person by a double),

though this is on the scale of a delusion.

• The Treasure of the Sierra Madre — Bogie again portrays a

paranoid character who becomes increasingly suspicious of his

prospecting partners as their dig proceeds.

• Falling Down — Michael Douglas plays a paranoid character who

acts with outrage against those who cross him.

• Unstrung Heroes (novel and movie) — Michael Richards portrays

one of the eccentric and very paranoid uncles of the main character.

• Conspiracy Theory (novel and movie) — While the truth was out

there, Mel Gibson had many paranoid ideas before it was discovered.

• The X-Files and Enemy of the State feature paranoid characters.

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Paranoia of moderate (or greater) severity is usually not difficult to

recognize. Hypervigilance, anger, hostility and vindictiveness become

obvious early in the interview. Considerable energy is expended trying

to foil the efforts of those whom patients perceive as trying to shame

or humiliate them. In most instances, these convictions are revealed

readily, with a long list of justifications. With time, patients become

aware that others see them as paranoid and they can suppress their

tirades, especially when there is an obvious gain in doing so (e.g.

avoiding hospitalization).

With higher-functioning patients, paranoia can be much less obvious

and detected only over time. For example, a request for assertiveness

training or relaxation therapy may be veiled paranoia. The key question

to keep in mind is why the request is being made. Further investigation

might reveal a sense of being picked on, or not being able to relax

because of constant vigilance. Dealing with the surface manifestation

alone can cause one to miss the underlying suspiciousness.

Interviewing paranoid patients can be difficult because they expect to

be exploited, taken advantage of, or even humiliated. Questions and

intentions will be scrutinized for “hidden” meanings. Frequently,

inquiries are made about how information will be used. Issues of

confidentiality may be magnified. Regardless of how the interview is

conducted, a lack of trust predominates.

Paranoid patients are prone to act on their misperceptions and

suspicions. When sufficient “evidence” is collected, a detailed account

of betrayal is delivered in a heated manner. They are able to confront

others without being able to accept confrontation themselves.

This tirade can be quite difficult to endure. It may be tempting to respond

with indignation, defensiveness, or by “setting them straight.” Paranoid

thinking lacks flexibility, but highlighting obvious logical incongruities

usually has no impact. Arguing with patients simply increases their

suspiciousness. Being genuine, open and frank is more likely to be a

successful strategy. An example of such an intervention might involve

pointing out how everything is twisted to fit their expectations.

Even small gains in trust may be short-lived. At any time, patients can

“attack” if they feel betrayed. They are more prone to lash out than

endure the indignity of what they perceive as inevitable mistreatment.

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Paranoid Themes

• Externalize blame for difficulties — see themselves as the continual

target of abuse; constantly complain about poor treatment

• Have repeated difficulties in dealing with authority figures; unable

and unwilling to follow the lead of others

• Overestimate minor events — “Make mountains out of molehills”

• Search intensively to confirm suspicions to the exclusion of more

reasonable conclusions — “Miss the forest for the trees”

• Cannot relax; have little to no sense of humor

• Projection of envy or even pathological jealousy onto others —

“They’re out to get me because they want what I have”

• Critical of those whom they see as weaker, needy, or defective

• Have difficulty exuding warmth or talking about their insecurities

• Create their own environment based on subjective expectation, not

objective attributes (called a pseudocommunity)

• Anger and hostility are the main affects

• Will only rely on themselves; fervently autonomous

• Often exhibit a strong degree of narcissism — are exploitative,

moralistic, condescending and try to appear omnipotent

Adapted from Beck, Freeman & Associates (1990) and Millon (1996)

Prevention of Violente

Prior to seeing the patient

Assess the acuteness of the situation to ensure that this remains

the patient’s emergency, not yours.

• Be aware of the security arrangements that are available. Attend to

your safety first — anxiety reduces an interviewer’s effectiveness.

• Arrange for the police or security guards to be in attendance or nearby.

• Read the emergency chart and/or the patient’s hospital file for perti¬

nent information.

• How was the patient brought to the hospital? (e.g. by police, with

friends, on his or her own)

• Is the patient intoxicated, restrained, or being held involuntarily?

• Has bloodwork been drawn? (e.g. for medication toxicity, ethanol

level or drug screens)

• Is an overdose or head trauma suspected?

• Has a medic-alert bracelet been found?

• Has someone searched for weapons?

• Is someone available to provide collateral history?

• Does someone from the emergency staff have additional informa¬

tion?

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Considerations While Seeing Patients

An old adage advises, “Just because you’re paranoid doesn’t mean

they’re not out to get you.” If there is a realistic aspect to issues of

safety, it is vital to establish the actual risk. Frequently, a kernel of

truth exists in even the most flagrant paranoid thoughts. Paranoid

patients are among the most likely to be violent. Below is a list of

recommendations to help prevent such an occurrence.

• Avoid confronting or colluding with paranoid thoughts.

• Give explanations for your actions; demonstrate openness.

• Respect patients’ autonomy.

• Maintain your composure.

• Stress verbalization, not action.

• Allow an adequate, even ample space for patients; sitting close to

the door or exit can facilitate your escape when necessary.

• Do not block the door should a patient bolt.

• Seating arrangements can be discussed with patients and should be

altered to suit them.

• Introduce others and explain their purpose in the room.

• Be attuned to your feelings (countertransference); don’t react with

anger, sarcasm or incredulity.

Mnemonics for the Assessing the Risk for Potential Violence

“ARM PAIN” (for the most common situations)

Altered state of consciousness (e.g. delirium, intoxication)

Repeated attacks — history of violence

Male gender

Paranoia (in schizophrenia, mania, or delusional disorders)

Age — more likely to be violent if younger and impulsive

Incapacity — due to brain injury, mental retardation or psychosis

Neurologic diseases — e.g. Huntington's Chorea, Dementia

“MADS & BADS” (for the most common diagnoses)

Mania — due to impulsivity, grandiosity and psychotic symptoms

Alcohol — intoxication or withdrawal states

Dementia — diminished judgment and behavioral disinhibition

Schizophrenia — due to command hallucinations or delusions

Borderline Personality Disorder— intense anger, unstable emotions

Antisocial Personality Disorder — disregard for the safety of others

Delirium — hallucinations or delusions can cause violent reactions

Substance Abuse — particularly with hallucinogens

141


Etiology

Biological: Chess and Thomas found the following temperamental

qualities were associated with paranoid disorders later in life:

irregularity, nonadaptability, high intensity of reaction, negative mood

and a tendency to hyperactivity. Innate aggression or irritability may

result in the angry and threatening qualities seen in this disorder.

First-degree relatives of those affected with schizophrenia have a

higher incidence of PPD. This disorder is considered part of the

schizophrenic spectrum (presented in the Schizotypal Personality

Chapter). It is not uncommon for those who develop late-onset

schizophrenia to have had PPD premorbidly.

Paranoid traits have also been associated with developmental

handicaps (e.g. impaired vision or hearing; physical deformities).

Psychosocial: Paranoid patients have often had repeated

experiences of feeling overwhelmed and humiliated during childhood.

Environmental factors often include: criticism, teasing, ridicule, arbitrary

punishment, parents who cannot be pleased, and being used as a

scapegoat. Children become vigilant for cues to impending sadistic

treatment from caregivers, leading to their defensive attitude.

Children who grow up in environments filled with condemnation

incorporate parental warnings about the outside world, even though

they may find more kindness outside their homes. Negative reactions

reinforce in children a sense that outsiders have persecutory goals.

Reality and feelings become incongruous. Fear and shame become

instilled instead of a sense of being understood.

Children learn to believe that their feelings and complaints have a

strong destructive power. Negative interactions with parents (e.g. being

insulted) increase anger and frustration, and magnify the confusion

about feelings and perceptions.

Paranoid behavior can also be modeled. Folie a deux (French for

double insanity) is a disorder in which the delusion(s) of one person

induce another to believe the idea. This most commonly happens among

family members, and the inducer usually has a degree of authority

over the recipient. The disorder can extend to involve a number of

recipients. Though folie a deux is usually seen in the context of a

psychotic disorder, it illustrates the power of environmental influences.

142

Epidemiology


The very nature of PPD makes it difficult to study and assess accurately.

Estimates of prevalence range from 0.5% to 2.5%. No gender

differences have consistently been reported.

Ego Defenses

The defense mechanisms used by paranoid patients are akin to selffulfilling

prophecies. They induce others to act or feel what the paranoid

patient accuses them of in the first place. The principal ego defense

used in PPD is projection. This substitutes an external threat for an

internal one, while keeping out of awareness struggles with power,

aggression, desire for same-sex closeness, racial or religious biases,

etc. Other defenses used are: projective identification, denial,

splitting and reaction formation.

Depending on ego strength, projection can take place on a psychotic,

borderline, or neurotic level. In PPD, it does not progress to a psychotic

level, but an understanding of this defense is important in all paranoid

conditions.

Projective Identification is a three-step process:

• First, as in projection, a threat is externalized toward the therapist.

• Second, the therapist is then controlled by the projection (via

interpersonal pressure from the patient), and starts to feel or act in a

way that is congruent with the projection.

• Third, the projected material is processed by the therapist and

incorporated (re-introjected) by the patient, confirming and perhaps

modifying his or her internal experience.

This is a conceptually difficult defense. In essence, projective

identification binds others to patients. It facilitates a degree of control

over the behavior of other people. An alternate explanation is as

follows: a patient tries to get rid of (project) certain feelings, but

maintains a connection with them and needs reassurance that they

are realistic. The projections “fit” the person on whom they are targeted.

This can provoke strong reactions in others. This happens because

within everyone exists the repertoire of reactions, defenses and

attitudes that are being projected by the patient (e.g. envy, greed,

selfishness, lust, etc.). Weathering this emotional barrage is an integral

part of dealing with paranoid patients. An example is as follows:

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Positive Exchange

Patient: I know this is just our second session — I don’t have a reason

to feel this way, but I already think that you’re waiting to expose and

humiliate me. You just hide it better than others.”

Therapist: In what way do you think that I will expose you? Why do

you suspect that I want to humiliate you?

Negative Exchange

Patient: You headshrinkers are all the same. You keep notes about

me and I can’t even see them. I don’t care what you say. You don’t

know me and you’ve been wrong about everything so far.

Therapist: Now look here — I’m trying to help you. If you can’t relax

and trust me this is going to be a waste of time.

In the first example, the patient projects a persecutory fantasy onto

the therapist and is aware that this seems irrational. It is done in a way

that shows an observing ego and allows the therapist to explore the

fantasy and work with the patient.

The second example shows that the patient has similarly projected

hostile feelings onto the therapist, but feels humiliated instead of

questioning why such a strong feeling is present. The accusation hasn’t

lessened the patient’s

suspicion, which

would be the main the

purpose of using

projection as a

defense. The angry

counterattack to the

perception of a threat

has already mobilized

interpersonal

defensiveness on the

therapist’s part,

provoking the very

reaction that was

feared in the first

place. Kernberg

described this as

“maintaining empathy”

with what has been

projected.

144


Projection/Projective Identification in Two Scenarios

145



A. A pervasive distrust and suspiciousness of others such that their

motives are interpreted as malevolent, beginning by early adulthood

and present in a variety of contexts, as indicated by four (or more) of

the following:

(1) suspects, without sufficient basis, that others are exploiting, harming

or deceiving him or her

(2) is preoccupied with unjustified doubts about the loyalty or

trustworthiness of friends or associates

(3) is reluctant to confide in others because of unwarranted fear that

the information will be used maliciously against him or her

(4) reads hidden demeaning or threatening meanings into benign

remarks or events

(5) persistently bears grudges, i.e., is unforgiving of insults, injuries,

or slights

(6) perceives attacks on his or her character or reputation that are

not apparent to others and is quick to react angrily or to

counterattack

(7) has recurrent suspicions, without justification, regarding fidelity of

spouse or sexual partner


Mood Disorder With Psychotic Features, or another Psychotic

Disorder and is not due to the direct physiologic effects of a general

medical condition.




Increasing Severity

146


Feelings of being watched, talked about, lied to, or taken advantage of

are universal human experiences. In this context, it is not difficult to

understand the non-bizarre delusions expressed in the above disorders.

The ability to perceive and react to danger in our environment is clearly

an adaptive mechanism, and is the first line in assuring our safety. In

Erikson’s life cycle theory, this is the first need to be met, and is

essential for further development to proceed.

PPD and delusional disorder, persecutory type may have a genetic

link, and distinguishing between the two disorders can be difficult. A

delusional disorder involves a systematized, encapsulated non-bizarre

delusion (for example, it is possible that a person is being sought by

organized crime). The most common themes in non-bizarre delusions

are: persecution, jealousy, grandiosity, erotomania and somatic fixation

(such as being infested with parasites).

Systematization involves a logical scheme of precautions and

concerns if the initial premise is taken as correct. Encapsulation

indicates that the activities of the person outside the delusion are not

obviously unusual. Paranoid personalities are hypervigilant, suspicious,

and self-referential, but fall short of having delusions. Additionally,

their behavior is not encapsulated — it is pervasive throughout most if

not all of their interactions with others.

Differentiation from paranoid schizophrenia is easier; bizarre

delusions, hallucinations, and a formal thought disorder are not present

in PPD. Patients with well-controlled paranoid schizophrenia (residual

phase) may still be prone to delusions. This, as well as the history,

helps distinguish these disorders. The diagnosis of PPD cannot be

made in the presence of schizophrenia, delusional disorder or other

psychotic disorders.


Manic or depressive episodes can manifest paranoid elements, which

are often congruent with the mood state. For example, a manic patient

may think he wields so much influence over others that he has become

a government target. In most instances the mood disturbance is present

first, and is usually significant enough that differentiation is not difficult.

Use of amphetamines or marijuana can also induce paranoid reactions,

though these have been described as being closer to paranoid

schizophrenia. Paranoia has been reported to be a common

psychological reaction in stimulant abuse.

147



Appearance:

Behavior:

Cooperation:

Affect:

Speech:

Thought

Content:

Thought

Form:

Perception:

None characteristic; patients may be wary and have

shifting eyes; in some cases physical abnormalities

or sensory deficits (such as hearing or visual

problems) may be present

Hypervigilant, anxious, or tense

Usually suspicious, guarded, or challenging

Often anxious, hostile, humorless

Fluent; goal directed; can be very articulate

Patients will try to decipher your “true” intentions

and can be quite confrontational when they believe

they have been discovered (such as their medical

information being revealed to others); otherwise, will

generally speak about the plots and conspiracies of

others; may have the belief that events (such as news

events, radio broadcasts, etc.) pertain specifically to

them (called ideas of reference)


Generally intact; heightened awareness to all stimuli

Insight &

Judgment:

Suicide/

Homicide:

Impaired; continually justify suspiciousness and

hypervigilance

More likely to be dangerous to others than to

themselves, but may be self-injurious to preempt

danger/catastrophic consequences that they see as

inevitable

Psythodynamit Aspects

At the core of this diagnosis is extremely low self-esteem. Paranoid

personalities are outwardly demanding, superior, mistrustful, vigilant,

lacking in sentimentality and moralistic. Internally, they are timid,

plagued with doubt, gullible, unable to grasp the big picture, and can

be quite inconsiderate. They exude a stilted, grandiose manner in an

attempt to compensate for their inner selves. Special attention is given

to those with a higher rank, or more power, as they desire strong

allies but are also fearful of being attacked. Self-referential

grandiosity is evident in that everything patients notice is directly related

148


to them. Self-esteem is enhanced by battling authority and people of

importance. Feelings of vindication and moral triumph provide a fleeting

sense of safety and righteousness. Paranoid personalities are litigious

and live out a need to challenge and defeat a persecutory parent.

The initial understanding of PPD involved an underlying conflict over

homosexuality. This evolved into the current understanding, which is

a wish for a same-sex relationship. As children, first attachments

outside the home are generally to same-sex friends. As adults, patients

tend to repeat this tendency because of their isolation. However, it

can be misinterpreted as homosexuality, triggering a series of ego

defenses. Another view is that they are more worried about passive

surrender to others than about homosexuality (Shapiro, 1965).

Homosexuals, minorities and deviants may serve as easy targets for

projected feelings of intimacy and dependency. Interestingly, the

persecutory group often bears at least some resemblance to the

patient. Paranoid patients are constantly warding off humiliation,

transforming any sense of their own culpability into a threat from the

outside. They are fearful of shocking others with their depravity. For

this reason, intimacy is avoided. They expect to be “found out” and

are continuously trying to find the evil intent in others’ behavior. To a

paranoid person, showing weakness invites an attack.

Because of past experiences, and the unacceptability of unconscious

yearnings for closeness, intimacy is avoided. Love is feared as much

as hate. Wishes for closeness are denied and projected. An example

of this process is as follows:

Yearning for closer relationship to someone of the same gender

*

Unconscious misinterpretation of the impulse as sexually motivated

Denial of unacceptable impulse

Projection of impulse onto external group

Unconscious

4, -

Suspicions of a conspiracy

Conscious

Here, this person would only be consciously aware of being

persecuted, while the other steps are carried out on an unconscious

level. Treating PPD can be difficult because of the many steps between

the initial feeling and its subsequent defensive handling.

149



The goal with paranoid patients is to try and create trust via a solid

working alliance. When trust is truly achieved, the therapeutic process

has been successful. The process of acknowledging weaknesses,

making disclosures and attempting an enduring relationship are

important steps in treatment.

There is a strong tendency to try and talk patients out of their

persecutory thoughts. Because people are not universally benevolent,

it is difficult to persuade patients against being bothered by the “clues”

they uncover. In fact, they may perceive the attempt as a ploy to get

their guard down, with the possible effect of increasing their level of

suspicion. It is more helpful to avoid confronting paranoid ideas. To

do this, adopt a “let’s agree to disagree” understanding. Paranoid patients

are incredibly attuned to the emotions and attitudes of those around

them. Their disorder involves a misperception of what happens, not

missing the details. Challenging their beliefs is seen as an overt comment

on their sanity, not on the fact that they have misinterpreted aspects of

their environment.

If asked directly about your beliefs, try to use an empathic statement

that validates their feelings but also offers an alternative explanation.

For example, “I can see why you are upset about people at work talking

about you. Anyone would find that uncomfortable. However, could it

be possible, just possible, that there is another explanation for what is

happening?” This at least opens the door to a future re-examination

by patients but gives them the option, in the short term, of feeling

supported, and taking or leaving what you’ve said.

The usual practices in psychotherapy are less likely to be successful

with paranoid patients. Interpretations that attempt to probe the depth

of their conflicts are not going to be graciously received. Consistency

is another critical element in the therapeutic process. Regardless of

the details of how therapy is carried out (missed sessions, telephone

calls, vacations etc.), it is important that the framework be consistent.

Attention to behavior or verbal slips (parapraxes) only increases

anxiety. Early scrutiny of ego defenses evokes unmanageable anxiety,

regression and the use of even more primitive defense mechanisms.

Another maxim in therapy is to “analyze resistance before content.” In

the interest of building an alliance, it may be better to provide

150


straightforward answers to patients’ questions. Giving answers, instead

of trying to get at a deeper meaning, conveys an openness and

genuineness lacking in their experiences with others.

However, observance of boundaries is especially important. Every

action or statement can be misinterpreted and prove to be a

complication. Patients are preoccupied with being used for personal

gain. They need to be shown that their tirades can be withstood, and

not alter a therapist’s customary stance.

A sense of humor can be a helpful factor in treating paranoid patients.

While there are risks, they are outweighed by the potential benefits.

Obviously, a sense of appropriateness is warranted. Patients can model

the behavior of the therapist laughing at himself or herself, life’s

coincidences and objects of humor without being degraded. Humor

can be used in therapy by making light of your mistakes, idiosyncrasies

and pretensions. Paranoid patients’ hypervigilance makes it very likely

that your deficiencies will have been noticed. For example, should a

patient mention that you yawned in his or her presence, try a light¬

hearted response about “not being able to get away with anything,”

instead of justifying a hectic schedule.

Another technique is to search for precipitants when patients are upset

(look for the DIR). By avoiding confrontation and focusing on the root

cause, paranoid thinking can be altered. When patients do this outside

of therapy, fear of malevolence from others gradually gives way to a

focus on their own motives.

Patients also learn by modeling. By making a distinction between

thoughts and actions, they can learn that it is acceptable to have morbid

fantasies. Patients can learn from their therapist’s capacity to

experience baser feelings and emotions without acting on them. One

does not become bad or evil for simply having thoughts. Patients can

enjoy feelings and fantasies and use therapy to discuss them.

The inner world of aggression, hostility, destruction and confusion

between thought and action leaves patients concerned that their ideas

can injure or annihilate. Convey to patients a personal strength and

frankness that can withstand their fantasies. Overtime, this can be a

rewarding effort. After their haranguing, an appreciation for your

devotion and honesty can emerge. Patients are capable of deep

attachment and protracted loyalty to those for whom they care.

151


Transferente and Countertransfereme Reactions

Paranoid patients are quite active. Their transference is swift, intense

and almost always negative. Their universal tendency to project is

their basis for transference, as there is a great need to disavow

upsetting attitudes, feelings, thoughts, wishes, etc. Therapists are often

seen as humiliating, hostile and derogatory. Paranoid patients

experience authority figures as being superior and having the mission

to expose them. Consequently, patients come across as grim, humorless

and poised to criticize.

In response to early transference reactions, raise the possibility that

there may be a way to help, and that the patient’s best interests are

being kept in mind. This may be difficult. It takes a considerable degree

of comfort to deal with the continued suspiciousness and negative

transference. Serving as a “container” for emotions helps patients learn

that they can’t destroy others simply with their bad thoughts.

Acceptance of strong feelings conveys a sense of safety from

retaliation. Patients eventually acknowledge that the human qualities

they consider unacceptable exist to some degree within everyone.

Same-sex therapists need to be aware that eroticized transference

can occur as a result of the patient’s deprivation and confusion between

thoughts and actions. Should this occur, examine the precipitants to

their reaction, and then explore the feelings behind these precipitants.

The goal is to differentiate fantasies from the boundaries present in

therapy.

Much of the initial time is spent with the therapist being the target of

the ego defenses of projection and projective identification. It is

easy to respond with a sense of vulnerability and defensiveness.

Countertransference is often anxious or hostile, and quite strong. These

powerful feelings can eventually cause a strong dislike for patients

who have the freedom to vent their feelings. However, using

countertransference is the best guide to understanding the affect, or

impulse, that patients are defending against.

Even when therapy has progressed in a stable and dependable

fashion, one minor disappointment can erase your credibility and leave

patients feeling convinced that the therapist’s agenda has finally been

revealed. If countertransference reactions become an impediment,

arrange for transfer or supervision. Personal therapy is an invaluable

asset in understanding countertransference reactions.

152


Suggested Therapeutit Techniques

• The cardinal modalities in treating paranoid patients are: respect,

integrity, tact and patience

• Don’t challenge patients’ negative views or their recollection of events

— instead, get details and empathize with feelings

• Don’t deflate grandiosity — behind it lies low self-esteem

• Share notes and records if requested

• Seek suggestions on how to improve therapy

• Encourage and demonstrate openness

• Accept tirades; avoid the issue of fault; make connections with feelings

— “You must be exhausted. .“It must be difficult. .

• Don’t interpret projections in the early stages of therapy

• Examine your actions for the possible legitimacy of patients’

observations

• Encourage and facilitate elaboration of precipitating factors

Pharmatotherapy

The diagnostic criteria can be grouped into discrete areas for possible

treatment with medication:

Psychotic Symptoms

• ideas of reference; paranoid ideation

Mood Symptoms

• social withdrawal; constricted affect; dysphoria; anhedonia

Obsessional Symptoms

• preoccupation with loyalty, trustworthiness of others, etc.

Anxiety Symptoms

• vigilance

Antipsychotic medications have been tried with some success. When

indicated, low doses of novel agents are used initially. In general,

improvement occurs when the affect associated with the paranoid

thoughts lessens, rather than a clear decrease in persecutory thinking.

Brief psychotic episodes, lasting from minutes to hours, can occur.

SSRIs are useful for decreasing obsessional features, anxiety and

mood symptoms. Reduction of anxiety in particular is necessary before

other types of treatment can begin. Paranoid patients are generally

known to be both wary and intolerant of side effects, so a thorough

explanation of potential reactions is required. PPD can be a premorbid

condition to an Axis I disorder.

153


Cognitive Therapy

Cognitive strategies stress the use of action over words to help develop

trust. The initial task is to increase patients’ sense of efficacy through

improving coping skills. If patients feel more confident, they can handle

the “attacks” of others, and in this way feel less bothered by them. The

step next involves a modification of their basic assumptions and

interpersonal reactions. For example:

Basic Assumption: “The world is a rotten place. It’s a dog-eat-dog

world and if you aren’t careful, you’ll get chewed up and spit out.”

Interpersonal Reaction: Sees others as threats and alienates them

with poor treatment (e.g. unjustified accusations or unwarranted

suspicion).

Result: Other people (understandably) react harshly, which reinforces,

and can even increase the strength of the negative basic assumptions.

The next goal is for patients to test their negative views by trusting

others with small matters and evaluating the outcome. By doing so,

patients become aware that the world has a spectrum of people in it,

ranging from malevolent to benevolent. Once this is achieved,

assertiveness training is used to increase social skills so they can

learn to deal with others in a way that does not provoke hostility.

Hypersensitivity to criticism is a reaction that can be targeted with a

behavioral approach. Initially, patients are taught a type of anxietyreducing

response (e g. progressive muscular relaxation or a

cognitive intervention). Next, biofeedback via physiologic indicators

such as electromyography (EMG) or galvanic skin response (GSR)

is used. When anxiety is generated via a hierarchy of criticisms, it can

be diminished using these methods.

Other interventions that can be used are:

• teaching patients to attend to a wider range of social stimuli, not just

the ones that they selectively abstract (e.g. watch a videotape together

and point out aspects that have been missed)

• helping to correct the interpretation of ambiguous stimuli

• encouraging adjustments in appearance, grooming, mannerisms, tone

of voice, and other factors that other people will notice immediately

teaching patients to anticipate the consequences of erroneously

accusing others

154


Group Therapy

Paranoid patients generally do poorly in group therapy due to their

active misinterpretation of others’ motives, and the difficulty in

understanding, and dealing, with projective identification. Factors

that make group therapy more likely to succeed are:

• a well-timed introduction — no active confrontational crises occurring

in the group when paranoid patients begin therapy

• well-balanced composition of the group

• ability of the therapist to act as an ally for the paranoid patient

• coincident introduction of a PPD patient with another newcomer

The ability of the group to provide a consensus about suspicions or

projections is a powerful intervention, and group therapy may be more

successful than individual therapy in this regard.


Benjamin (1993) emphasizes the role of sadistic, calculated and

potentially abusive parenting in the etiology of PPD. The child was

made to feel intrinsically bad or evil, and for this deserved to be

ostracized and made into the family scapegoat. When punishment

was given, it was done with a sense of righteousness. Regardless of

how bad the child was, sharing “secret” family information with outsiders

was viewed as an even worse thing to do, so a form of loyalty, and

indeed identification with the parents, develops. The child was seen as

the ultimate cause of his or her own problems (e.g. when injured in a

fight, it was he or she that started it). Ultimately, the child learned that

others were not a source of comfort and could not be trusted.

Benjamin proposes a particular technique to help develop rapport with

paranoid patients — take the position that they are making complete

sense and try to see their world as they see it. Once an alliance has

begun to develop, patients need to learn that not all environments are

the same as the one in which they were raised. Patients treat others in

a way that wards off an attack (anticipatory retaliation) that is unlikely

to occur. When a patient can become aware that he or she is acting like

a hated parent, the motivation to alter maladaptive patterns may emerge.

Because patients are both loyal to, and identified with, an abusive parent,

it may be more helpful for them to understand how vulnerable this parent

was, rather than vilifying the responsible party. This helps avoid the

feelings of guilt patients may develop by participating in a therapeutic

process that is critical of their family.

155


Case Example

Mr. Noyd is a 42-year-old, divorced man. He is quite comfortable in his

present occupation as a movie theater projectionist, but his life has

been punctuated with hardship and abrupt changes until he found this

job. He was an avid fan of military history as a child. In particular, he

was impressed at the respect given to his grandfather, who was an

infantryman. Mr. Noyd joined the armed forces and initially did very

well there. His difficulties began when he could not tolerate the antics

of his peers. On one occasion he was the target of a practical joke

during a ceremonial parade, and he felt he was held back from a

promotion because of this. It became impossible for him to tolerate the

idea of camaraderie with those whom he saw as sabotaging his progress.

A movie theater near the base hired him as an assistant manager. He

was again uncomfortable with having to be responsible to one party

(the manager) for the activities of others (the staff) and instead applied

for the position of projectionist. He enjoyed the power of having a

unique skill in the organization. Mr. Noyd was protective of new

releases and did not want theater staff telling anyone he allowed a

preview before the proper date. While he alienated many potential

friends this way, he wanted to be seen as doing his job properly. He

enjoyed his occupation because movies, in his view, confirmed his

view that people were by nature malevolent.

Course

Comparatively little research has been conducted on PPD because it

has a tradition of being poorly treatable. PPD tends to run a chronic

course, and is resistant to therapeutic efforts in general. Patients readily

find evidence from their surroundings and interactions with others to

reaffirm their suspiciousness. On a daily basis, newspapers, TV, and

radio programs pass along the details of personal tragedies, validating

the degree of vigilance maintained by paranoid patients.

Patients tend to have enduring problems at work and in relationships.

Little is known about the longitudinal course of this disorder. However,

later in life paranoid ideation becomes an increasingly common finding.

As cognitive faculties wane, exaggerated issues of safety emerge.

Many geriatric patients are brought to therapeutic attention by families

tired of the endless accusations of theft or swindling. Elderly patients

not infrequently limit their travels outside their dwellings, and in extreme

cases, will barricade themselves in their rooms.

156


References



Edition


L. S. Benjamin

Interpersonal Diagnosis & Treatment of Personality Disorders





G. Gabbard

Psychodynamic Psychiatry in Clinical Practice, The DSM-IV Ed.


H. Kaplan, B. Sadock, Editors

Comprehensive Group Psychotherapy, Second Edition





N. McWilliams






E. Othmer& S. Othmer



D. Shapiro

Neurotic Styles

Basic Books, New York, 1965

157


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158


Review Questions

1. Which of the following statements is not consistent with the underlying

cognitive schema for PPD?

a. I will not let others take advantage of me because I am smart enough

to notice the small signs that reveal their intentions.

b. I do not trust that other people will assist me.

c. I severely punish those who betray me or are about to betray me.

d. I follow the rules exactly and I strive to be completely correct.

e. I am a private person. What I experience is not your concern.

2. One of the key features of generalized anxiety disorder is the

persistent expectation of events turning out poorly. Patients with social

phobia fear public embarrassment and humiliation. How do these

disorders differ from PPD?

3. Millon has described a subtype called the “fanatic” paranoid.

Characteristics include: enhanced self-image, haughty behavior,

arrogance and exploitation. To which other condition does this

description apply?

159



1. Choices a, b and c are clearly reflective of PPD. Choice d is more

reflective of the obsessive-compulsive personality disorder, though it

can apply to PPD. Paranoid patients are often lonely figures who re¬

main out of sight except when on “missions” of a righteous nature.

Many paranoid patients desire acknowledgment for their achievements

but are quick to sense criticism. They respond with resentment and

indignation whereas obsessive patients will usually redouble their ef¬

forts and keep trying. Choice e applies to PPD as well as other diag¬

noses such as the obsessive-compulsive and schizoid personalities.

This answer was derived from the DSM-II criterion that the intellectual

processes of the paranoid patients are intact except for circumscribed

areas and that self-control is valued more highly than emotional ex¬

pression.

2. Patients with generalized anxiety disorder manifest excessive worry

about a number of events. The anxiety is egodystonic, difficult to

control and can cause a number of somatic symptoms. Patients with

PPD are more concerned with when something will happen, than whether

it will occur. Anxiety-prone patients see themselves more as the victims

of fate, whereas paranoid patients feel themselves to be victims of

design. Similarly, anxious people take a passive stance towards their

concerns, whereas paranoid people take active steps to avoid or pre¬

vent feared consequences, or to punish those they see as responsible.

In social phobia, the humiliation comes from within the patient and is

automatic. Paranoid patients believe that other people cause or con¬

tribute to their feelings of humiliation.

3. The narcissistic personality disorder. These two disorders also

share expansiveness, self-referential grandiosity and an air of con¬

tempt.

References

L. S. Benjamin

Interpersonal Diagnoses & Treatment of Personality Disorders








160

Rapid Psyrhler Press

The Sthizotypal Personality

161



Name:

Occupation:

Appearance:


Favorite Song:

Motto:

Aldrina Q. Cosmos

Developer for a UFO landing pad

Tin foil hat, unpaired socks, mood

ring, dress hemmed with staples

Laments the fact that her pet budgie

remains dead, despite seances

Dark Side of the Moon

There are no strangers, just friends

from past lives


Before Session:


During Session:

Fantasies Involve:



Brings to Session:

Reads palms, tea leaves and tarot

cards of others in the waiting room

Astrology Weekly

Initiates session by talking to herself

A management position with the

Thought Broadcasting Corporation

Casts a spell on therapist

Plays with voodoo Barbie doll

An autographed copy of her new

book on neologisms,

“How to Call ’Em as I see Em”


"UFO AIDER"

Unusual perceptions

Friendless except for family members

Odd beliefs, thinking and speech

Affect is inappropriate or constricted

Ideas of reference

Doubts others — suspicious and paranoid

Eccentric appearance and behavior

Reluctant in social situations

162

Introduction

The Schizotypal Personality

The word schizotypal is a contraction of schizophrenic genotype. This

diagnosis is characterized by deficits in interpersonal relationships

and distortions in both cognition and perception.

Some of the key names associated with this disorder are:

• Kraepelin (1920’s) — noted that relatives of schizophrenic patients

often had schizophrenic spectrum traits.

• Bleuler (1924) — described latent and simple schizophrenia; these

were precedents for this diagnosis (in the Differential Diagnosis Section).

• Fairbairn and Guntrip (1969) — made contributions to the description

and understanding of this disorder.

• Kety (1971) — in his Danish adoption studies, reported on a condition

that resembled schizophrenia but was not as severe; this was initially

called borderline schizophrenia, but the name was changed to avoid

confusion with the borderline personality disorder.

• McGlashan (1983) — conducted a long-term study demonstrating

similar outcomes in schizophrenia and schizotypal personalities.

The schizotypal personality disorder (SztPD) was first included in the

DSM-lll. It is the only personality disorder defined empirically on the

basis of a genetic relationship to an Axis I disorder (schizophrenia).

The symptoms are schizophrenia-like, but are expressed to a lesser

degree, and cause a less severe impact on social and occupational

functioning. Patients exhibit peculiar behavior, exaggerated social

anxiety and idiosyncratic speech.

SztPD overlaps with the positive symptoms of schizophrenia, while

the schizoid personality overlaps more with the negative symptoms

(explained in detail in the Schizoid Personality Chapter).

Patients with SztPD rarely seek medical attention because of their

personality eccentricities alone. Usually an acute stressor or the

encouragement of a family member brings them for help. In response

to stress, these individuals may experience periods of psychosis that

last from minutes to hours. These episodes, often referred to as

micropsychotic episodes, usually last less than twenty-four hours

and therefore do not meet the criteria for a brief psychotic disorder.

These patients have an increased risk of suffering from mood

(depression, dysthymia) and anxiety disorders (social phobia,

generalized anxiety disorder).

163


Media Examples

Schizotypal characters are frequently cast as fortune tellers,

clairvoyants, mystics, psychics, mediums and mind readers. The

presumptive ability of these characters to predict the future or make

revelations about other characters enhances plot development. The

visions, predictions and warnings offered by these characters often

turn into self-fulfilling prophecies for the main characters. Here is a

compilation of some schizotypal characters:

• Ghost — Whoopi Goldberg won an Oscar for her performance as a

storefront medium who conveys messages from a wrongfully murdered

banker to his girlfriend. The humorous scenes involving her fraudulent

attempts to contact the deceased relatives at a seance make her actual

abilities that much more memorable.

• Hello Again — Judith Ivey turns in an endearing performance as

Zelda, the witch-like sister, who resurrects the main character one

year after her death. Her name, apparel, supernatural bookstore and

various incantations all add to a colorful portrayal.

• Benny & Joon — Mary Stuart Masterson portrays Joon, a troubled

young woman, who alternates between being a creative spirit when

things are good and a raging arsonist when she is upset. Though her

diagnosis is not directly revealed in the film, she most likely suffers

from schizophrenia. Her difficulties with relationships, along with her

eccentricities, provide a sampling of schizotypal qualities.

• Macbeth (Shakespearean play, movie versions released in 1948 &

1971) — The three witches who issue puzzling prophecies to Macbeth

and Banquo have schizotypal features. They use unusual speech (“Fair

is foul, and foul is fair”), perform a ritualistic dance and concoct a

magical brew in a cauldron.

Other schizotypal characters can be seen in:

• Live and Let Die

• Pet Semetary

• The Witches of Eastwick

• Beetlejuice

• Practical Magic

• The Addams Family (1960’s TV show, movie versions in 1991 &

1993)

164



Schizotypal patients often seem unusual in interviews. Empathy and

nonjudgmental acceptance of (but not agreement with) their irrational

perceptions is necessary in order to establish rapport. Once this is

achieved, persistent inquisitiveness reveals a sanctuary of unusual

ideas. Often these patients will reveal insights, eccentricities and

connections that make them sound like they are from another planet.

It is not usually difficult to maintain the interview once these patients

feel accepted. Use facilitating techniques such as open-ended questions,

and ask for specific information and examples to illustrate answers. As

long as patients feel you can appreciate their experiences, they will be

cooperative.

In a well-conducted interview, schizotypal patients may sense a

connection, and ask if you share the same experiences. In this situation

it is important to preserve the tone you have set. Do not dismiss their

views or prematurely confront them with reality. “Agree to disagree”

on the idea/point/issue in order to preserve rapport.

Sthizotypal Themes

• Clairvoyance

• Ideas of reference

• Suspiciousness

• Emotional reasoning

• Ineffectual existence

• Cognitive autism

• Periodic decompensation

• Depersonalization

• Premonitions

• Alternative/fringe interests

• Existential concerns

• Magical thinking

• Flat, emotionless affective style

• Pan-anxiety and pan-neurosis

• Concrete thinking

• Erratic progress in life

Etiology

Biological: The schizotypal personality disorder has a strong genetic

link to schizophrenia. Adoption and family studies have consistently

found an increased prevalence of schizophrenic spectrum disorders

in the relatives of patients with SztPD.

Similarly, there is an increased prevalence of SztPD in the relatives of

patients with schizophrenia. Epidemiologic studies have shown the

prevalence of SztPD to be three times that of schizophrenia in the

general population. It may be that the SztPD is a milder and more

common expression of the schizophrenic genetic diathesis.

165


Biological and physiological findings in schizophrenia may also be

abnormal in patients with SztPD:

• Smooth pursuit eye movement (SPEM) abnormalities — when

following a moving object, rapid eye movements (saccades) occur

instead of smooth, conjugate tracking.

• Auditory evoked potentials (EP) measure neural activity in response

to a sound. Potentials are identified by polarity (positive or negative

— P or N) and latency after the stimulus (in milliseconds). In these

patients, there is a decrease in the size of the positive peak at 300ms

(P300) which may represent a defect in cognitive processing.

Impairment is also seen on other tests of visual or auditory attention.

• Elevated levels of homovanillic acid (HVA) in the cerebrospinal fluid

and plasma may be associated with positive symptoms.

• An abnormally high ventricle-brain ratio (VBR) is seen on CT scans.

Psychosocial: The concordance rate for schizophrenia in

monozygotic twins approaches fifty percent. Put another way, if one

twin develops schizophrenia, the other has a fifty percent chance of

doing so. This emphasizes the role of psychosocial factors in the

development of psychiatric disorders. Due to the relatively recent

description of SztPD as a separate disorder, there are few theories

about what may constitute a definite psychosocial contributor.

A number of psychosocial theories have been advanced regarding

schizophrenia and may be operative in the pathogenesis of SztPD:

• Social Causation: This theory postulates that being a member of

lower socioeconomic classes is significant in causing mental illness.

• Learning Theory: Emotionally disturbed parental figures act as

models for the irrational behavior seen in patients.

• Double Bind: Conflicting messages within a family cause patients

to withdraw into a regressed state to avoid unsolvable problems.

• Schisms and Skews: This theory postulates that abnormal patterns

of interaction within families lead to an unhealthy alignment of a parent

(or an abnormally dominant caretaker) with a child.

• Pseudomutual and Pseudohostile Families: The mutual/hostile forms

of interaction suppress emotional expression. Such a family develops

an idiosyncratic pattern causing difficulties when children are required

to relate to others.

166


• Expressed Emotion (EE): This is defined as showing hostility,

criticizing, or becoming overinvolved with patients. This is an important

educational point for the families of affected individuals, and also has

therapeutic and prognostic implications.

Given the genetic correlation of SztPD with schizophrenia and the

difficulties schizotypal personalities have with cognitive processing, it

can be hypothesized that environmental conditions create difficulties

at all stages of development. In the vulnerability-stress model, a person

is genetically “loaded” (called a diathesis), and then a stressor causes

the emergence of the disorder. The actual stress can take many forms:

• Parents who are too indulgent, neglectful, authoritarian or just overly

something.

• Substance use, abuse or dependence.

• The threatened or actual break-up of a relationship.

• Intrusion into a usually secretive, isolated lifestyle.

• The stresses of leaving home and/or academic hardship.

In summary, it seems that an inherited schizophrenic genotype causes

deficits in neural integration which, when combined with environmental

influences, lead to an abnormally organized personality.

Epidemiology

The prevalence is estimated to be 3% of the population. While there is

no consistently reported gender difference, women may display more

positive symptoms.

Ego Defenses

Ego defenses in SztPD are generally primitive or narcissistic, and

used to extreme degrees (psychosis in some cases):

• projection: discussed in the Paranoid Personality Chapter

• denial: abolishment of external reality, which is replaced with a wishfulfilling

fantasy

• distortion: reshaping reality to meet inner needs, leading to unrealistic

beliefs, overvalued ideas, hallucinations, etc.

• idealization: external objects are seen as being “all good” and are

viewed as being omnipotent

• splitting: dividing external objects into all good or bad with abrupt

shifts between these perceptions

• schizoid fantasy: the avoidance of intimacy, and an autistic retreat

in an attempt to resolve conflicts

167



A. A pervasive pattern of social and interpersonal deficits marked by

acute discomfort with, and reduced capacity for, close relationships as

well as by cognitive or perceptual distortions and eccentricities of

behavior, beginning by early childhood and present in a variety of

contexts, as indicated by five (or more) of the following:

(1) ideas of reference (excluding delusions of reference)

(2) odd beliefs or magical thinking that influences behavior and is

inconsistent with subcultural norms (e.g., superstitiousness, belief in

clairvoyance, telepathy, or “sixth sense”; in children and adolescents

bizarre fantasies or preoccupations)

(3) unusual perceptual experiences, including bodily illusions

(4) odd thinking and speech (e.g., vague, circumstantial, metaphorical,

overelaborate, or stereotyped)

(5) suspiciousness or paranoid ideation

(6) inappropriate or constricted affect

(7) behavior or appearance that is odd, eccentric, or peculiar

(8) lack of close friends or confidants other than first-degree relatives

(9) excessive social anxiety that does not diminish with familiarity and

tends to be associated with paranoid fears rather than negative

judgments about self


Mood Disorder With Psychotic Features, another Psychotic Disorder,

or a Pervasive Developmental Disorder.




The term schizophrenic spectrum has been used to describe disorders

that appear to share a common genetic basis but differ in the degree

of expression. This spectrum is illustrated on the next page.

There is a considerable overlap in the mental status findings and the

symptoms of these disorders. In many cases, differentiation is made

by the degree to which such findings are expressed instead of just

their presence or absence. For example, overvalued ideas are often

encountered in personality-disordered patients, but the rigidity in thinking

is not of delusional intensity. Similarly, hallucinations in personalitydisordered

patients are brief and less frequent than in schizophrenia.

168


The Sthizophrenit Spectrum of Disorders

4*

severity

increases

with

progression

down the

page

*

SztPD is differentiated from schizophrenia, delusional disorder and

a mood disorder with psychotic features by the absence of enduring

psychosis. The presence of one of these disorders excludes the

diagnosis of SztPD. Patients with SztPD also lack the clear change in

level of function that occurs with more severe disorders. In order to

distinguish this personality disorder from the residual or prodromal

stages of schizophrenia, collateral history may be required.

Additionally, thought form and content in SztPD are disturbed to a

lesser degree than in schizophrenia.

Brief psychotic episodes lasting minutes to hours can occur in SztPD.

The diagnosis of brief psychotic disorder requires that a psychotic

disturbance last at least one full day, but less than one month, with a

florid thought disorder. Disorders due to substance use or to a general

medical condition must be considered in the differential diagnosis of

all psychiatric patients.

169



As with SzdPD, any disorder that is marked by eccentric behavior,

isolation and peculiarities of language needs to be differentiated from:

autism, Asperger’s disorder, expressive and mixed receptiveexpressive

disorders. Language disorders are established by the

primacy and severity of these difficulties in relation to other symptoms.

Prior to the DSM-III, schizotypal features were incorporated under

certain subtypes of schizophrenia. Although the terms below are not

included in the DSM-IV, they are still used occasionally and encompass

descriptions that overlap with the concept of SztPD:

Latent Schizophrenia: A thought disorder or occasional behavioral

peculiarities occur; progression to a clear state of psychosis does not

occur. Also knows as borderline or pseudoneurotic schizophrenia.

Simple Schizophrenia: Gradual, insidious loss of drive, interest and

initiative. Vocational performance deteriorates and there is marked

social withdrawal. Hallucinations or delusions may be present, but

only for brief periods of time.

In the ICD-10, the schizotypal personality is called the schizotypal

disorder and is considered a major psychiatric disorder along with

schizophrenia and delusional disorders.

Mental Status Findings

The most notable abnormalities in the mental status examination of a

schizotypal patient occur in the areas of perception, thought content

and thought form. Examples of these findings are as follows:

Perceptual Abnormalities

A hallucination is a perception of a nonexistent external stimulus,

occurring in any of the five senses; most frequent are auditory, then

visual; other types are more indicative of general medical conditions

(e.g. temporal lobe epilepsy). An illusion is a misperception of an

existing external stimulus, which can also occur in any of the five

sensory modalities.

Depersonalization is the subjective sense of feeling unreal, unfamiliar,

or that one’s identity is lost. Derealization is the subjective sense that

the environment is unreal or strange.

170


Thought Content

Thought content refers to what a person is thinking or talking about.

Delusion: A fixed, false belief out of keeping with cultural norms, and

inappropriate for the level of education or intelligence.

Overvalued Idea: Similar to a delusion, but of lesser intensity.

Idea of Reference: Belief that the actions of others refer to that person,

or that radio or television broadcasts may contain special messages

for that person; if unshakable, this is called a delusion of reference.

Idea of Influence: Belief that another person or force controls that

person. If not amenable to change, called a Delusion of Influence.

Magical Thinking: Belief that thoughts, words, or actions have special

powers. For example, something can happen simply by wishing it.

Thought Form or Process

Thought form refers to how a person is thinking or talking.

Neologism: A new word with an idiosyncratic meaning. Sniglets are

made-up words that have an understandable meaning:

Neologism: Flogblock — the name for the tongue on a shoe.

Sniglet: Burgicide — when a hamburger patty falls between the slats on a

barbeque grate.

Circumstantiality: An indirect form of speech eventually addressing

the point or answering the question, but overinclusive of detail. If A is

the starting point and B is the goal, circumstantial speech is:

Tangentiality: An inability to express goal-directed thought. If A is

the starting point and B is the goal, tangential speech is:

Loosening of Associations: Flow of thought where ideas do not follow

an understandable or logical sequence. If A is the starting point and B

is the next logical step, loose associations are symbolized as follows:

A-»G-»X-»J-»K-»V-»R-»Q-»F

171



Appearance:

Behavior:

Cooperation:

Affect:

Speech:

Thought

Content:

Thought

Form:

Perception:

Insight &

Judgment:

Suicide/

Homicide:


Often peculiar; may have amulets, charms, odd

jewelry; don’t reflect social convention or current

styles; accessories/colors may have special meaning

May be anxious towards a skeptical interviewer;

behavioral oddities may include unusual facial

expressions; odd affectation

Cooperative, especially in a receptive atmosphere

Ranges from restricted/flat to animated; varies from

topic to topic

Unusual or idiosyncratic meaning to some words;

context can be odd; may use neologisms

Paranoid ideas; suspiciousness; magical thinking;

telepathy; premonitions; “sixth sense”; out of

body experiences; bizarre coincidences; extra

sensory perception (ESP); “otherworldly” matters

No characteristic abnormality; may be tangential,

circumstantial, vague, overelaborate or metaphorical

May have unusual perceptual experiences

Partial; may be aware others consider them odd;

judgment is based heavily on their perception of

reality which is not verifiable

Need to consider this in conjunction with any Axis I

disorder; not generally dangerous to others or

themselves; risk increases with the presence of a

formal thought disorder or marked paranoia

The psychodynamic theories regarding schizophrenia and SztPD are

similar, and the disorders can be considered as mainly varying in degree

of severity. Freud hypothesized that schizophrenic patients are fixated

at an early stage of development. The resulting defects in ego structure

facilitate psychotic regression in response to conflict or frustration.

Additionally, Freud thought that schizophrenic patients reinvest psychic

energy (known as cathexis) back into the self, instead of towards

people (objects) around them. This contributes to the development of

an autistic world with subjective thinking, introversion and personal

use of language, which are features also seen in SztPD.

172


Some of the psychoanalytic concepts that pertain to the psychological

factors in the etiology of schizophrenia are relevant to understanding

the development of the SztPD:

• Object constancy is not achieved. This is defined as the ability to

develop evocative memory and create a stable intrapsychic image of

a caregiver. Without this, the person faces difficulty in progressing

beyond the oral stage of development, typified by complete

dependence on a caregiver. A defect in developing a separate identity

predisposes a patient to a personality structure that is vulnerable to

disintegration under stress. Due to the fixation of development at this

early stage, primitive ego defenses are used.

• Conflict between the ego and id is theorized to cause neurotic conflict,

characterized by anxiety, hypochondriasis, obsessions and

compulsions (called pan-anxiety and pan-neurosis). The conflict in

psychosis is between the ego and the external world, where reality is

disavowed and reconstructed via hallucinations, delusions, etc.

• Psychotic thought processes have a symbolic meaning for the patient.

Schizotypal patients may be overwhelmed by the demands and stresses

placed on them, and create an alternate reality that is more manageable

and comprehensible. Perceptual abnormalities and delusions often

represent inner wishes or fears. Magical thinking and ideas of influence

represent wishes for child-like omnipotence over uncontrollable,

unbearable or unpleasant events.

An infant having temperamental difficulties with attachment may

perceive his or her mother as rejecting, and then withdraw from her.

However, the infant’s needs grow until they seem insatiable. At this

point, the infant may fear that its own greed will devour mother, with

subsequent abandonment. As adults, schizoid and schizotypal patients

are affected by highly conflicting feelings, on the one hand fearing

that their neediness will drive others away, but also fearing that others

will devour them (projected greed) if they get too close. These oral

issues of devouring others or being devoured stem from stasis at the

oral stage of development.

As with schizoid patients, a schism exists within schizotypal patients,

resulting in a diffusion of their identity. They seek distance to maintain

their safety and separateness, and though desiring closeness, may

complain of alienation and loneliness.

173


Psychodynamit Therapy

For all psychiatric conditions, a higher level of functioning prior to

entering therapy generally predicts a better outcome. Diagnosis is

only one parameter that needs to be considered in a treatment plan.

A comprehensive assessment of a patient’s strengths, coping skills,

intelligence and ability to form attachments is essential in guiding

psychotherapy of any type.

In general, Cluster A patients are vulnerable to decompensation under

stressful conditions. Along the continuum of techniques, a supportive

focus is recommended over an exploratory or confrontational one.

Typically, a “here and now” directive approach is more useful.

Schizotypal patients often use primitive ego defenses because of their

presumed fixation at the oral stage of development. The importance

of establishing and preserving rapport is critical for initiating therapy.

An interested and accepting stance needs to be maintained, regardless

of how odd the material they share.

The most frequent complication arises when patients seek to test their

perceptions, or ask for reassurance about them. It may be more

profitable to address the feelings expressed (fear, sadness, etc.) with

these unusual ideas and experiences than it is to be the arbiter of

reality. Internalization of a nonjudgmental relationship with a respectful,

interested therapist is much more helpful for schizotypal patients than

are interpretations regarding their use of the psychic hotline or other

forays into alternative pursuits.

As in any therapy, patients’ attempts at altering their interpersonal styles

will frequently be met with resistance. In schizotypal patients, this is

likely to take the form of silence because their fundamental difficulty is

that of relating to other people (DSM-IV criteria eight and nine). Just

as with the expression of unusual perceptions and ideas, silence should

be non-judgmentally accepted. Silence in this situation is a defensive

retreat on the patient’s part. Use of projective identification evokes

distancing responses from therapists, as it does from others in the

patient’s life.

As therapy proceeds, the therapist may need to serve as an auxiliary

ego. Schizotypal patients have a tendency to misinterpret reality and

focus on hidden or symbolic meanings, rather than on the intended or

most obvious ones.

174


SztPD shares two key features with schizophrenia:

• concrete thinking: a style of thinking characterized by literalness

and lack of generalization or abstraction; patients often miss the humor,

irony or multiple meanings in situations

• difficulties with ego-boundaries: patients do not have a well-developed

sense of themselves and may be confused about where they end and

another person begins (called identity diffusion)

Other situations may arise where patients need help with practical

matters or guidance with decision making. Once trust has developed,

entertaining a creative or benevolent skepticism about patients’ ideas

and perceptions will improve reality testing. Over time, the goal of

therapy is to help patients develop a more cohesive, integrated sense

of self. Internalization of the therapeutic relationship facilitates an

awareness of unconscious conflicts and provides an opportunity to

reduce conscious fears about intimacy.

Transferente and Countertransference Reactions

The initial transference reaction schizotypal patients manifest is to

test whether the therapist is concerned enough about them to tolerate

their peculiarities and distant interpersonal style. Long silences may

need to be endured, as these patients are prone to detach and withdraw

while overcoming the fear of being dismissed as amusing crackpots.

Countertransference manifestations are generally due to the

painstakingly slow progress made by these patients. Therapists must

be able to tolerate the limited gains that may be made initially in areas

outside of interpersonal relationships. Therapists must also be wary

of the process of projective identification and monitor their reactions

without ridiculing patients or falling into a state of counterdetachment.


• be patient; the process of therapy outweighs the content

• consistency and punctuality help foster a stable image of the therapist,

the therapy, and ultimately the patient

• try to understand the latent or symbolic content of perceptions and

unusual thoughts

• be flexible in giving advice, or assisting in making decisions

• maintain firm ego boundaries; clarify distortions when they occur

175


Pharmatotherapy

The diagnostic criteria can be grouped into discrete areas that can

each be targeted by a group of medications:

Psychotic Symptoms (positive symptoms)

• ideas of reference; paranoid ideation; thought disorder (odd thinking);

perceptual distortions

Mood Symptoms

• social withdrawal

Anxiety Symptoms

• social anxiety

Intuitively, it would seem that antipsychotic medication would be useful

in treating SztPD. Neuroleptics are the mainstay of treatment for

schizophrenia and work well for reducing positive symptoms, which

are mainly those manifested in SztPD. The response of schizotypal

patients to antipsychotic medication is a good test of the biological

dimension of this personality disorder.

Some studies have looked at the use of antipsychotic and antidepressant

medication, specifically the SSRIs. Overall the results revealed:

• significant reductions in impulsivity and aggression with SSRIs

• psychotic symptoms showed the best response to medication,

especially cognitive/perceptual disturbances

Newer antidepressants, with their combined action on both

dopaminergic and serotonergic receptors, may have a greater role in

the treatment of SztPD.

Cognitive Therapy

Basic Cognitive Distortions:

• Mistrust, suspiciousness or frank paranoid ideation

• Ideas of reference — “There are special messages for me”

• Magical thinking — “I can make something happen just by wishing it"

• Illusory percepts — “I see important historical figures every day”


The automatic thoughts in SztPD often reveal the distortions of

emotional reasoning and personalization. In emotional reasoning,

the person has a negative emotion and automatically forecasts that

there will be a negative occurrence. Personalization is similar to an

idea of influence in that a person falsely believes he or she is

responsible for, or has control over, an external situation. Concrete

thinking is also a feature, a typical example being:

176


Q. “What brought you to hospital today?”

A. “An ambulance.”

After a solid working alliance has been established, cognitive strategies

focus on increasing social appropriateness. This helps improve dayto-day

functioning in the areas of hygiene, social skills and personal

management. These skills are reinforced through modeling, roleplaying,

structured sessions and setting short-term goals that are

subject to frequent review.

The next step involves the critical aspect of teaching patients to look

for objective evidence in the environment with which to evaluate their

automatic assumptions. Along with this, patients are asked to consider

the consequences of relying only on their emotional responses.

Practice and patience are required because schizotypal patients have

many distorted cognitions, and not all are amenable to change over a

short time period. Some gains can be made by having patients first

record their predictions and later assess their accuracy.

It is unlikely that these patients will ever completely eradicate their

bizarre notions, but they can gain some emotional relief by recognizing

inaccuracies. A realistic goal is to teach coping skills that decrease

behavioral and emotional responses, and increase patients' awareness

of their inappropriateness. An example is repeating a coping statement

such as "Just because I have this thought/feeling doesn’t mean that it

is really happening.”

Finally, schizotypal patients may need help with their communication

style. Some patients overlook essential information in a situation and

need to focus their attention on the most salient points. Other patients

get lost in a sea of irrelevant detail and can be encouraged to make

summary statements to streamline their circumstantiality.

Group Therapy

Group therapy can be of considerable benefit to schizotypal patients,

particularly in the area of increasing their socialization skills. The group

functions as an extended family providing corrective emotional

experiences that increase schizotypal patients’ comfort with others.

Difficulties can arise with patients who are too bizarre, or too different

from other members. Prolonged silences and lack of contribution may

cause the group to ignore or ridicule schizotypal patients.

177


Interpersonal Psythotherapy

Benjamin (1993) hypothesizes that as children, schizotypal patients

were punished in a “do as I say, not as I do" situation, which she terms

inappropriate autonomy. For example, a parent who ate chocolate

chip cookies before dinner would discipline the patient for doing the

same thing. Furthermore, that parent would profess to know what the

patient was doing even when not in the room (such as being telepathically

aware of the cookie count). In this way, the parent facilitated the

development of an altered sense of reality, which involved magical

thinking. As this continues into adulthood, patients believe that they

receive valid and important information through special channels, also

called having a “sixth sense.” However, whereas many people will

entertain hunches or have premonitions, schizotypal patients treat these

notions as if they are factual.

Other factors considered to be contributory are a history of abuse and

prohibitions against leaving the home to be with others. Patients may

also have been told that they carried a special destructive power, and

that adherence to illogical protocols was required in order to avoid or

prevent a catastrophe. All of these factors together promoted deference

to unknowable powers and complex rituals. Spending a good deal of

time alone as children interfered with adequate social opportunities

and allowed only their imaginations to answer questions about how the

world works.

The schizotypal patient presents to therapy with a mixture of

omnipotence, deference, detachment and restrained aggressive

feelings. In order to engage patients in therapy, it will be necessary to

allow them to “control” early sessions. This involves such aspects as

not answering your questions, leaving sessions when they have had

enough and choosing the time of the next appointment. Pattern

recognition can come about by linking patients’ chaotic early

experiences to their assumptions about why things happened (for

example, assuming that a parent must have been overtaken by an evil

spirit when he or she was abusive). Caution must be used in being

critical of caregivers early in therapy. Patients often identify with their

abusers and are likely to experience guilt and traitorous feelings if too

critical a stance is taken. Distortions in reality can eventually be corrected

when they occur in therapy by teaching patients to make connections

between their early experiences and unrealistic thoughts. Helping

patients understand how the “real world” failed them can help strengthen

their will to learn new ways of coping.

178

Case Example


Ms. Cosmos is a single woman in her early forties. She has never

been married and is not currently in a relationship. Though describing

herself as highly intelligent and possessing a college degree, she is

not currently employed and has not been since her stepfather died.

She spends a lot of time reading about UFOs, extraterrestrial life and

unexplained coincidences. She is convinced that our planet is regularly

visited by aliens. She reasons that humans, by nature, are too violent

to properly receive visitors and would rather dissect them to find out

about their physiological processes. For this reason, she is committed

to developing a landing area which will guarantee that alien visitors

won’t be taken away for experimental purposes. She believes her actions

are monitored and that when her project is complete we will have a

regular stream of visitors from other planets.

Her father left home when she was less than a year old. Her mother

blamed the patient for this departure. In order to “atone” for this, Ms.

Cosmos assumed all of the household duties and developed elaborate

rituals to “will” another man into her mother’s life. When this finally

occurred, she dedicated her existence to attending to his every wish

so that he wouldn’t leave. When he fell ill, she studied aromatherapy

and reflexology in order bring him back to health. At his urging, she

enrolled in a degree program in college. When he passed away, he

left her an inheritance, which currently supports her financially. In

leaving her this money she believes he designated her our planet’s key

representative for contacting alien species.

She believes that she is aided in her quest by ideas from both living

and deceased scientists and astrologers. Some of her ideas are sent

to her from off-world sources, which she experiences as concentrated

forms of thought as opposed to auditory stimuli.

Course

The overlap of genetic, biological and phenomenological findings with

schizophrenia gives SztPD one of the more pessimistic outcomes

among the personality disorders. At long-term follow-up, ten to twenty

percent of patients go on to develop schizophrenia. The remainder

appear to have a stable course. Three characteristics of this personality

disorder have been positively correlated with later onset of

schizophrenia: magical thinking, paranoid ideation and social isolation.

179


References



Edition





L. S. Benjamin

Interpersonal Diagnosis and Treatment of Personality Disorders


G. Gabbard

Psychodynamic Psychiatry in Clinical Practice, The DSM-IV Edition


R. Hall & Friends

Sniglets

Macmillan Publishing Company; New York, 1984







N. McWilliams


The Guildford Press; New York, 1994




R. Pies



180


References for Pharmacological Treatment

E. F. Coccaro

Clinical Outcome of Psychopharmacologic Treatment of Borderline

and Schizotypal Personality Disordered Patients

Journal of Clinical Psychiatry 59: Suppl. 1: p. 30 - 37, 1998

S. C. Goldberg, S. C. Schulz, P. M. Schulz, R. J. Resnick et al

Borderline and Schizotypal Personality Disorders Treated With

Low-Dose Thiothixene vs. Placebo

Archives of General Psychiatry 43(7): p. 680 - 686, 1986

P. Hymowitz, A. Frances, L. B. Jacobsberg, M. Sickles & R. Hoyt

Neuroleptic Treatment of Schizotypal Personality

Compr. Psychiatry 27(4): p. 267 - 271, 1986

P. J. Markovitz, J. R. Calabrese, S. C. Schultz & H. Y. Meltzer

Fluoxetine in the Treatment of Borderline and Schizotypal

Personality Disorders


L. H. Rockland

Effect of Tranquilizers on Borderline and Schizotypal Patients

Questioned (letter)


S. C. Schulz, P. M. Schulz & W. H. Wilson

Medication Treatment of Schizotypal Personality Disorders

Journal of Personality Disorders 2: p. 1 - 13, 1988

G. Serban & S. Siegel

Response of Borderline and Schizotypal Patients to Small Doses

of Thiothixene and Haloperidol


P. H. Soloff, A. George, S. Nathan, P. M. Schulz, R. F. Ulrich et al

Amitriptyline and Haloperidol in Unstable and Schizotypal

Borderline Disorders

Psychopharmacol. Bulletin 22(1): p. 177 - 182, 1986

181


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182

Review Questions


1. In the References for Pharmacological Treatment section (listed

two pages previously) a number of studies looked at the borderline and

schizotypal personality disorders together. Why was this?

2. Which of the following are not DSM-IV diagnostic criteria for the

SztPD?

a. ideas of reference

b. delusions of reference

c. occasional, transient minipsychotic episodes with prominent

illusions, hallucinations (usually auditory), and delusion-like ideas

d. excessive social anxiety that doesn’t decrease with time and is

usually associated with suspicious thoughts

3. What is Asperger’s disorder and how is it related to SztPD?

183



1. Establishing diagnostic criteria to distinguish BPD and SztPD has

been a challenge that was still being addressed with the writing of the

DSM-lll-R. Both of these diagnoses involve patients who commonly

manifest thought disorders. Much of the confusion stemmed from the

widespread use of the term “borderline,” which was used in a at least

eight contexts. The aspect that pertained most directly to SztPD was

the term borderline schizophrenia. The aim in developing diagnostic

criteria was to be able to differentiate between SztPD as a

characterological variant of schizophrenia and BPD as being indicative

of an “unstable” personality disorder.

2. Ideas of reference are part of the DSM-IV diagnostic criteria, but

not if they are on the scale of a delusion. Choice c is from the ICD-10

criteria for schizotypal disorder (recall is it not considered a personality

disorder). Here, “delusion-like ideas” are included, which may be

considered overvalued ideas. Micropsychotic episodes are known

to occur in SztPD, but are only included in the ICD-10 criteria.

3. Asperger’s disorder is one of the pervasive developmental

disorders (PDD) listed as an exclusion criterion for SztPD. It is

characterized by impairments in social interaction and restricted,

repetitive, stereotyped patterns of behavior. Other PDDs are: autistic

disorder, Rett’s Disorder, childhood disintegrative disorder, and

PDD Not Otherwise Specified (NOS).

References

L. S. Benjamin



R. L. Spitzer, J. Endicott & M. Gibbon

Crossing the Border into Borderline Personality Disorder and Borderline

Schizophrenia






Pocket Guide to the ICD-10 Classification of Mental & Behavioural

Disorders


184

The Histrionit Personality


185


Biographital Information

Name:

Occupation:

Appearance:


Favorite Song:

Motto:

Cindi L. Valentine

Cosmetician & Aesthetician

Coordinated shoes, earrings, purse,

nails and accessories

Has cats named Puffy, Buffy & Muffy

Love Me Tender

It’s not how you feel, it’s how you look!

At the Therapist's Offite

Before Session:


During Session:

Fantasies Involve:



Brings to Session:

Flirts with others in the waiting room

Does quiz from fashion magazine

Gives quiz results to therapist

Becoming a radio sex therapist

Writes best-selling novel based on

sexual fantasies with therapist

Faints when quiz results are

interpreted

A perfumed business card, which she

hides in the seat cushion

Mnemonit for Diagnostit Criteria

"I CRAVE SIN"

Inappropriate behavior — seductive or provocative

Center of attention

Relationships are seen as closer than they really are

Appearance is most important

Vulnerable to the suggestions of others

Emotional expression is exaggerated

Shifting, Shallow emotions

Impressionistic manner of speaking which lacks detail

Novel situations are sought

186

Introduttion

The Histrionic Personality

The word histrionic is derived from hysteria, a term originally used to

describe phobias, dissociative and amnestic phenomena, as well as

somatoform disorders (such as conversion disorder and

hypochondriasis). The histrionic personality disorder characterized by

excessive emotional expression and attention-seeking behavior.

Some key names associated with development of this disorder are:

• Sydenham (17th century) — gave a description of hysterical patients:

“Tears and laughter succeed each other... all is caprice ... the worst

passions of the mind arise without cause.”

• Charcot (19th century) — delineated and classified differing

manifestations of hysteria, and demonstrated that some symptoms

had a psychological etiology.

• Janet (1889) — demonstrated a relationship between trauma and

hysterical dissociation of feelings or memories of the experience.

• Kraepelin (1904) — characterized hysterical personalities as having

multiple symptoms, capricious and inconsistent behavior, histrionic

exaggeration and a life of illness.

• Freud (1905) — focused on the childhood sexual investment and

conflicted eroticization of the opposite-sex parent.

•Schneider (1923) — was influential in making the distinction between

an “attention-seeking” personality and hysteria.

The histrionic personality disorder (HPD) was first called the hysterical

personality in the DSM-II. The name was changed in the DSM-III, and

the conditions previously called “hysteria” were distinguished from each

other as somatoform disorders.

The term histrionic is derived from the Greek word hystera, meaning

uterus. Descriptions of hysterical conditions date back to antiquity when

it was thought that the uterus could dislodge itself and wander throughout

the body, causing symptoms at different sites. Due to the ambiguity

and possible pejorative connotation of the term hysteria, it no longer

appears in diagnostic nomenclature.

Separation of associated Axis I conditions and the development of

psychoanalytic theory have helped define HPD as a discrete disorder.

These patients have an increased incidence of somatoform disorders

(i.e. somatization disorder, conversion disorder, hypochondriasis) and

mood disorders. There is also a considerable overlap with the other

Cluster B personality disorders.

187


Media Examples

Histrionic characters are frequently cast in romantic roles and

comedies. Their capricious style and vanity are qualities around which

the plot or sub-plots can be built. They are very good at attracting other

characters and are naturals for “center of attention” situations. A classic

pairing is that of a histrionic female with an obsessive-compulsive male.

Here, her unpredictability and unmodulated affect contrast with his

emotional constriction and pedantic nature. A variation on this theme

sets the flair and joie de vivre of a histrionic character against the

rigid, oppressive rules of society.

• Gone with the Wind — Vivien Leigh won an Oscar for her

performance as Scarlett O’Hara, the southern belle caught in the drama

of the Civil War. At the beginning of the film she teases two brothers

into a competition for her company at a barbecue. There, we see her

in her element, surrounded by men who are vying for her affection.

Leigh also portrayed another histrionic southern belle, Blanche DuBois,

in A Streetcar Named Desire.

• The Prime of Miss Jean Brodie — Maggie Smith won an Academy

Award for her witty caricature of a romantic crackpot teacher in an

upscale private girls’ school. With her romantic notions of art, music

and politics, she assembles a coterie of adoring students. She readily

displays histrionic elements: snobbery, raving, ranting, cooing and

other dramatic affectations. Her “jumble-shop” mind and ill-advised

admiration of fascism set the plot.

• Private Benjamin — Goldie Hawn plays a “Jewish-American

Princess” who impulsively signs up for a stint with the Army. Fully

believing the recruiter’s outrageous offer, she is shocked when the

promised amenities do not materialize, and responds with indignation.

• Madame Bovary (Gustave Flaubert character from 19th Century

France; movies were made in 1934, 1949, 1991) — Madame Bovary

is a famous character from French literature. She is carried away from

the void of rural life by romantic longings which are enhanced by her

shallow, selfish personality.

Other histrionic characters can be seen in:

• Breakfast at Tiffany’s — 1961 drama starring Audrey Hepburn

• Born Yesterday — 1950 film redone in 1993 with Melanie Griffith

188



Histrionic patients give dramatic and exaggerated interviews. Histories

are often erratic with inconsistencies becoming obvious as more

information is obtained. Open-ended questions usually lead to long,

animated answers peppered with gestures, affectations and segues.

Despite the abundance of “talk” there is a paucity of detail. Answers

are frequently vague and evasive, dealing with only superficial

elements. Additionally, the outpouring of emotion lacks substance,

with discrepancies readily observed between reported symptoms and

genuine emotional investment. La belle indifference refers to an

obvious emotional detachment from symptoms. This is also seen in

other conditions such as conversion disorder and strokes.

It is not usually difficult to initiate an interview with histrionic patients.

In any setting, time is given at the outset for patients to “tell their story.”

They revel in this opportunity and respond to the attention of an

interested listener. As the interview proceeds, there is a lot of “weather"

but a lack of "news.” Redirection does not usually affect the interview,

as new topics are pursued with the same relish.

Maintaining the interview requires redirecting answers back to the

presenting complaint or another central focus. The major challenge is

in obtaining complete and accurate information. Polite persistence,

curbing answers, closed-ended questions and asking for concrete

examples will help complete the history.

Histrionic patients can present difficulties at the outset of the interview.

Commonly, patients of the opposite sex to the interviewer become

flirtatious and seductive; patients of the same sex see the interviewer

as a rival. A continual search is made for signs of interest and approval,

even in professional settings. Should the interview become difficult

due to inappropriate answers or behavior, keep in mind that these

patients are largely unaware of their actions. Histrionic patients often

experience feelings of rejection that have no concrete basis.

Confronting their behavior or the contradictory aspects in the history

often only brings about further dramatization and disorganization.

It can be difficult to preserve rapport with these patients. They carry

out their internal agenda with flattery and overt seductiveness. A polite

but firm return to the presenting problem can help assuage this. It

may be necessary to have another person present or to even terminate

the interview if concerns of a medico-legal nature develop.

189


Histnonit Themes

• Emotional instability

• Egocentricity/vanity

• Suggestibility/dependence

• Self-dramatization

• Exhibitionism

• Sexual provocativeness

• Fear of sexuality

• Overreaction/Immaturity

Etiology

Biological: There is an increased prevalence of HPD in the firstdegree

relatives of patients. As discussed, HPD and somatization

disorder share a historical association. Some studies have found a

genetic link between the two disorders, as well as associations between

HPD, ASPD and substance abuse (particularly alcohol).

Certain temperamental factors may predispose individuals to a histrionic

personality style: intensity, hypersensitivity, extroversion and reward

dependence. There is a strong orality or appetitive desire within

histrionic individuals. They crave love, attention and gratification, but

may be overwhelmed by too much stimulation.

An overly “generalized” cognitive processing is one of the remarkable

features of this personality, and may also be an innate quality. Histrionic

people tend to give overly impressionistic answers to questions. This

has been described by Shapiro (1965) as “global, relatively diffuse,

and lacking in sharpness, particularly in sharp detail... the hysterical

person tends to cognitively respond to what is immediately impressive,

striking, or merely obvious.” For example, when asked to describe

another person, global impressions such as “He’s wonderful” or, “She’s

so funny. We’re really good friends” are typical responses.

In the left-brain/right-brain scheme, Histrionic people are considered

to be right-brain dominant. Obsessive-compulsive personalities are

the prototype for left-brain dominance. Instead of answering questions,

histrionic patients give vivid impressions, whereas obsessive

personalities relate a plethora of factual information.

Psychosocial: The family dynamics of HPD patients often reveal a

power distribution perceived as or actually favoring males. In such

families, females or temperamentally affectionate males may have

received attention only for their physical appearance or cute antics.

Neglectful parents may unconsciously or unwittingly encourage their

children to dramatize and exaggerate in order to get attention.

190


Mothers who are weak or ineffectual may also have an etiologic

contribution. Without a strong and mature role model, children may

learn to depend on seduction or “feminine" wiles to deal with others.

Another consistent feature is a father who was both intimidating and

seductive. Narcissistic qualities such as criticism, angry outbursts and

selfishness transmit the message that males must be approached

with caution. Some patients have fathers who turned to them for

gratification not available in the marriage. The father who turned to

open collusion, covert sexuality or even incest creates the approachavoidance

conflict that is a prominent feature of this disorder.

Histrionic patients are fixated in a range between oral and oedipal

stages. A diagrammatic representation for a female is as follows:

Child constitutionally predisposed to intense reactions or neediness

Unsatiated by mother; oral needs remain unmet

Devalues mother as reaction to unmet attachment needs

Turns to father for gratification of dependency needs;

idealization magnified by unmet oral needs

Learns that flirtatiousness and exhibitionism get attention

Family dynamics as outlined above

Fixation at oedipal level: conflicted erotic attachment to father;

devaluation of mother, self and other female figures

Coexistence of sexual exhibitionism and inhibition

The oedipal complex (electra complex in females) is usually resolved

by repression of impulses towards the opposite-sex parent, and

identification with the same-sex parent. This resolution is not satisfactorily

achieved in HPD because the patient:

• rejects identification with her (devalued) mother

• represses her sexuality to remain “Daddy’s little girl”

• learns she cannot possess her father and feels rejected by him;

this is also facilitated by a father feeling uncomfortable with his

daughter’s physical and sexual maturity, and withdrawing from the

closeness that was once shared

191


Epidemiology

The prevalence is estimated to be 3% of the population. There is a

gender difference, with women being diagnosed more frequently than

men. Some studies have found an equal prevalence among men and

women, with rates as high as 15% in some psychiatric populations.

Sociocultural factors are a key consideration in making this diagnosis

(e.g. the milieu in the movie Gone with the Wind).

Ego Defenses

The ego defenses employed in HPD are: repression, regression,

dissociation, sexualization (giving an object or act a sexual

significance) and denial (avoiding an awareness of some painful aspect

of reality).

Repression is defined as expelling from consciousness unacceptable

wishes, feelings and fantasies. It is an unconscious process. Primary

repression refers to the process whereby ideas or feelings are prevented

from reaching consciousness. Secondary repression is the exclusion

of what was once a conscious experience. Freud observed that although

repressed memories are consciously inaccessible, they are still “known”

and cause hysterical symptoms. Histrionic patients’ cognitive style

facilitates the use of repression and denial. Experiences are recalled

in a sketchy, impressionistic manner, which facilitates repression. With

attention easily distracted, elements of reality are disavowed (denial).

The distinction is that repression defends against inner experiences,

such as thoughts and impulses, whereas denial blocks out an awareness

of external reality.

Regression is seen when patients are faced with challenges that

stimulate unconscious fear or guilt. The return to a helpless, childlike

state may be an attempt to disarm potential rejecters or abusers. There

is a three-fold contribution to the use of dissociation:

• high level of unconscious guilt and anxiety

• fears of intrusion and rejection

• temperamental predisposition to intense reactions

Histrionic individuals are easily overwhelmed and readily detach

themselves from events emotionally charged situations. This “dissociation"

manifests itself in many ways: poor recollection of childhood memories,

obliviousness to their flirtatious manner, la belle indifference, fugue

states, hysterical rages, predisposition to conversion disorders, etc.

192



A pervasive pattern of excessive emotionality and attention seeking,

beginning by early adulthood and present in a variety of contexts, as

indicated by five (or more) of the following:

(1) is uncomfortable in situations in which he or she is not the center

of attention

(2) interaction with others is often characterized by inappropriate

sexually seductive or provocative behavior

(3) displays rapidly shifting and shallow expressions of emotions

(4) constantly uses physical appearance to draw attention to self

(5) has a style of speech that is excessively impressionistic and lacking

in detail

(6) shows self-dramatization, theatricality, and exaggerated expression

of emotion

(7) is suggestible, i.e., easily influenced by others or circumstances

(8) considers relationships to be more intimate than they actually are




Many diagnoses stem from the initial concept of hysteria. These are

classified in the DSM-IV under somatoform disorders, dissociative

disorders and anxiety disorders. The pervasive and virtually life-long

traits of HPD and the absence of cardinal symptoms help distinguish

these disorders. Histrionic personalities may, however, have a greater

propensity to develop these related disorders.

Patients who are distractible, gregarious, attention-seeking, and who

exaggerate emotions with inappropriate sexuality may be suffering

from a manic or hypomanic episode or cyclothymia. The distinction

can be made on the basis of other mental status findings, collateral

information and medical history.

Dramatic or histrionic responses can also be seen in individuals with

dysthymic disorder. There is a syndrome called hysteroid dysphoria

that bridges dysthymia and HPD. The concept of hysteroid dysphoria

is not included in the DSM-IV. This condition closely resembles an

atypical depression and is defined as an abrupt change in mood in

response to feeling rejected (rejection sensitivity). It almost exclusively

affects people (mainly women) who are excessively prone to seek

approval, praise and romantic attention and who experience a surge in

193


energy and mood state when these yearnings are satisfied. When

euthymic, such patients have a considerable overlap with HPD and

some features of the borderline personality disorder. When depressed,

the clinical picture is that of multiple somatic complaints, anxiety,

emotional overreactivity, interpersonal rejection sensitivity and reversal

of the vegetative symptoms. This disorder may respond preferentially

to the monoamine oxidase inhibitors (MAOIs).

Because of their suggestibility, patients can develop substance use

disorders. An overlap in symptoms is particularly evident with stimulant

use (cocaine, amphetamines, etc.), but can occur with other substances.

A careful history focusing on the reported changes after use of the

substance will help make the distinction.

With the attention to physical appearance that Histrionic personalities

display, an eating disorder must also be considered. Additionally,

they may suffer from sexual disorders such as vaginismus,

dyspareunia, and arousal/orgasmic disorders. Finally, there are

general medical conditions that can overlap with histrionic symptoms,

e.g. multiple sclerosis, strokes, dementia, etc.


Appearance:

Behavior:

Cooperation:

Affect:

Speech:

Thought

Content:

Thought

Form:

Perception:

Insight &

Judgment:

Suicide/

Homicide:

Often very fashionable; pay particular attention to:

grooming, accessories, designer clothing, dyeing hair

Vivid expressions; frequent, dramatic gestures

Notably cooperative

Wide range of affect expressed; can change quickly

Animated, highly modulated voice

Superficial descriptions; use colorful adjectives;

global impressions lack detail; use hyperbole


circumstantial, vague, overelaborate


Partial; often unaware of flirtatious manner; can place

themselves in danger with their provocative speech

and mannerisms


disorder; can overreact to losses or abandonment

194



As discussed in the Psychosocial Etiology section, histrionic individuals

are left with unresolved oral and oedipal elements. This fixation is

characterized by immaturity. HPD patients are like caricatures of

femininity by appearing shallow, vain, dependent, dramatic and selfish.

Their internal existence is that of a helpless, fearful child trying to

navigate in a world dominated by powerful figures. They fear intrusion

(retaliation from mother) and rejection (the internal experience of losing

father).

The central psychodynamic feature in histrionic patients is anxiety.

The classical explanation is that defenses are recruited in response

to signal anxiety, an unconscious process in which the ego is

mobilized against internal or external threats. In other personalities,

sexual energy is expressed or sublimated, but histrionic patients have

repressed sexuality as part of their development. However, repression

is soon overwhelmed because this defense covers normal impulses

that are continually aroused and seek discharge. Because of this,

other defenses are needed, and histrionic patients act in ways to cope

with the “leftover” anxiety.

The DSM-IV diagnostic criteria emphasize the behavioral aspects of

HPD, which achieve three goals for these patients:

• security and sanctuary from an environment perceived as hostile

• increasing self-esteem

• attempting mastery of frightening situations by initiating them

As outlined in the Psychosocial Etiology section, histrionic patients

see male figures as strong and exciting, but also dangerous. Because

of their idealization of father figures, they are attracted to men they

see as powerful, though this remains steeped in conflict. They seek

the protection that such men offer, while fearing abuse of this power,

and may unconsciously hate men for it. They learned that flirtatiousness

gets attention, but this left a conflict over erotic impulses. Sexuality is

used in a defensive manner instead of as a true expression of libido.

Thus, patients may appear highly seductive (a return of repressed

impulses), but are largely unaware of the sexual nature of their

invitations, and are often surprised when their actions are interpreted

as such. Should they proceed with an encounter, it may well be to

placate a threatening internal object, and to reduce the guilt which

emerges after being confronted with their seductive behavior. These

two factors drastically reduce enjoyment of the experience. Histrionic

195


patients regard power as a male attribute. As mentioned above, they

idealize powerful men and attach to them, in an attempt to increase

their self-esteem, as if it could be transferred by association. Histrionic

patients, seeing their only strength as sexual attractiveness, become

highly invested in appearance and have difficulties with aging.

These patients also seek security and self-esteem by initiating

frightening situations which they attempt to master. The term

counterphobic attitude is used to describe behavior in which feared

situations are sought out. Acting out is the process of living out an

unconscious wish or impulse in order to avoid becoming aware of the

idea, or the emotion (affect), that accompanies it. Much like patients

who take up activities like parachuting after a heart attack, histrionic

patients tend to act out in counterphobic ways, often related to their

preoccupation with the fantasied power and the dangerousness of

the opposite sex. Examples include:

• seductive behavior, when sex is frequently not enjoyed

• flirtatiousness, which covers a sense of bodily shame

• craving and attracting attention while feeling inferior to others

• launching into dangerous situations when aggression is feared

• provoking authority, when those in control are actually feared

The anxiety underlying HPD also manifests itself in dramatization.

Because of early experiences, patients do not expect to be taken

seriously or to receive respectful attention. Their behavior invites the

feared reaction, an example of repetition compulsion. As adults, they

yearn for acceptance, but relate to others in a mixed fashion. Emotional

expression teems with conflict. Feelings are conveyed in a way that

allows retraction in case patients are ignored by the more “powerful”

people present. Coquettish mannerisms and flowery adjectives facilitate

a retreat in such instances. Another view holds that the combination of

intensity, shallowness and impressionistic style defends against an

awareness of stronger emotions (hate, envy, etc.).

The situation for histrionic males is similar to females. They also

experience maternal deprivation and look to their fathers for nurturance.

When this is not provided, some men develop an effeminate identity

influenced by their mothers. Others model themselves after cultural

stereotypes of hypermasculinity. Both adaptations are fraught with

future difficulties in relationships. The former may remain celibate to

preserve loyalty to an idealized mother; the latter may be promiscuous

in order to reaffirm a sense of masculinity.

196



Psychoanalysis was developed by Freud for the treatment of patients

with hysteria/histrionic personality qualities. Psychodynamically oriented

psychotherapies remain the preferred treatment for HPD. Histrionic

patients who function in a moderate or better range can thrive in

psychotherapy. To a significant degree, they “make themselves well”

with moderate guidance.

It is important to establish a therapeutic contract or working alliance

as soon as possible. The parameters and goals of psychotherapy

should be clearly explained and conveyed in an open, professional

manner. Some patients have the expectation that therapists “know all

about them” or “know them better than themselves.” This perception

needs to be corrected at the outset. Patients should be encouraged to

be as open as possible about their feelings, regardless of the degree

of embarrassment involved. Exploring reactions and resistance,

instead of “demanding” they tell all, avoids making therapy an

experience of submitting to yet another authority figure.

One of the first therapeutic interventions with histrionic patients is to

obtain a detailed account of their present functioning and history.

Redirection and persistence will be required to get past the “I don’t

know” and “I told you everything already” replies. The vague and

impressionistic cognitive style in HPD is a form of resistance against

experiencing deeper thoughts and feelings. Some patients benefit from

the exercise of giving a cohesive account of their lives.

By encouraging patients to be more reflective and attend to internal

and external experiences in greater detail, repression is lessened.

The increased amount of emotional information allows an examination

of both ideas and feelings, and most importantly, the connection

between the two. Awareness of this association, with the ability to

discuss thoughts and feelings in detail, increases the interest in, and

tolerance for, deeper experiences. Patients benefit by internalizing

the therapist’s interested attitude and using this awareness to alter

relationship patterns.

Caution is also advised in using interpretations too quickly. To histrionic

patients, who sexualize experiences, this can have a “penetrating”

quality and cause feelings of powerlessness or of being violated. A

more helpful approach is to raise questions that do not occur to patients,

and have them search for answers instead of being “told what to think.”

197


Histrionic patients express a considerable interest in finding out about

therapists’ lives. This form of resistance becomes apparent at times of

stress, either in or out of the therapeutic relationship. The defensive

maneuver camouflages difficulties in accessing their own feelings.

Regardless of the tenacity of such attempts, self-disclosure is illadvised.

While questions of a general nature can be answered, much

can be gained by not gratifying the attempts at sexualizing the therapy.

In a sense, “failing” in the seduction has therapeutic value. Having

strong desires that are not exploited in a relationship with a powerful

figure who considers their best interests is unique. This encourages

patients to become more autonomous and to value themselves.

As with all personality disorders, HPD occurs in a range of severity

from the healthier “oedipal” to less functional “oral” histrionics. Patients

who function at lower psychological levels will require a more active

and educational approach. Such patients may particularly benefit from

construction of a detailed history focusing on their maladaptive

responses to anxiety. For example, pointing out that a wish to flee

from therapy is part of the same process that interferes with their

relationships and jobs helps patients gain some perspective and

maintain the therapeutic relationship.

Lower-functioning patients are more prone to experience physical

symptoms with emotional difficulties. Somatic manifestations may

herald regression, or even psychotic decompensation. Still, these

symptoms have a psychodynamic relevance and an awareness of

this is helpful in dealing with them. Conversion symptoms achieve the

primary gain of anxiety reduction by resolving the conflict between

wishes and their prohibition. Secondary gain is a real-world advantage

from others (attention from others, relief from duties, etc.). Tertiary

gain refers to the benefit that others receive from the patient’s

secondary gain (e.g. financial support).

Another important issue is that of incest and childhood seduction. Freud

initially believed the accounts he heard from his patients. Later, he

ascribed them to fantasies related to oedipal wishes. Currently,

therapists must consider many facets of this issue. Many patients are

victims of sexual abuse from male relatives, which is a significant

etiologic contributor to the severity of HPD. Some patients had fathers

that were not frankly abusive, but were sexually inappropriate.

Histrionic patients can express vivid fantasies and wishes involving

fathers or father-figures, whether abuse was perpetrated or not.

198

The Histrionii Personality


Just as Freud’s work in hysteria led him to develop psychoanalysis,

the concept of transference occurred to him in dealing with such

patients as well. He found it anachronistic that patients misperceived

current relationships — in particular, the relationship with him —

because of past trauma. Again, he recognized that what is not

consciously accessible remains active in the unconscious, being

expressed in symptoms and reenactments.

Histrionic patients are quite emotionally expressive and develop strong

transference manifestations early in therapy. The gender of the patienttherapist

dyad influences the transference. For example, female

patients frequently reenact oedipal conflicts, and respond to male

therapists in an excited, provocative and seductive manner. Female

therapists may be viewed by female patients as competition, and

treated in a hostile manner. Irrespective of the gender differences,

histrionic patients frequently have intense reactions to their therapists.

Working through the transference is the main intervention from which

patients benefit in therapy. Transference has been variously referred

to both as a “gold mine” and as a “minefield.” The outcome of therapy

depends on how successfully transference is handled. It gives therapists

a first-hand understanding of how patients interact in other current

relationships, and the effects of previous ones. A rule of thumb is to

make interpretations about transference only when it turns into

resistance. A complete interpretation involves making a three-way

connection between past relationships, current relationships (outside

of the therapy) and the therapeutic relationship.

A most difficult aspect to manage is eroticized transference, which

is the development of overt sexual feelings for the therapist. In healthier

patients this develops gradually and is egodystonic. They recognize

that it is inappropriate to act on these feelings, as this will sabotage

the therapy. Lower-functioning patients have a more immediate,

overwhelming eroticized transference. In these situations, it is

advisable to ask for consultation and supervision. Transfer of care to

a same-sex therapist may become necessary. Higher-functioning

patients may still need encouragement to discuss their feelings. Shame

and embarrassment often accompany the eroticized component. The

strength of the therapeutic alliance often determines whether patients

continue or are frightened by their feelings and terminate therapy. It is

important to keep in mind that eroticized transference is another

199


manifestation of histrionic patients’ defensive handling of their anxiety.

Sexualization is a smoke-screen that obscures deeper, more germane

issues. It is more “grist for the mill” and is best managed in an nonexploitative,

accepting manner. Patients may need to be reminded

that a variety of feelings will emerge in therapy and that their discussion

is the work of therapy. Patients may act out the transference long

before they verbalize it. Examples include: starting a relationship with

someone who has the same name as, or is similar in appearance to,

the therapist; overdressing for appointments (especially with liberal

amounts of cologne or perfume); and giving gifts. While eroticized

transference may be seen as a positive step, it is quite the opposite.

Histrionic patients may unconsciously need to defuse “powerful" people

(like therapists), while seething with hostility and aggression under the

veneer of sexuality.

Countertransference reactions can be intense. It can be gratifying to

have patients take an eager and apparently genuine interest in our

lives. Additionally, the flirtatiousness of attractive, well-groomed

patients of the opposite sex can be difficult to resist. It is important to

keep in mind that this behavior reflects the patient’s means of

adaptation, and is not an authentic appreciation of the therapist’s

qualities. Therapists need to monitor their reactions to patients.

Particular concerns are:

• contributions therapists make to patients’ eroticized transference

• personal narcissistic needs being met by adoring patients

• voyeuristic enjoyment of patients’ fantasies

• a sense of disgust being conveyed at patients’ disclosures

• a sadistic enjoyment from being “unavailable” to patients

It takes skill to manage the eroticized transference material in an

accepting and non-exploitative manner. While the difficulties with

overinvolvement have been mentioned, countertransference

distancing from patients can also occur. Through the use of projective

identification or regression, histrionic patients may also provoke

infantilizing or condescending reactions from their therapists.

Suggested Therapeutit Tethniques

• encourage reflection; aim for a proactive, not reactive style

• guide patients to build self-esteem in areas other than attractiveness

• be attuned to transference and countertransference issues

• encourage patients to use their own resources to solve problems

• resist self-disclosure, giving advice, or other departures from therapy

200

Croup Therapy


Histrionic patients can present in assessments as charming, outgoing

and expressive. They are often chosen readily and can serve as

valuable figures in group therapy. Their energy activates the more

passive members, and their seductiveness can stir transference

reactions that help fuel group interaction.

However, there are drawbacks to having histrionic members in a group.

Craving attention, they shift allegiances frequently and may escalate

their dramatic ways if overshadowed by others. Flirtatious behavior

may well attract more than one group member, creating a rivalry in

addition to the one already existing between patients and the therapist.

Histrionic patients may also view group sessions as a forum to express

themselves rather than learn about their interactions.

Histrionic patients can also be seen as help-rejecting complainers.

These individuals play the role of victim and induce caregiving behavior

in others (advice giving, offering favors, etc.). When this is done, the

patient devalues the effort and resumes complaining. This can be a

very difficult situation to deal with in a group setting.

Histrionic patients can benefit from group therapy when they

understand that their loquaciousness and endless dissatisfaction serve

to isolate them from others and perpetuate their unhappiness.

Cognitive Therapy


• “I am incapable of looking after myself. I can’t do it on my own.”

• “I need to have a powerful man’s interest at all times.”

• “If I’m not fun and exciting, no one will want me around.”

• Overgeneralized, diffuse, impressionistic, or catastrophic thinking


The central cognition in HPD is, “I am inadequate and unable to

manage by myself.” This is not unique to HPD — it is also seen in

depression and dependent personalities. Unlike patients having these

two disorders, histrionic patients actively find others who will accept

them and attend to their needs. This perpetuates a cycle in HPD.

Patients feel they are inadequate, use emotional reasoning (“if I feel

this way, I must be this way”), and then set out to find someone to

take care of them, reinforcing their initial sense of inadequacy. Histrionic

201


patients are so focused on external approval and acceptance that they

have little consideration left for their own internal existence. While

capable of introspection, they do not initially attend to details. Frequently,

patients are not able to identify what they need and avoid self-knowledge

because it feels foreign. The cognitive-behavioral treatment of HPD is

less well established than in other personality disorders. These

treatments require the patience to examine thoughts and test alternatives,

which is contrary to the histrionic style. However, histrionic patients

can benefit from the following interventions:

• developing a more systematic, problem-focused style of thinking by

setting a reasonable agenda and attending to one item at a time

• considering the long-term costs of impulsivity; looking for alternatives

such as drawing up pro and con tables for important decisions

• assertiveness training, which may take some time to work because

patients fear rejection when they ask for what they want

• role-playing with an element of rejection so patients learn ways to

reduce their sense of embarrassment

It is important to reassure patients that their “basic character” will not

be altered in cognitive therapy. On a practical level, patients can be

encouraged to seek employment that satisfies their need for visibility:

acting, dancing, politics, teaching, the arts, etc. Histrionic patients can

be quite creative when integrating their emotions with their work.

Pharmaiotherapy

With the wide fluctuation in mood and affect seen in this disorder,

there may be a role for mood stabilizers when alterations are sustained

long enough to warrant a trial of medication. Rejection sensitivity,

irritability and anxiety symptoms may respond preferentially to

antidepressants, particularly SSRIs and MAOIs. From time to time,

judicious use of sedative/hypnotics and anxiolytics may be needed to

help patients through crises. Generally medications play less of a role

in the treatment of HPD than they do in other personality disorders.


Benjamin (1993) formulates the following hypotheses for HPD:

• being valued for appearance over competence

• one must be attractive in order to have any leverage or power

• as children, unpredictable changes in the home environment made

life seem interesting, setting the pattern of “as-if relationships

• in some cases, nurturance was given for being ill or sickly

202

The Histrionie Personality

One of the challenges in therapy is to convey to HPD patients that if

they become competent, others will still find them attractive. Patients

need to learn about the factors that automatically influence their

decisions so that they can actually exercise their free will. For example,

patients may have an underlying drive to recreate their family of origin

because of the perceived benefits, such as an adoring father or a

mother who provided support for debilitation. Once the destructive

nature of these wishes can be made clear, the strength to try an

alternate approach can develop.

Case Example

Ms. Valentine is a (perpetually) twenty-nine-year-old woman who works

for a major cosmetics manufacturer. She has done well in this position,

which was given to her because she was in the right place at the right

time. She used her previous position with an advertising agency to

facilitate a meeting to propose a new marketing strategy to the CEO

of the cosmetics firm. She had relationships with two of the senior staff

at the advertising agency. She thought a job change was in order

because she was bored and emotionally handcuffed in starting a new

relationship. Ms. Valentine chose her boyfriends from the men at work.

Her pattern at the agency was to concentrate her energy on the single

executives.

When in a relationship, she works very hard at staying in shape. She

goes regularly to a tanning salon and hair stylist, and has a personal

shopper to ensure her clothes are always in style. She has always felt

that her part of the “bargain” was to win accolades for the man she was

involved with in exchange for his taking care of her. In the advertising

agency, she declined to even apply for a promotion in order to not

challenge the status of her boyfriends. However, she engaged in an

unconscious “coercive dependency” by expecting that her sacrifice to

be rewarded with a proposal of marriage. Her decision to forgo the

applications was unilateral (and not even discussed with her boyfriends),

which ultimately lead to the demise of both relationships.

Course

Little is known definitively about long-term outcome. As with other

Cluster B disorders, it takes a lot of energy to maintain this personality

configuration. Patients may “burn out” and show fewer symptoms with

time. Because HPD is among the Axis II disorders most amenable to

therapeutic intervention, the outcome can be viewed optimistically.

203


Referentes



Edition





L. S. Benjamin



G. Gabbard

Psychodynamic Psychiatry in Clinical Practice, The DSM-IV

Edition





N. McWilliams



H. Merskey, in J. Livesley, Editor






R. Pies



D. Shapiro

Neurotic Styles



You’ve got a hectic day . . .

An appointment at 10 downtown, a seminar at 11

uptown and a power luncheon at 12 cross-town . . .

Then there are greetings, eatings and meetings all

afternoon . . .

You have to make an impression,

and when you do, do it El flagrante!!

That’s your trademark, and you

have to look your best doing it!!

You need makeup that won’t let you down

when you’re in the spotlight.. .

Cosmetics for the woman who wants to leave an impression,

not just a business card.

live it... wear it.. . live it. . . wear it.. . live it.. . wear it. . . live it

205


Fill-in-the-blank Personalities:

Anatomy of a Romance Novel

Act I

A beautiful, unspoiled histrionic lives a marginal and repressed

existence under the cruel tyranny of her husband. However, she gave

her word on the altar and remains deeply committed to this schizoid

lout even though he is just a shell of the man she married. His distant

manner and frequent business trips don’t arouse her suspicions until

she is tipped off by his paranoid secretary that he is having an affair

(with the same woman who broke up the secretary’s marriage). She

seeks the comfort of her hapless obsessive boss who, seeing an

opportunity, can’t contain himself and confesses his undying love.

Act II

Reeling from the betrayal of this trusted friendship, she enters a trance¬

like state and wastes away in her still elegantly fashioned apartment.

In the nick of time, her trusty but highly dependent confidante offers

her some banal advice which depresses her even more. Summoning

her last ounce of strength, she sets out on a journey of recovery. Her

life takes an intriguing twist when she takes the advice of a

schizotypal fortune-teller and leaves for a distant, enchanting land.

Act III

The heat and lush, undulating landscape cause her to let down her

guard and fall prey to the affections of a dashing, wealthy narcissist.

Unbeknownst to her, libidinal strivings are simultaneously aroused in

this man's nefarious, but strikingly handsome, antisocial brother.

While being royally courted by these two, she catches a glimpse of a

kindred spirit, the mysterious avoidant who works as a stable-hand.

Act IV

The long-seated rivalry between the two brothers reaches a fever pitch

and they agree their dignity can only be settled by a duel. As high

noon approaches on the appointed day, the borderline ex-lover of

one of the brothers returns and quells his ire with her own passion.

Besides, the passive-aggressive matriarch of the family was fed up

with her ill-tempered sons and loaded blanks in their dueling pistols.

Epilogue

As our heroine takes up with her man of mystique, clouds in the shape

of wedding bells begin to form on the horizon.

206

The Histrionif Personality

Review Questions

1. The original concept of hysteria is now accounted for by a number

of DSM-IV conditions — which ones are depicted below?

2. Which aspects of “gain” are shown in the following illustration?

207



1. (a) dissociative disorders — characterized by a disruption in

consciousness, identity, memory and perception of self and the

environment

(b) phobic disorders (specific phobia in this case) —

characterized by a persistent fear of clearly identified objects

or situations; these stimuli are avoided or endured with difficulty

(c) somatization disorder — characterized by complaints

of: gastrointestinal symptoms, sexual symptoms, pseudoneurological

symptoms, pain; not due to a medical condition

or the effects of a substance

(d) conversion disorder — characterized by complaints of:

deficits in motor or sensory function; inability to account for

these complaints on the basis of a known illness or the effects

of a substance; adverse psychosocial factors are deemed to

be involved in the onset of this condition

Other somatoform disorders are:

pain disorder, body dysmorphic disorder, and

hypochondriasis, which is characterized by an excessive and

unreasonable concern with having a serious medical illness

despite adequate investigations and reassurance; the

preoccupation is not of delusional intensity

The initial formulation of hysteria involved both physical symptoms,

which have been detailed above, and the seductiveness shown by

patients who meet the DSM-IV criteria for HPD. In practice, many

histrionic patients have a “somatic" component to their symptoms and

may qualify for an additional diagnosis on Axis I.

Reference




2. Primary gain is the resolution of a conflict yielding an intrapsychic

benefit (indicated by her smile). Secondary gain is a real-world

advantage from others (the cash). Tertiary gain refers to the benefit

that others receive from the patient’s secondary gain (her motley crew).

208

The Antisotial Personality


209



Name:

Occupation:

Appearance:


Favorite Song:

Motto:

Vinny Scumbagglia

Arsonist-at-large for Fire Dept.

Sideburns, muscle shirt, tattoos

Trained dog to snatch purses

Criminal Mind

I don’t mind and you don’t matter


Before Session:


During Session:

Fantasies Involve:



Brings to Session:

Robs pharmacy in the lobby

Steals magazines; leaves copies of

Playboy, sans centerfold

Starts sentences with “!@#$%&*”

Seducing probation officer

Picks therapist’s pocket, takes long¬

distance phone card

Carves up armrest, finds

Histrionic’s phone number in the

seat

Brochure for a car alarm (that he

knows how to dismantle)


"CALLOUS MAN"

Conduct disorder before age 15; current age at least 18

Antisocial activities; commits acts that are grounds for Arrest

Lies frequently

Lacunae — lacks a superego

Obligations not honored (financial, occupational, etc.)

Unstable — can’t plan ahead

Safety of self and others is ignored

Money — spouse and children are not supported

Aggressive, Assaultive

Not occurring during schizophrenia or mania

210

Introduction

The Antisodal Personality

The antisocial personality disorder (ASPD) is the oldest and best

validated of the personality disorders. Some of the key names

associated with the development of the concept of ASPD are:

• Pinel (France, 19th Century) — described this condition as “moral

insanity” in that there is a circumscribed deficiency in morals or morality

without other signs of mental illness.

• Cleckley (1941) — published The Mask of Sanity, a seminal

publication in the description of this disorder; he distinguished the

psychopathic personality from criminal acts and social deviance; his

views influenced the DSM I & II and appear again in the DSM-IV.

• Lee Robbins (1960’s) — his classic study called “Deviant Children

Grown Up” specified the antisocial acts in the diagnostic criteria of the

DSM III & lll-R.

• Maudsley, Meyer, Kraepelin, Schneider, Alexander & Rush — all

made contributions to the description of ASPD.

ASPD is characterized by guiltless, exploitative and irresponsible

behavior with the hallmark being conscious deceit of others. ASPDs

have a lifelong pattern (defined as being present prior to age fifteen)

of disregard for the rights of others. This disorder has also been called

the psychopathic, sociopathic and dyssocial (ICD-10) personality.

The DSM-lll/lll-R diagnostic criteria for ASPD involved a checklist of

specific acts. The term psychopathy is defined as a cluster of both

personality traits and socially deviant behaviors. The DSM-IV criteria

are based on this definition instead of listing sociopathic behaviors.

Criminal activity itself does not necessarily imply the presence of ASPD.

Those who run afoul of the law may do so for reasons other than

having this personality disorder. Similarly, not all ASPDs have criminal

records. Some carry on lengthy sprees of emotional and financial

destruction without getting caught. These can be “con men” or business

executives who exploit others.

Because ASPD is egosyntonic, these patients virtually never come to

attention because they are distressed by their actions. The most

common reasons for psychiatric contact involve aspects of secondary

gain, such as: prescriptions for drugs with a street value, a note or

medical reason for missing work, a forensic assessment to relieve

them of criminal responsibility for a chargeable offense, and wishing to

avoid military service or work they consider undesirable.

211


Media Examples

TV shows, movies and fictional bestsellers are teeming with antisocial

characters. They fulfill the requirements of the media “id” — sex and

violence — and, as such, are intruiging characters to have in any kind

of drama. ASPDs make for fascinating entertainment because they

commit acts that strike at the core of morality: murder, sexual assault,

blackmail, kidnapping, extortion, torture, theft and vandalism. They

carry out common fantasies of such behavior, satisfying many audience

members’ voyeuristic interests and advancing the action.

A vast array of antisocial characters exist in the popular media. Bad

guys, Mafioso, con men, murderers, “psycho-killers,” forgers,

adulterers, terrorists, drug lords, and James Bond villains are just a

few. The number of films and novels with these characters would

constitute a book on its own. Some notable examples are seen in:

• Silence of the Lambs — contained a brilliant portrayal of a sociopath

by Anthony Hopkins. He skillfully exploited the vulnerable Agent

Starling (Jodie Foster), and gave a very good feel for the

remorselessness seen in this disorder. The transvestite in this film gave

a good demonstration of antisocial detachment by seeing people only

as objects to be used (this is not object relations). He used the word “it”

to refer to the woman he'd kidnapped. The manipulative qualities of the

FBI supervisor were noteworthy.

• The Dirty Dozen — a number of stars portrayed ASPDs who were

sent on a suicide mission during W.W. II. This movie tried to

demonstrate that the “talents” possessed by these characters would

be useful during war. However, actual experience in the armed forces

is quite unlike the movie version. It is a long-standing Hollywood myth

that inside every sociopath lurks a hero waiting for an opportunity.

• Wall Street — Michael Douglas played the part of a ruthless tycoon

who cared nothing for the companies he liquidated, or the lives

disrupted in the process. He gave an excellent example of a moralityfree

zone with his “Greed is Good” speech.

• Whispers in the Dark — included a compelling performance by

Alan Alda (Hawkeye from M*A*S*H) as a psychopathic psychiatrist

who has an erotomanic attachment to a former student.

• Face Off — the character played by Nicholas Cage

• The Usual Suspects — particularly the role played by Kevin Spacey

• Broken Arrow — the pilot played by John Travolta

• Pulp Fiction — almost every character

212


The Antisocial Personality

Antisocial patients can be easy or quite difficult to interview. They

have what Kernberg has termed a malignant grandiosity — a

deliberate attempt to use others (as opposed to the more unconscious

kind of manipulation seen in other personality disorders). Antisocial

characters openly brag about con jobs, conquests and scams to

impress others. They will shamelessly try to pull one over on you in

the midst of telling you how successful they’ve been in deceiving others.

As long as there is an interest in hearing about these exploits, along

with free rein to speak, rapport is easily established. This can be subtly

or even overtly encouraged, and needs to be developed before looking

at more sensitive areas. For example, statements such as the ones

below will have ASPDs eagerly awaiting to tell you more.

• “You really seem to have a way with people.”

• “You’re a pretty smart guy.”

• “You must have a lot of respect out on the street.”

• “How did you get away with that?”

Once they realize that condemnation is not forthcoming, it is not difficult

to maintain a positive atmosphere. It is important to remain morally

neutral, and not do anything that could be misconstrued as approval

for the antisocial acts mentioned. To ASPDs, this will seem like

collusion. Difficulties begin when patients’ manipulations are resisted,

or their requests are refused. They can then become hostile, critical,

derogatory, intimidating and even violent. A gentle segue can be helpful

in refocusing attention to clinical matters:

• “How could someone so clever end up in so much trouble?"

• “How come nothing seems to be going right for you?”

• “Where did things go wrong for you this time?”

• “What are they doing to you now?”

If rapport is lost or difficult to initiate, it can be obtained by appealing

to patients’ sense of grandiosity. They strive to be the center of attention

and may respond to an air of indifference from interviewers. By

demonstrating that this interview is not of the highest priority, and

being vague about rescheduling, cooperation can be obtained. Also,

if someone of “lesser” clinical rank is suggested as an alternative

interviewer, patients may not be able to bear the insult to their selfimportance.

ASPDs desire immediate gratification, and seize

opportunities when they are available.

213


Like patients with other personality disorders, ASPDs can be found at

higher levels of functioning. Such patients can be quite sophisticated,

and may be to able deceive others with rehearsed lines and convincing

explanations for their “dilemmas.” This will be especially evident with

remorse. Most will relate feeling bad about something, but this has

more to do with being caught than genuine regret.

Another interview consideration is that ASPDs tend to minimize their

involvement in a situation, or the outcome of their actions. Words are

twisted to achieve this effect (for example “skirmish” or “spat” instead

of fight). Language is used to manipulate others, which is an important

clue in interviews.

Antisocial Themes

In addition to the DSM-IV diagnostic criteria and Cleckley’s sixteen

descriptive elements (both are listed later in this chapter), the following

features become evident in the interview and history:

Glibness, shallow emotion

Requires constant stimulation

Criminal versatility

Parole/probation violations

Promiscuity

Juvenile delinquency

Grandiosity

Poor impulse control

Avoids responsibility for actions

Abuse of substances

Superior physical prowess

• Behavioral problems as a child

• Social “parasites;” may have several sources of financial assistance,

“under the table” cash, or profit from stolen property or drugs

Etiology

Biological: The antisocial personality disorder provides some of the

strongest evidence for the heritability of personality disorders. Chess

and Thomas found that as children, antisocial patients were innately

aggressive, with higher activity and reactivity levels and lowered

consolability. This may indicate an inborn tendency toward aggression

and a higher-than-average need for excitement.

Twin studies also indicate a genetic factor is operative. Other studies

have shown a higher than (societal) average incidence of ASPD in the

adopted-away children of antisocial biological parents (the studies

included an evaluation for the presence of ASPD in adoptive parents).

If such a genetic component exists, physical aberrations (particularly

neurological) may serve as a marker, with a number being reported:

214


• lower than average reactivity of the autonomic nervous system (also

reported is an inability to learn from experience)

• low cortical arousal and reduced level of inhibitory anxiety

• lowered levels of 5-HIAA (a metabolite of serotonin) in impulsive and

aggressive patients, indicating reduced serotonin metabolism

• changes in skin electrical conductivity and EEG abnormalities

• alcoholism: ASPD appears to be genetically related to alcoholism and

is frequently complicated by abuse or dependence

• attention-deficit/hyperactivity disorder (ADHD)

• soft neurological signs (non-localizing), especially in childhood:

• persistence of primitive reflexes, e.g. palmar-mental, grasp, snout

• impaired coordination, balance and motor performance

• graphesthesia, a positive Romberg sign, dysdiadochokinesis

(rapid alternating movements)

• Gait abnormalities, especially walking on the lateral edge of the feet

(stress walking) and heel-to-toe (tandem gait)

Psychosocial: Several factors in childhood are thought to be

etiologically significant in the development of ASPD:

• frequent moves, losses, family break-ups; large families

• poverty, urban setting, poorly regulated schooling

• little emphasis on communication and expression of feelings; instead,

language was used as a tool with which to manipulate

• provision of material needs but emotional deprivation

• enuresis, firesetting and cruelty to animals are particularly strong

indicators of future ASPD

Parents who are neglectful, harsh, physically abusive or substance

dependent have a large impact on the development of this disorder.

Often, patients with ASPD were victims themselves. A family history

readily reveals physical/sexual/emotional abuse, often with a

substance-abusing caregiver. Frequent parental characteristics are:

• Mother: weak, depressive, masochistic, somatizing

• Father: explosive, inconsistent, sadistic, alcoholic, criminal history

By blending genetic and psychosocial factors, etiologic factors indicate

that children with a high degree of aggression, who are difficult to calm

down, comfort and love, are more prone to develop ASPD. Recalling

that the goodness of fit between child and parent is a crucial factor,

these children may be at the extreme where a poor fit has disastrous

long-term consequences (e.g. a good fit for a hyperactive or demanding

child requires an active, energetic and consistent parent).

215


Children need a benevolent authority figure to check aggression and

balance crime with punishment. Attachment to only one caregiver may

not be sufficient for some children. Some studies indicate the increase

in single parent families may be a cause for higher numbers of

sociopaths. Without a father figure, there may be a lack of effective

limits set on behavior and punishments for impulsive actions. Children

learn that in an environment lacking consistent discipline,

consequences can be avoided by seducing or bullying others.

Epidemiology

Estimates of the prevalence of ASPD are in the range of 3% for men

and 1% for women. The prevalence can be up to 75% for incarcerated

individuals. There is a gender difference in that men are more frequently

diagnosed with ASPD, and women with BPD.

Ego Defenses

Antisocial individuals use primitive defenses to exert power, for the

purpose of defending against shame. The primary defenses are:

• controlling (need for control over others and the situation)

• projective identification (described in the PPD Chapter)

• acting out (described in the BPD Chapter)

• dissociation (also in the Other Personality Topics Chapter)

Controlling is an excessive attempt to manage or regulate events,

objects, or people, in order to minimize anxiety and resolve inner

conflicts (primary gain) and to achieve secondary gain.

ASPDs are very prone to act. They gain no increased self-esteem

from controlling their impulses. Many lack even social anxiety, though

it has been suggested that this has to do with the speed with which

they act. Feelings are not well tolerated (especially “weak” ones), and

action is taken quickly enough to prevent the experience of anxiety.

Dissociation is a temporary but drastic modification of one’s sense

of identity or character in order to avoid emotional distress. Dissociative

phenomena range from minimization to total amnesia for a violent

crime. Indeed, the majority of murderers claim to be amnestic for the

event. This raises the question of whether emotional dissociation is

related to a history of abuse. There is evidence for such an association

in other disorders, and because of the high incidence of abuse in

ASPD, there may be a relationship between abuse and dissociation.

216



A. There is a pervasive pattern of disregard for and violation of the

rights of others occurring since age 15 years, as indicated by three (or

more) of the following:

(1) failure to conform to social norms with respect to lawful behaviors

as indicated by repeatedly performing acts that are grounds for arrest

(2) deceitfulness, as indicated by repeated lying, use of aliases, or

conning others for personal profit or pleasure

(3) impulsivity or failure to plan ahead

(4) irritability and aggressiveness, as indicated by repeated physical

fights or assaults

(5) reckless disregard for safety of self or others

(6) consistent irresponsibility, as indicated by repeated failure to sustain

consistent work behavior or honor financial obligations

(7) lack of remorse, as indicated by being indifferent to or rationalizing

having hurt, mistreated, or stolen from another

B. The individual is at least age 18 years.

C. There is evidence of Conduct Disorder with onset before age 15

years.

D. The occurrence of antisocial behavior is not exclusively during the

course of Schizophrenia or a Manic Episode



DSM-IV Diagnostic Criteria for Conduct Disorder

A. A repetitive and persistent pattern of behavior in which the basic

rights of others or major age-appropriate societal norms or rules are

violated as manifested by the presence of three (or more) of the

following criteria in the past 12 months, with at least one criterion

present in the past 6 months.

Aggression to people and animals

(1) often bullies, threatens, or intimidates others

(2) often initiates physical fights

(3) has used a weapon that can cause serious physical harm to others

(4) has been physically cruel to people

(5) has been physically cruel to animals

(6) has stolen while confronting a victim

(7) has forced someone into sexual activity

217


Destruction of Property

(8) has deliberately engaged in fire setting with the intention of causing

serious damage

(9) has deliberately destroyed others’ property (other than by fire setting)

Deceitfulness or Theft

(10) has broken into someone else’s house, building, or car

(11) often lies to obtain goods or favors or to avoid obligations

(12) has stolen items of nontrivial value without confronting a victim

Serious Violations of Rules

(13) often stays out at night despite parental prohibitions, beginning

before age 13 years

(14) has run away from home overnight at least twice while living in

parental or parental surrogate home (or once without returning for a

lengthy period)

(15) is often truant from school, beginning before age 13 years

B. The disturbance in behavior causes clinically significant impairment

in social, academic, or occupational functioning

C. If the individual is age 18 years or older, criteria are not met for

Antisocial Personality Disorder


©American I


ASPD is not diagnosed if the antisocial acts occur during a manic

episode, or during the course of schizophrenia. In a manic episode,

218

The Antisoa'al Personality

an inflated amount of energy and enthusiasm and a sense of grandiosity

(entitlement, privilege, etc.) are present. These factors, combined with

serious impairments in insight and judgment, can result in impulsive

behavior putting the patient at risk for committing illegal acts. Similarly,

the delusions or psychotic thought processes in schizophrenia or

severe mania can fuel actions resulting in criminal charges. Mania,

schizophrenia and ASPD can share features such as: willful destruction

of property, financial irresponsibility (evasion of debts, spending sprees,

etc.), theft, vandalism, physical intimidation and violence. General

medical conditions such as dementia or and epilepsy can lead patients

to commit violent acts on an infrequent basis. Substance abuse is a

key factor to consider in ASPD. Many individuals commit crimes to

obtain drugs, or while intoxicated, but not at other times. Males with

ASPD may have a distinct type of alcoholism, associated with: an

early age on onset, a high degree of novelty seeking and criminality in

their fathers, but only an average prevalence of alcoholism in the

extended family.

A key diagnostic point is that not all criminal behavior is due to ASPD,

and not all ASPDs commit chargeable offenses. A proper evaluation

requires a longitudinal history, with an understanding of the patient’s

interpersonal behavior. The main diagnostic criterion for ASPD is a

pervasive and long-standing disregard for the rights of others, with

unlawful behaviors being the usual but not exclusive manifestation.

ASPDs are supportive of criminal activity, and are shallow, proud or

remorseless when confronted. This is different than the response given

by a patient who committed an illegal act while in the midst of a manic

episode or psychotic break.

Other DiagnostU Considerations

The overlap of ASPD with substance abuse (especially alcoholism)

has already been mentioned. Teasing out a cause-effect relationship

can be quite difficult — the disorders are frequently intertwined and

both tend to start at an early age. First-degree female relatives of ASPD

males have been found to have a higher incidence of Briquet’s

syndrome (one of the historical antecedents to the present diagnosis

of somatization disorder). ASPDs are also prone to engage in

malingering, defined as the intentional production of physical or

psychological symptoms for the purpose of obtaining secondary gain.

Ganser’s syndrome is a related syndrome of giving approximate but

incorrect answers to questions. This is thought to be more due to

conscious malingering than dissociative or hysterical causes.

219



Appearance:

Behavior:

Cooperation:

Affect:

Speech:

Thought

Content:

Stereotypically have long hair, open shirt, jewelry,

scars, tattoos, tight-fitting pants with large belt buckles,

boots, carry knives; females may have heavy make¬

up; tight-fitting or revealing clothing

Strutting walk and erect posture; use space around

them as if trying to impress; move closer when trying

to manipulate; move forcefully; strong handshake;

Varies with degree of interviewer’s interest — ranges

from highly engaging to quite hostile

Expansive, cocky, hostile, irritable, shallow

Exaggerated, vague, grammatical errors; glib, foul

language; malapropisms; try to appear sophisticated

Grandiosity quite evident; past exploits are

repeatedly emphasized; blame environment exclusively

Thought Form: No characteristic abnormality

Perception:

Insight &

Judgment:

Suicide/

Homicide:

If abnormalities are present, consider malingering

Impaired, but can give “lip service” to what sounds

morally decent; have great difficulty in seeing their

deficits or contributions to problems

More likely to be dangerous to others than to

themselves, but may emphasize suicide to

manipulate for their agenda

Cletkley's Psychopathic Personality Features

• Superficial charm and good “intelligence”

• Absence of delusions and other signs of irrational thinking

• Absence of “nervousness” or psychoneurotic manifestations

• Inadequately motivated antisocial behavior

• Poor judgment and failure to learn from experience

• Pathologic egocentricity and incapacity for love

• General poverty in major affective reactions

• Unresponsiveness in general interpersonal relations

• Fantastic and inviting behavior with drink and sometimes without

• Sex life impersonal, trivial and poorly integrated

• Suicide rarely carried out

• Failure to follow any life plan

• Unreliability

• Untruthfulness and insincerity

• Lack of remorse or shame

• Specific loss of insight

Source: Cleckley (1988). Reprinted with permission.

220



Sociopaths primarily need to exert power over others to defend against

an awareness of shame. The central dynamic is an absence of

conscience or a defective superego (Cleckley, 1988). Meaningful

attachments to others are conspicuously lacking. Other people are

seen only as objects over which to exert control. The harsh inner world

of the antisocial is one of chaos, insecurity and intolerance. Expressing

ordinary emotions reveals weakness and vulnerability; only the

extremes — blind rage or maniacal exhilaration — are experienced.

Tender or softer emotions expressed by others are actively devalued.

Sociopathic patients exhibit a primitive envy and may seek to destroy

what they most desire. For example, the victims of many serial killers

are attractive women or members of happy, stable families. It may be

that aggressive and sadistic acts stabilize the perpetrator’s sense of

self and boost feelings of esteem.

Sociopathic patients have profound deficits in internalization. They do

not attach to others, have not experienced a good object, and do not

identify with a caregiver. They have never received love, do not love

others, and have no sense of society or culture.

Modeling parental psychopathy is another psychodynamic mechanism.

Parents may encourage a demonstration of power with repeated

messages that life should pose no limits, which leaves their children

feeling entitled to exert dominance. An example would be be parents

who act with outrage at teachers, police, or counselors who try to set

limits. The term superego lacunae is used to describe the process

whereby parents who have their own problems with authority encourage

this attitude in their children. It is “inherited” in the sense that parental

attitudes are handed down.

Lacking a sense of omnipotence and power at developmental^ important

phases leaves patients spending their lives seeking to confirm their

power. If they are temperamentally more difficult to love, the lack of

attachment leaves them more focused on themselves, and they make

up and follow their own rules.

A common denominator may be that after such continual blows to their

self_esteem, they view the external world as barren and self-serving.

They become predators, and remorselessly justify their disregard for

the rights of others and the rules of society.

221



It is frequently stated that antisocial personalities are not treatable. At

this time, there is no form of psychotherapy or pharmacotherapy which

has been consistently successful in reducing sociopathy.

“Why should I treat this lowlife?” is a question that crosses the minds

of all therapists. Everyone involved in providing therapy needs to make

personal decisions about investing their time and talents in attempting

to help antisocial personalities. To assist with this decision, a thorough

assessment is critical. Some patients may be so damaged, dangerous

or determined to destroy the therapy that it is not possible to provide

assistance. It may well be that these patients should not be accepted

for treatment. Reasons for such a decision may be as follows:

• a history of serious assault (sexual/weapon), murder, sexual sadism

• lack of remorse for a crime committed against an individual

• secondary gain for “being in treatment”

• long periods of time spent in institutions or prison

• extremes of intelligence

• an inability to develop any emotional attachment

• threatening to the therapist (overtly or implicitly)

• arousal of strong countertransference reactions

Source: Adapted from Gabbard (1994)

The diagnosis of ASPD encompasses a range of sociopathy. On one

extreme is the predatory serial killer. The other end of the continuum

are mildly sociopathic professionals who cheat on their spouses, steal

office supplies from work, leave debts unpaid, etc. The presence of at

least some of the following factors is necessary for therapy to have a

chance of succeeding: ego strength, an ability to express remorse,

evidence of compassionate feelings, and at least one enduring

attachment.

If a sufficient number of positive factors are present to justify starting

therapy, the most important feature is incorruptibility of the therapist

and the therapy. Convey this almost to the point of being inflexible.

Any deviation will be experienced as a sadistic triumph, not gratitude

for wavering from the boundaries of therapy. Anything that can be

interpreted as a weakness will be seen as such. Sociopaths don’t

understand empathy; they see people only as interchangeable objects.

Use unwavering honesty in outlining a therapeutic contract. Use direct

language, keep promises, make good on penalties and address reality.

222


Antisocial patients project their cold and self-serving nature onto others.

They will try to discern what you gain from being a therapist. You may

have to admit to a “selfishness” regarding your fees. Gratitude is not

likely, but respect may be forthcoming for being scrupulous, toughminded

and exacting. Do not bend to patients’ “special needs,” regardless

of the reasonableness of their explanations.

There is power inherent in confession; most patients want to talk about

themselves. The first step in “acquiring” a conscience is caring enough

about someone that that person’s opinion matters. This can develop if

the therapist is consistent, nonpunitive and nonexploitable. Power is

all that ASPDs respect. They can inflict extreme violence on someone

seen as “dissing” or “disrespecting” them (treating them as powerless

or worthless). Some demonstration of power, e.g. “out-conning” or

“out-psyching” them as a means of getting respect or at least attention,

may be helpful. We can use our own antisocial fantasies or reactions

in a way to seek a connection to their emotional world.

At least initially, empathy can’t be used therapeutically. Also, inviting

the expression of feelings is not likely to be useful because of these

patients’ deficient superego. Because of this, they are committed to

act in order to feel strong and omnipotent. Restrict discussion to the

possible outcomes of antisocial behavior, and focus interventions on

confronting denial and minimalization. If possible, use your sense of

humor when making this point. While the penalties of breaking the

law may be severe, discussing this doesn’t have to be sterile.

Avoid emotional investment in patients or the progress of therapy.

Show an independent strength verging on indifference. As a

demonstration of their power, patients are likely to sabotage therapy

when they sense there is an investment in the outcome. However, it is

important to be respectful and to weather their continual grandiosity.

Callousness is their response to an environment which they see as

incomprehensible or abusive, a generalization from early experiences.

Progress is being made when words start being used not to manipulate,

but to express feelings. Another positive indication is feeling pride at

suppressing impulses. A profound or even psychotic depression may

develop in a successful therapy. This depression may herald extreme

remorse and the onset of feelings for others. Despite these possible

gains, psychotherapy with ASPDs is fraught with difficulty and unlikely

to have much success.

223



Basic transference is the projection of predation; patients view the

therapist as using them for selfish purposes. Patients will not be

convinced of genuine motives and will try to figure out your “angle” or

what you gain by conducting the interview, therapy, etc.

ASPDs will be preoccupied with using the therapist, and trying to

outsmart the therapist’s (perceived) agenda. Countertransference is

felt as resistance to the extent that an identity as a helper becomes

eroded. A common reaction from the therapist is to repeatedly try to

prove good intentions and helpfulness. When this fails, hostility,

contempt, moral outrage, and even outright hatred may ensue. When

this happens, the patient doesn’t care about the therapist, and the

therapist finds it difficult to care about the patient.

Countertransference frequently involves an ominous fear, often

described as an eerie feeling of being under patients’ influence.

Commonly, the particularly cold, remorseless stare of sociopaths

contributes to the feeling of being their “prey.”

It is very difficult to be actively or sadistically devalued. This produces

a sense of hostility or hopeless resignation. Tolerate, but don’t deny or

minimize these feelings. However, do not disclose feelings of

countertransference to patients. This will be seen as frailty, and may

cause them to try and take control of the situation. Privately admit

countertransference (such as in your own therapy or to a colleague);

otherwise, hostility may be ignored, causing a potentially dangerous

situation. Strike a balance between being confrontational and nonjudgmental,

but rigorously avoid anything than may be construed as

collusion with antisocial acts.


• don’t moralize

• invest in increasing understanding of the “here and now,” particularly

with transference reactions and devaluation of therapy

• set a tone of doing the job competently; be stable and persistent

• communicate that it is up to the patient to take advantage of therapy

(or not); progress is slow; be attuned to control issues

• firmness of purpose and rock-bottom respect seem to be a winning

combination

• be constantly vigilant for not putting yourself at risk with these patients

224


Group Therapy

Some institutions have reported gains via group therapy with inmates

or inpatients. A frequent observation is that group members develop

remarkable insight into the problems of others, but have a striking

lack of insight into their own. A homogeneous group of ASPDs is the

only indication for group therapy (hilariously demonstrated in the movie

Raising Arizona). Even in inpatient educational groups, ASPDs mock

authority, cause disturbances among other patients, and often try to

lead a “rebellion" of other patients. They act as catalysts for disruptive,

acting out behavior among impressionable and fragile co-patients.

Cognitive Therapy

Basic Cognitive Assumptions:

• Justification — “The end result justifies the means.”

• Thinking is believing — “I say it or feel it and it has to be right.”

• Infallibility — “I always find a way to get away with it.”

• Devaluation of others — “Other people do not matter.”

• Denial of consequences — “I won’t get caught.”


Cognitive therapy involves a series of guided discussions, structured

exercises and behavioral experiments designed to give patients a

broader, more prosocial way of interacting with others. For example,

in the following exercise, patients determine the advantages for them

in following a certain course of action after being demoted at work:

Choice

Tell boss to

shove it and quit

Find a way to

make boss look

stupid at work

Meet minimum

expectations

Show a positive

attitude; work hard

Advantage

Immediate revenge;

“Don’t mess with me”

message sent

Feel better about

what happened

Keep job; get some

satisfaction

May get job back

sooner; not boring

Disadvantage

Need to find

another job; looks

bad on resume

Boss may find out I

did it and get me back

at a later time

Won’t get old job back

as soon; boring

Company demoted

me and now get more

work out of me

From this exercise, patients learn that their actions affect others, and

have long-term outcomes that are important for them.

225


Pharmatotherpy

The degree to which sociopathy is a “medical” disorder has been the

subject of intense debate between mental health professionals and the

legal community. An evaluation of the DSM-IV diagnostic criteria for

treatable symptoms yields two potential areas for the use of medication:

the reduction of impulsivity and controlling angry outbursts.

Most classes of psychiatric medication have been used to try to reduce

these behavioral manifestations. SSRIs and mood stabilizers have been

shown to have some success and have the advantage that there is no

risk of addiction. Other medications that have been reported to be of

some use are: gabapentin, lamotrigine, verapamil, pericyazine,

propranolol, buspirone, buproprion and venlafaxine. Benzodiazepines

and antipsychotics are less desirable to use in ASPD.


Benjamin (1993) emphasizes the childhood experience of gross

neglect occurring at a crucial time period as a pivotal factor in the

development of ASPD. While this can occur in any family, it tends to

be more common in those who are socially disadvantaged. Harsh and

inconsistent discipline causes the internalization of neglect and

abandonment. Because of this, patients learn to expect no assistance

from others (only punishment) and for this reason fiercely protect their

autonomy— the antithesis of being under the arbitrary control of others.

The concept of inept caring is also operative. Here, patients do not

have the experience of a concerned and capable parent, and later in

life evidence a flagrant disregard for the welfare of both themselves

and others. Over time, they learn to create their own opportunities by

manipulating others in a charming but emotionally detached manner.

Benjamin (1993) notes that ASPDs are unreachable in ordinary dyadic

psychotherapy. Because they generally are brought for help at the

request of courts or family members, they have no personal interest

in changing. Their pervasive hostile autonomy may well be reachable

only addressable through nonverbal means such as structured inpatient

behavior therapy, wilderness survival camping trips or giving them some

responsibility in a situation that allows them to experience feelings of

benevolence. In particular, she cites the examples of inmates being

given kittens to care for or having sociopathic patients teach children a

sport in a supervised setting (probably not pole vaulting).

226


Case Example

Mr. Scumbagglia is a divorced man is his late thirties. He has an

effervescence about him and a disarming smile that is at odds with his

cold gaze. He sees himself as a man of the world and never passes up

the opportunity to become a raconteur for an interested group. While

officially unemployed and on social assistance for a medical disability,

his expensive clothing and gold jewelry betray another source of income.

After being assured that the nature of his activities will remain confidential

(especially from the police), he discloses that he is a highly soughtafter

arsonist for businesses needing to collect insurance money. He

jokingly refers to this as the “lightning lottery.” While he won’t discuss

his recent “work” or past “employers” he does go into considerable

detail about his methods. Mr. Scumbagglia has a sound knowledge of

combustible materials and fire investigation protocols. He rationalizes

his activities by comparing his services to those of high-ranking business

executives who amass wealth through predatory means. He also says

he doesn’t see too many insurance companies going out of business,

and aside from this, he considers them bigger criminals than anyone

else he knows. A self-proclaimed artist, he proudly states that he has

never personally injured anyone in his activities, nor has he ever been

convicted of arson.

Course

By the time patients qualify for the diagnosis of ASPD, they have

exhibited years of chaotic behavior. As children, they were often

enuretic, hyperactive, sadistic and disruptive. With growth in size and

strength, more damaging acts became possible, especially aggressive

and sexual ones. As young adults, they exploited others financially and

emotionally. The inability to live up to the demands of society is quite

obvious by the time the diagnosis is made. Antisocial activity appears

to peak in early adulthood and then diminish slowly. However, there is

controversy over the degree to which it disappears. In general, the

best predictor of future sociopathic behavior is the extent to which is

has already been present. Some authors report that antisocial behavior

dramatically declines over age forty-five, while others feel it continues

well beyond this age. Sociopathic behavior can be attenuated by social,

economic, legal, medical and interpersonal consequences. Long prison

sentences, injuries, and financial or emotional bankruptcy later in life

can have an impact. Other factors that may cause the diminution of

sociopathic behavior are the loss of speed or strength, continued

substance abuse or positive life events (marriage, employment, etc.).

227


Referentes



Edition





L. S. Benjamin



H. Cleckley

The Mask of Sanity, Fifth Edition

Emily S. Cleckley (Publisher), Augusta, Georgia, 1988*

G. Gabbard


Edition





N. McWilliams






*The Mask of Sanity, Fifth Edition is available from:

Emily S. Cleckley, Publisher

3024 Fox Spring Road

Augusta, Georgia

U.S.A. 30909

The cost is $25 plus $4 shipping and handling (US dollars).

228


Introduttion:

Erik Erikson developed the now

familiar stages of his Life Cycle

Theory. In one of his first

applications, he compared the

anomalous development of the

Singleton twins, one of whom

called in a bomb threat the very

night his brother was to receive

the Nobel Peace Prize.

Sotiopathy 101

Normal (Nobel Prize)

Stage 1

Trust vs.

Mistrust

Stage 2

Autonomy vs.

Shame & Doubt

Stage 3

Initiative vs.

Guilt

Stage 4

Industry vs.

Inferiority

Stage 5

Identity vs.

Identity Confusion

Stage 6

Intimacy vs.

Isolation

Stage 7

Generativity vs.

Stagnation

Stage 8

Integrity vs.

Despair

Antisodal (No Prize)

Lust vs.

Misogyny

Auto Theft vs.

Doubtful Shame

Insanity Defense vs.

Guilty Plea

Repeat Offender vs.

Reform School

Narcissism vs.

Phony Sincerity

Gang Allegiance vs.

Solitary Confinement

Crime Spree vs.

Collecting Social Assistance

Most Wanted List vs.

Two-Bit Reputation

229


Aggressive

We met in the Uomo Menswear store; he had to steal a tie for

his probation hearing. Blunt and direct, he was a man of

few words, most of them having four letters.

Slitk

He said I

could call him Ted, Billy Ray, or Freddy — he had i.d. for

each name. The sex was fast, furious and always in a

public place. He missed his other girlfriend, and got her

to join us after threatening to turn in her dealer.

Predatory

He wanted to commemorate the occasion with matching tattoos —

black scorpions. It complemented the ones he already had —

NFA on his left arm and NRA on the right. He promised the artist

payment next week, but ended up ripping him off anyway.

Dangerous

We skipped his AA meeting; it only drove him to drink, and drive. So

we did, racing another stolen car into the sunset.

He handled it all like a pro — and said so.

Truly an 8 Ball man.

The cologne for real men.

230

Rapid Psyehler Press

Fill-in-the-blank Suspense:

Anatomy of a Bond Adventure

Act I

Bond, a government contracted antisocial, is summoned from some

exotic locale where he is risking his life recreationally, instead of in

the line of duty. His sadistic, schizoid boss, who has never even set

foot outside the building to serve England, briefs him on an impossibly

dangerous mission.

Bond picks up a great new gadget from the schizotypal in the

research department. Though it seems cumbersome and the

instructions tedious, it inevitably saves his life — only after he tries it

out on a lowly obsessive-compulsive sap from elsewhere in the

department.

Act II

Bond quickly dumps his dependent girlfriend, who actually portrayed

the histrionic in his last adventure. His itinerary is abruptly changed

when his boss’s passive-aggressive secretary uses his plane tickets

for her own vacation.

Act III

After arriving first class at an even more interesting destination than

originally planned, he is enamored by the charms of the borderline

sent by his nemesis. Although she plans to kill him, Bond’s superficial

charm persuades her to switch allegiances. In doing so, she pays

with her life but not before revealing the identity of a gorgeous avoidant

who is the right-hand assistant to the bad guy.

Act IV

Bond enlists the help of the local paranoid FBI/CIA/I RA/IBM./IRS agent

with a soft spot for assisting the British. Though Bond prefers to work

alone, the assistance he is invariably forced to accept enables him to

defeat the evil empire built by the megalomaniac narcissist, and return

the world to safety.

Epilogue

Bond takes full advantage of the post-traumatic effects of the recent

mayhem on the heroine. On principle, he avoids returning to work for

at least a fortnight while still collecting his full salary.

231


Cereal Killers

Voodoo Vic

the Vengeful Vulture

Vic puts a voodoo curse on

those who dig out the enclosed

giveaway before

the cereal box is empty.

The Quacker State

Oil & Oats Man

This ruthless tycoon

amalgamated Quacker State Oil

and Quacker Oats to produce a

high-octane crisp that explodes

on contact with milk.

Captain BoneCrusher

This sadistic seadog produces

a nugget that absorbs calcium.

He is sought for the quasimodoric

deformation of the

Crunchback of Notre Dame.

Antonio the Sicilian Tiger

Known for his bellowing voice

and loud snarl, Antonio is also

known to “frost over” those who

interfere with the family’s

breakfast business.

232

Review Questions


1. How can the concept of “insanity” be applied to the antisocial


2. Which of the following behaviors are consistent with the DSM-IV

concept of the antisocial personality disorder?

a. a marked tendency to blame others for unsavory conduct

b. the inability to form long-lasting, monogamous relationships

c. a lack of concern for the feelings of others

d. significant unemployment

e. frequently leaving jobs without arranging for other employment

f. marked absenteeism from work

g. no regard for honesty

h. lack of a fixed address for more than one month

i. traveling from place to place without a job, a clear goal for the period

of travel or a plan for when the travel will end

233



1. Insanity is a legal term, not a medical one. While there are different

definitions, insanity generally refers to a state of mind that prevents a

person from knowing the nature and quality of an act, or, if this is

known, from appreciating that the act is wrong. Here the word “wrong”

means illegal, not immoral. No personality type has been a greater

source of debate for legal and medical scholars that the sociopathic

patient. For example, many sociopathic patients commit acts that appear

to be caused by a clear defect in reasoning. However, upon evaluation,

no indication of a major mental illness is found. In this sense, the

sociopathic patient has a moral insanity, meaning that he or she has a

circumscribed area of “insanity” involving moral, ethical or prosocial

behaviors. Otherwise, these patients are often well spoken, polite,

capable and seem to appreciate that certain behaviors are illegal. Pinel,

Rush and Pritchard were all key figures in defining the entity currently

known as ASPD. Pinel in particular noted that “madness,” in the sense

of impulsive or self-damaging acts, did not have to be associated with a

“delirium” (defect in reasoning). Pritchard also differentiated long¬

standing (trait) antisocial behavior from that occurring episodically (state)

as in mania or schizophrenia.

Reference




2. All of these criteria define sociopathic behavior and in this way are

consistent with the description provided in the DSM-IV. The first three

are paraphrased from the ICD-10 description of the dissocial

personality disorder, the next three from DSM-III criteria and the last

three from the DSM-lll-R. The previous two editions of the DSM had a

checklist of specified antisocial behaviors instead of the generalized

criteria that were used for the other personality disorders.

References


Pocket Guide to the ICD-10 Classification of Mental & Behavioural Disorders



Diagnostic and Statistical Manual of Mental Disorders,

Third Edition, 1980

Third Edition Revised, 1987

234

The Borderline Personality


235



Name:

Occupation:

Appearance:


Favorite Song:

Motto:


Before Session:


During Session:

Fantasies Involve:



Brings to Session:


"I RAISED A PAIN"

Identity disturbance

Tara Bull

Emotional hotline counselor

Dresses entirely in either black or

white; today it’s black

Sleeps with teddy bear and an

assortment of stuffed animals

Love Rollercoaster

Come here! Go away! Come here!

Fights with ex-lover outside office

Castrates all pictures of men in

magazines

Smells Histrionic’s perfume and

goes into a rage

Menage with therapist and partner

Threatens blackmail over above

fantasy

Widens hole made by Antisocial

Suicide note, with weekly changes

Relationships are unstable

Abandonment is frantically avoided

Impulsive

Suicidal gestures are made (attempts, threats, self-mutilation)

Emptiness is a description of their inner selves

Dissociative symptoms

Affective instability

Paranoid ideation

Anger is poorly controlled

Idealization of others, followed by devaluation

Negativistic — undermine their efforts and those of others

236

The Borderderline Personality

Introduttion

The word borderline refers to the “border” between neurosis and

psychosis. Prior to the narrowing of criteria in DSM-III, the diagnosis

of schizophrenia encompassed a much wider range of symptoms and

behaviors. Borderline personalities were initially thought to have a

variant or atypical form of schizophrenia. In the DSM-IV, borderline

personality disorder (BPD) is characterized by impulsivity and instability

in the areas of mood, self-image and relationships.

Some key names associated with understanding of this disorder are:

• Hoch and Polatin (1949) — called this condition pseudoneurotic

schizophrenia, characterized by “pan-neurosis, pan-anxiety and

pan-sexuality” (these were all considered neurotic symptoms).

• Knight (1950’s) — identified a group of patients in his hospital practice

who had severely impaired ego functions, manifested by primary

process thinking and an inability to suppress primitive impulses.

• Grinker (1968) — pioneered research into the phenomenology of

this disorder, finding four consistent features: anger as the main affect;

poorly established self-identity; pervasive moodiness (usually

depression or dysthymia); and deficiencies in the capacity to form

intimate relationships.

• Gunderson and Singer (1975) and Gunderson (1984, 1990) —

identified criteria that clearly discriminated the borderline personality

from other psychiatric conditions.

• Kernberg (1967, 1975) — described borderline patients from a

psychoanalytic perspective, finding four key features that allowed a

definitive diagnosis: nonspecific manifestations of ego weakness; shift

toward primary process thinking; specific defensive operations; and

pathological internalized objects; he also developed the concept of

the borderline personality organization which applies to personality

disorders other than BPD (see the Psychodynamic Aspects Section).

Borderline personality disorder was first included as a discrete disorder

in the DSM-III. Previously, the term borderline had been used to refer

to: a spectrum of disorders, a difficult patient, diagnostic uncertainty

and a type of personality organization. Not only was BPD initially

considered a subtype of schizophrenia, it was later thought of as an

atypical mood disorder. Further research has supported the validity of

BPD as an independent diagnostic entity. Many complete textbooks

have been written on BPD, which remains a controversial, complex

and convoluted diagnosis. The material in this chapter is confined to

the DSM-IV description of BPD.

237


Media Examples

Borderline characters are unpredictable, emotional, vindictive and

intense. For these reasons, they are cast as main characters or

“movers and shakers” in plot development. Borderlines frequently fill

the roles of: “boyfriend/girlfriend/roommate from hell,” or a spurned

lover. Their mission of revenge adds considerable drama and the

“showdown” is usually the climax of the movie. They differ from

sociopathic characters in that they seek revenge generally for rejection

(perceived or actual), whereas antisocial personalities do not need a

reason for their destructive actions.

• Fatal Attraction — Glenn Close portrays a classic borderline

personality in this thriller. She readily agrees to an uninhibited weekend

affair with a married man, and then becomes pathologically attached

to him. When he subsequently distances himself from her, she

becomes frantic in her attempts to woo him back. Finally, she terrorizes

him, vandalizes his car, stalks his family and kidnaps his daughter.

This character evoked such strong reactions (see the Transference

and Countertransference section) that audiences were not satisfied

with the original ending in which she did not die. It is of interest to note

that movie reviewers describe her behavior as “psychotic” and “loco,”

illustrating some of the confusion over the diagnosis of the condition.

• The Crush — Alicia Silverstone portrays a Lolita who becomes

obsessed with a male boarder in her parents’ home. She gains his

attention with her considerable talents, but can’t comprehend the

inappropriateness of a relationship with him. He suffers her increasingly

destructive wrath when he pursues another relationship.

• Malicious — Molly Ringwald portrays a borderline medical student

in this film. This movie illustrates some of the family dynamics that led

to her troubled emotional state.

• Presumed Innocent — Greta Scacchi portrays a more subtle

variation of the borderline personality, emphasizing the rapid

idealization and devaluation, and shifts in mood that also characterize

the diagnosis.

Other borderline characters can be seen in:

• Play Misty For Me

• The Temp — the role played by Lara Flynn Boyle

• The Hand That Rocks the Cradle — the Rebecca De Mornay

character

• Single White Female — the role played by Jennifer Jason Leigh

238



Borderline patients are often verbal, and it is not usually difficult to

initiate an interview. They may even interrupt introductions to begin

talking about something that is upsetting them.

A formidable obstacle in interviews is the intensity of affect expressed

by borderline patients. They are often in a state of turmoil and express

anger readily. These patients will also abruptly shift allegiances. At

one moment, they idealize a relationship, only to devalue it in the next.

While the content of the interview may bring about a heated tirade, a

response to internal cues may also leave an interviewer quite bewildered

about the source of the affect.

Borderline patients present unique difficulties because their arsenal

of primitive defenses and potent anger can be readily aimed at the

interviewer. Caregivers are perceived either as all powerful and placed

on a pedestal, or as depriving and discarded to a dumpster. Abrupt

shifts occur between these two perceptions. This can occur when patients

receive something they want (medication, admission, sick leave, etc.),

or when they are denied these requests.

To maintain rapport, interviewers need to recognize that these patients

interact with everyone in this way, and not to take such difficulties

personally. Acknowledging instability as an issue for further exploration

may help sustain the interview. Use of open-ended questions,

redirection back to clinically relevant material, and simply hearing

patients out can be helpful.

Borderline patients can develop micropsychotic episodes under

stressful situations and display features such as hallucinations,

delusions (particularly paranoid), and loosening of associations.

Borderline Themes

• Chaotic childhood

• Disrupted education

• Parental neglect and abuse • Legal difficulties

• Impulsivity

• Substance abuse or dependence

• Sexual abuse; early onset of sexual activity; promiscuity

• Fears of abandonment; maintenance of self-destructive relationships

• Failure to achieve potential or long-term goals

• Frequent suicidal ideation or gestures (burns, lacerations, etc.)

• Poor ego boundaries; unduly influenced by those around them

239


Etiology

Biological: BPD may have a genetic contribution. Studies have found

familial tendencies towards poor regulation of mood and impulses.

BPD patients may be temperamentally aggressive and have intense

attachment needs. Low serotonin levels have been found in individuals

who have been aggressive (both to themselves or others). Dysfunction

in serotonin regulation has been well established as an etiologic factor

in mood disorders. Additionally, dopamine seems to facilitate aggression,

and is the major neurotransmitter system implicated in psychosis. It

has been proposed that dysregulation of either, or both, systems may

provide a neurobiological mechanism for some of the features of BPD.

Another theory implicates a lowered threshold for excitability in the

limbic system.

The extended families of borderline patients have increased rates of

substance use disorders, conduct disorders, mood disorders,

learning disabilities, and other Cluster B personality disorders

(particularly antisocial).

Psychosocial: The adage that “borderlines are made, not born” rings

particularly true when virtual carbon copies can be made of their

personal histories. While this is obviously not universal, there is an

uncanny similarity in the family and social situations of many patients.

Development is thought to be interrupted at Mahler’s rapprochement

subphase of separation-individuation. At sixteen to thirty months

of age, children begin to explore the world around them as entities

separate from mother. They venture away from caregivers cautiously,

returning readily for reassurance and security. Caregivers who interpret

this return as an indication that children do not want to be autonomous

will squash future attempts. Similarly, caregivers who have

pathologically strong desires to be loved and needed may engender

strong separation fears in their children. Children may subsequently

be punished for attempts at autonomy.

Borderline patients can be viewed as constantly reliving this struggle

with autonomy. As children they do not develop object constancy,

and fear that attempts to separate will result in disappearance of

caregivers, subsequent abandonment, and the possible disintegration

of self. This can result in being unduly intolerant of being alone, and

more difficult to parent.

240


Initial provision followed by frustration of attachment causes children to

find maternal substitutes. The first transitional object often takes the

form of a cuddly toy, usually a teddy bear or other stuffed animal. It is

a frequent sight on inpatient units to see adults bring in stuffed animals

to comfort them during their admission. One study investigating this

phenomenon reported a sixty-one percent correlation with BPD!

(K. B. Schmaling et al, The Positive Teddy Bear Sign: Transitional Objects

in the Medical Setting, J. Nerv. Merit. Dis., Dec. 182 (12), p. 725, 1994)

In general, failure to provide adequate attention invalidates children’s

feelings and experiences. Without this, they do not develop a stable

image of themselves or others, and instead begin to rely on substitutes.

Other contributions may be due to erratic caregiving such as:

• parental absence; substance abuse; episodes of mood disturbance

• inadequate maturity or characterological disturbances in parents

• divorce; frequent moves; relationship break-ups or other losses

Disturbed parent-child relationships cause particular difficulty in the

handling of anger. Children who later go on to develop BPD may sense

that the expression of anger has a destructive potential, and instead

deal with it by splitting it off or through dissociation. Severe childhood

trauma is also considered to be strongly correlated with adult BPD.

This is most often present in the form of emotional, physical, and

especially sexual abuse. These devastating occurrences overwhelm

children to such a degree that use of the above defenses is necessary

to cope with the trauma. While a genetic component may be present,

a more accurate etiologic understanding is that BPD is more likely

“made” than “born.” This is supported by the emergence of this disorder

after accumulated developmental insults, usually in late adolescence

or early adulthood. Patients who have BPD at an early age usually

exhibit a worsening in their symptoms as they get older.

Epidemiology

The prevalence is estimated to be approximately 3% of the general

population. BPD is by far the most common personality disorder

diagnosis made in clinical settings. Here, the prevalence can be as

high as 10% on inpatient units and 20% in outpatient clinics. There is

a gender difference, with women being diagnosed at least three times

as often as men. This may also reflect cultural stereotypes in that men

exhibiting the same symptomatology are likely to be diagnosed with an

antisocial or narcissistic personality disorder.


Ego Defenses

The use of ego defenses in BPD is readily apparent. The defensive

structure used by these patients evokes strong reactions in others and

is not as subtle as in other personality disorders. As with other “self

disorders, the defenses are primitive in nature and used to extreme

degrees, including psychosis in some cases.

Foremost among the defenses in BPD is splitting. This is the process

whereby people are seen as “all good” or “all bad,” with sudden shifts

between these perceptions. Patients express a fixed, rigid attitude

while regarding the opposite view as having no validity.

What makes this such an obstacle in dealing with borderline patients

is the intense affect occurring with these “splits.” They have not been

able to integrate coexisting good and bad images of themselves or

others to the point of experiencing ambivalence (e.g. seeing shades

of gray instead of a black-and-white situation). People are either

unrealistically idealized as nurturing rescuers, or devalued as the

personification of evil and neglect. Splitting can be seen in:

• self-representation; patients experience rapidly fluctuating views of

themselves (also referred to as identity disturbance or diffusion)

• attitudes and behaviors towards other individuals

• groups of people; this is frequently seen on inpatient units where

patients split staff members into those who feel either sympathy or

antipathy for them

Other defenses used in BPD are:

• Denial — which is the abolishment of external reality. This is used

particularly in BPD to disavow the other side of the “split.”

• Distortion — the reshaping of reality to meet inner needs or to fulfil

fantasies. Use of this defense leads to unrealistic beliefs and

overvalued ideas, and may facilitate micropsychotic episodes. This

defense reinforces the narrowing of perception that maintains splitting.

• Dissociation — a temporary disconnection from a situation that is

too painful to deal with. In this state, there is usually a drastic change

in character. While this can be a benefit under certain circumstances,

it is a drawback in situations where a less dramatic defense or

adaptation would suffice.

• Projective Identification works in concert with splitting to induce

others to behave according to the projections (side of the split they

are on) of the patient. It operates like a self-fulfilling prophecy.

242



A pervasive pattern of instability of interpersonal relationships, selfimage,

and affects, and marked impulsivity beginning by early

adulthood and present in a variety of contexts, as indicated by five (or

more) of the following:

(1) frantic efforts to avoid real or imagined abandonment. Note: Do

not include suicidal or self-mutilating behavior covered in Criterion 5.

(2) a pattern of unstable and intense interpersonal relationships

characterized by alternating between extremes of idealization and

devaluation

(3) identity disturbance: markedly and persistently unstable self-image

or sense of self

(4) impulsivity in at least two areas that are potentially self-damaging

(e.g., spending, sex, substance abuse, reckless driving, binge eating).

Note: Do not include suicidal or self-mutilating behavior covered in

Criterion 5.

(5) recurrent suicidal behavior, gestures, or threats, or self-mutilating

behavior

(6) affective instability due to a marked reactivity of mood (e.g., intense

episodic dysphoria, irritability, or anxiety usually lasting a few hours

and only rarely more than a few days)

(7) chronic feelings of emptiness

(8) inappropriate, intense anger or difficulty controlling anger (e.g.,

frequent displays of temper, constant anger, recurrent physical fights)

(9) transient, stress-related paranoid ideation or severe dissociative

symptoms




BPD in its more florid forms is not difficult to diagnose. These patients

frequently present to emergency rooms, day programs and outpatient

clinics in a state of turmoil. Usually, a psychosocial crisis that threatens

a relationship (DIR) causes an upheaval. In response to this, borderline

patients become overwhelmed and regress to the point of being lost

in a crisis, and obtain admission to hospital by making suicidal gestures

or attempts. An inpatient stay is often required because patients feel

they cannot trust their impulses, thereby forcing caregivers into a

protective, “parental” role. As outpatients, they remain “stably unstable”

and often make demands for ongoing therapy. In its less obvious forms,

243


BPD can present a diagnostic challenge. Historically, syphilis was

referred to as the “great imitator” because of its protean physical

manifestations. Currently, the manifold expressions of AIDS and HIV

seropositivity would claim this title. BPD may be the “great imitator” of

psychiatry because of the extensive overlap of symptoms with other

conditions, as indicated below.

/ Impulse \ /Substance\

I Control ( Use j

V DisordersJ

\Disordery'

unrestrained

aggression/

impulsivity

impulsivity/

abuse of

substances

instability

of mood and

affect

(Dissociative\

l Disorders J

dissociate / Borderline ^i micro- f Psychotic\

1 Personality 1- psychotic -

\ Disorders )

V Disorder j

' episodes

-in response -

to stress

sexual and

identity

diffusion

impulsivity

with/abuse

of food

obsessions,

phobias,

anxiety

There is an increased familial risk for substance-related disorders,

mood disorders and ASPD. Somatization disorder shares many

etiologic factors with BPD. Because borderline patients make

numerous demands for medication and hospitalization, factitious

disorder and malingering also need to be considered. There is a

good deal of overlap with other Cluster B disorders. Borderline patients

can run afoul of the law when acting impulsively, often for motor vehicle

offenses or shoplifting. More overt antisocial acts are usually directed

at gaining the attention of lovers, partners, caregivers, friends or

employers. Over ninety percent of patients with BPD have two

diagnoses, and over forty percent have three or more diagnoses.

244



The development of BPD as a diagnostic entity separate from

schizophrenia has been mentioned previously. Latent, simple and

pseudoneurotic schizophrenia referred to atypical and mild forms

of this condition. DSM-IV criteria for BPD have little overlap with these

earlier concepts, or with the current definition of schizophrenia. The

major change from DSM-lll-R was the inclusion of criterion nine —

transient stress-related paranoid ideation or severe dissociative

symptoms. The micropsychotic episodes occurring in BPD do not

appear to predict a future psychotic disorder, even if they fulfill the

criteria for a brief psychotic disorder. Studies comparing BPD and

schizophrenia have shown a distinctly different course and outcome.

BPD has more recently been associated with mood disorders. There

is considerable overlap with the symptoms and clinical course of these

conditions. The mood disorder having the greatest overlap with BPD

is dysthymic disorder. Borderline patients appear chronically empty,

bored and lonely, and have a pervasively negative affect. In BPD, unlike

dysthymia, vegetative signs are usually absent and there is a reactivity

of mood symptoms to social situations.

Several characteristics are common to BPD and depression: low self¬

esteem, feelings of worthlessness, depressed mood and suicidality.

However, the “depression” in BPD is qualitatively different than in mood

disorders. Again, one of the main distinguishing factors is the absence

of vegetative signs. Although there is a high lifetime incidence of major

depressive episodes in BPD, this is not a finding unique to this

personality disorder.

BPD has also been posited to be an atypical bipolar disorder, most

closely resembling cyclothymia or an ultra-rapid cycling bipolar mood

disorder, with which it shares the long-term oscillation of mood.

Additionally, the amplitude of mood change is dramatic enough to be

in the cyclothymic spectrum. Despite the similarities, the “up” phase

in BPD rarely encompasses the required number of criteria or severity

of symptoms seen in a hypomanic episode. Also, elevated mood states

in BPD almost always have interpersonal precipitants.

Despite the many similarities between BPD and Mood Disorders, there

are important phenomenological differences supporting the existence

of BPD as a separate disorder. In the ICD-10, BPD is called the

emotionally unstable personality disorder, borderline type.

245



Appearance:

May be dramatic; many prefer black — clothing, hair

dye, nail polish; overabundance of eyeliner and

excessive eyebrow plucking; pierced body parts

(other than ears); tattoos; may have unusual hair

styles — multiple lengths and colors; forearms, neck

or other areas may have scars from slashing

Behavior:

Cooperation:

Affect:

Speech:

Thought

Content:

Thought

Form:

Perception:

Insight &

Judgment:

Suicide/

Homicide:

Often sit cross-legged, curled up, sideways in the

chair or on floor; may get up and pace due to

agitation; in extreme cases patients can be violent

towards property, themselves or others

Highly variable, may be ingratiating or hostile; will

cooperate as long as interviewer remains

sympathetic; can change abruptly to a rage if denied

requests or confronted about behaviors

Intense and labile; ranges from seductive to outbursts

of emotion (anger, tears, etc.)

May be punctuated with epithets; otherwise normal

Generally related to questions; spontaneous

elaboration about interpersonal difficulties, themes of

idealization and devaluation; obvious contradictions


circumstantial, overinclusive

Generally unremarkable; may have positive findings

during micropsychotic episodes

Variable; depends on severity of disorder and

current stressors; generally impaired; do not have the

emotional distance to foresee consequences

Suicidal threats, gestures and attempts are a constant

concern especially when faced with losses, stress or

intoxication; can also be a factor in transference

reactions and at times of therapist’s vacations;

violence towards others may occur during “rages"

246


Psychodynamic Aspects

Developmental fixation at the rapprochement phase of separationindividuation

leaves patients overwhelmingly preoccupied with issues

of abandonment and separation. Because of this, object constancy

is not achieved. This leaves children feeling that because caregivers

are not in sight, they cease to exist. Without object constancy,

ambivalence cannot develop, as this requires simultaneously

experiencing good and bad feelings toward a person (object).

This fixation facilitates an all-or-nothing reaction in children. When a

parent is present, all is well with the world. When absent, the child feels

abandoned. This develops into a dichotomous thought process, where

things are either all good or all bad, and facilitates splitting as an ego

defense to make sense of these experiences. Factors pertinent to

children (e.g. temperamental aggression or cognitive difficulties), or

caregivers (e.g. overinvolvement, neglect, abuse), or both, cause a

pattern of increasingly negative interactions. Such children develop

predominantly negative “introjects” of themselves and others. They

feel they are bad, the people they know are bad, and the world is bad.

This explanation does not encompass all of the difficulties that

borderline patients manifest. It is too great a simplification to pinpoint

a single aspect of personal development as the cause of this complex

disorder. Difficulties with other developmental stages are readily seen

in BPD. Additionally, parenting usually does not deteriorate at one

developmental stage; it is more likely to remain uniform throughout.

Nevertheless, this explanation facilitates an understanding of some

of the symptoms seen in BPD.

Oral issues persist, typified by a longing for caregivers or substitutes

(called transitional objects) on whom complete dependence can be

assured. Failing this, borderline patients reenact their primitive rage

over abandonment. Splitting continues to be used as a defense to

lessen the overwhelming anxiety felt with confusing or threatening

experiences. In order to maintain this split view, patients distort their

perception of events (sometimes profoundly) to restore equilibrium.

Borderline patients continue their quest for attachment, and anyone

who can provide a semblance of gratification is viewed with primitive

idealization, which enhances splitting. Because such expectations

are doomed to disappointment, primitive devaluation inevitably

results.

247


Developmental fixation at early stages and the use of primitive defenses

engender behaviors related to ego weakness — another cardinal feature

of borderline patients. Normally, the ego delays the discharge of impulses

and/or directs them towards a healthy or socially appropriate outlet.

However, borderline patients have difficulty sublimating their desires

(drives) and modulating their feelings (which are usually strong affects).

This process is generally referred to as acting out. This term was

originally used to describe behavior fueled by an unconscious need

to master the anxiety accompanying forbidden wishes and feelings.

When such scenarios were enacted, a sense of power replaced

helplessness. Currently, acting out is used to refer to behaviors relating

to transference manifestations that have not yet reached awareness,

or are too anxiety-provoking to discuss (e.g. abandonment). Examples

of acting out include exhibitionism, voyeurism, counterphobia, etc.

Borderline patients have a low threshold for delaying action. Their

primitive feelings are expressed in a venomous rage, their impulses

as the desire to destroy articles, relationships, etc.

What also happens frequently in BPD is acting up. This is a conscious

attempt to get attention, nurturing, sympathy, or other gains. Borderline

patients have poorly developed superegos and do not typically use

their conscience to guide their actions.

Borderline patients also have poorly developed ego boundaries, known

as identity diffusion. They experience themselves as discontinuous,

and have trouble knowing where they “end” and another person “begins”.

This makes them especially impressionable and vulnerable to influences

around them. Helen Deutsch coined the term “as if” personality to

refer to this characteristic. This is reflected in DSM-IV criteria three

and seven. Patients live their lives “as if they were someone else. This

is frequently seen in the area of sexual identity. Borderline patients

may manifest “pansexuality” by defining themselves according to those

around them. This can result in bisexual promiscuity, fetishism,

sadomasochism, etc. Despite this, reality testing on psychological tests

remains largely intact.

Kernberg introduced the concept of a borderline personality

organization that encompasses a common pattern of ego deficits.

Use of primitive defenses and long-standing difficulties in relationships

are two key features. Several personality styles can emerge from this

“borderline” organization (e.g. histrionic, narcissistic and antisocial).

248



There are an increasing number ofwhole textbooks devoted to describing

approaches to the therapy of borderline patients. This has been an

increasingly popular focus for research, which continues to yields new

approaches and new combinations of therapy. The psychotherapeutic

treatment of BPD can be a most difficult, challenging and ambitious

task. It is a long and arduous process with no shortcuts.

Psychotherapy seeks to instill what temperament, upbringing and

numerous disappointing relationships have left patients without. The

goal is to help patients emerge as integrated and dependable, with

enough self-esteem to value themselves and others.

Initially, patients are seen as requiring more “support” if they are lower

functioning, and a more “interpretive” type of psychotherapy if they

are stable and psychologically minded. This supposition has aroused

controversy, though there is no particular “formula” or approach that

works best with all borderline patients. What appears to be most helpful

is a therapist who is flexible enough to employ techniques of both

approaches at appropriate times. Given the identity diffusion and

instability characteristic of BPD, it is crucial to establish a “contract”

for therapy that is consistently reinforced. Borderline patients have a

poorly developed sense of self, and will, over time, benefit from this

external structure. The details of the various parameters of therapy

(fees, frequency of sessions, provision for emergency sessions,

penalties for lateness, after-hour telephone calls, etc.) are less

important than their consistent reinforcement. Additionally, these limits

should be enforced with appropriate consequences, should they not

be respected. Therapists can choose limits according to their level of

comfort, but two maxims in the treatment of BPD are that:

• boundary issues will be continually tested

• no amount of gratification will be sufficient; the more patients receive,

the more they desire

Some patients react harshly to this structure and complain that they

“came for help and all they got were rules." Working within rules is an

important aspect of the therapy. Reinforcing boundary issues begins

the process of dealing with patients as responsible adults. The therapist

becomes the model of a self-respecting person who avoids becoming

exploited, corrupted, or manipulated into gratifying patients’ every whim.

With time, therapists are required to act as a “container” for strong

249


affects, particularly anger. Caregivers are powerful transference figures

for patients. Verbal barrages and venomous tirades will pervade

sessions. At these times, patients are not in a frame of mind to ponder

interpretations. These episodes must be endured and at a later time

recalled in a way that will benefit patients. Two gains can be made

during sessions such as these:

• the therapist’s empathy with the defense of splitting will help patients

realize that they see themselves and others only in polarized terms

• patients incorporate the experience that expressing their “badness”

does not destroy themselves, others, or the therapeutic relationship

What makes therapy particularly difficult with borderline patients is

their use of projective identification. Patients outwardly project a part

of themselves that is unacceptable, while maintaining a link with it. The

projected material is made to “fit” by unconscious pressures, inducing

the projected emotional state in the therapist. For example, a borderline

patient who is angry with the limits of therapy, regardless of the degree

to which his or her requests have been indulged, may say something

like:

“How is this therapy supposed to be useful? I come here each week

and all I get is psychobabble. I don’t want to talk about my parents.

They’re in the past and I have bigger problems right now. When are

you going to earn your money and do something?”

or

“I’ve been coming here for four months and nothing has changed. I

tell you everything that goes on in my life. You’ve given me a pile of

useless pills, admitted me to hospital twice, and had me off work for

two weeks. All this and I’m no better. You’re useless!”

Patients will insist that they are angry because the therapist is angry,

but statements like these provoke therapists’ anger. Borderline patients

are exceedingly good at manipulating (unconsciously) their projections

to make them realistic or fit the person on whom they are projected.

This process can be very difficult to endure, and can cause marked

countertransference. Interpretations in such instances need to be made

with the understanding that borderline patients do not have an

observing ego. Simply telling patients that they are projecting their

own anger seems to them like an attack. It may be more effective to

demonstrate a less confrontative approach that incorporates an

element of observation:

250


“I can see that you feel angry at what goes on here. Perhaps you think

I have given up on you, and treat you like a hopeless case, much as

others have.”

This interpretation maintains a “here and now" focus, validating the

person’s feelings, but offering an alternative for further exploration.

Such an approach is necessary, because confrontation, and failure to

achieve or maintain a therapeutic alliance, are the two most common

reasons patients terminate therapy.

Borderline patients are best suited for face-to-face therapy. This

requires at least a moderate amount of “activity" on the therapist’s

part, because long periods of silence are difficult for borderline patients

to endure, often fostering regression and being countertherapeutic

overall. The other major difficulty in dealing with borderline patients is

their propensity for acting out, particularly in the area of self-damaging

behaviors. They often demonstrate a level of denial (bordering on

magical thinking) regarding the consequences of their acts. Possible

sequelae should be examined in detail with patients, and risks repeatedly

emphasized. As part of this process, patients should be prompted to

look for precipitants to their actions or mood states. This helps establish

the connection between feelings, thoughts and actions that will help

decrease impulsivity. Because most of the impulsive behavior in BPD

is egosyntonic, patients may be quite unaware of what causes them to

act at certain times. It is most often worthwhile to look at the details of

their current relationships as a starting point for this examination.


• Consistency helps foster a stable image of the therapist, the therapy

and ultimately the patient.

• Maintain a “here and now focus;” transference provides crucial

information, and if dealt with in the session, may decrease acting out.

• Ask for patients’ help in resolving dilemmas.

• Be active; engage patients; do not let silences continue for too long;

discuss strong affects and splits as they are expressed.

• Reward assertiveness, not regression.

• Be flexible; there is no cookbook treatment for BPD; try different

approaches to find effective interventions.

• Patients need to experience therapists as empathic, supportive and

interested before they need interpretations about themselves.

• Strike when the iron is cold. (Pine, 1986)

251



Transference manifestations with borderline patients can be rough

(rougher than even Rodney Dangerfield has it). Patients live out the

unsolved struggles from their early development in therapy. Intimacy

evokes fears of being engulfed or controlled by another person. Being

separate from others is experienced as abandonment. These

oscillations become the central dynamic in the therapeutic relationship.

Patients can tolerate neither closeness nor distance. They have been

aptly referred to as help-rejecting complainers for frantically seeking

and then discounting the attempts of others to help.

This upheaval manifests itself in at an early stage in therapy. Therapists

represent parent substitutes in terms of authority, knowledge, power,

etc. Some patients initially idealize their therapists as rescuers and

make their affections readily known, e.g. “You are the best doctor in

this hospital... You are the only one who understands me ... I want

you to look after me.” Patients begin to seduce idealized caregivers in

a number of ways: emotionally, morally, sexually, etc. They give lavish

presents, stop by for social reasons, etc. Very quickly, they start to

develop unrealistic notions and make unreasonable demands. A

person who was once trustworthy is seen as completely so, until he or

she disappoints the patient. At this point, this person is then viewed

as completely untrustworthy, with an accompanying extreme emotional

response. Thus begins the devaluation, which is inevitable because

no person can possibly meet the patient’s escalating demands. At this

time, the devalued person is not treated just like someone who

disappointed the patient, but “as if’ the patient’s life was ruined.

Countertransference reactions can be just as strong. Borderline

patients can exert irresistible pull on therapists, who respond by

dissolving boundaries. Intimate relationships are started, sessions are

extended and given more frequently, notes for absences are from

work are given, prescriptions are given for addictive medication, etc.

Alternatively, therapists can respond by being unnecessarily punitive

or sadistic. Sarcasm, teasing or hurtful interpretations can dominate

sessions. An awareness of these feelings is essential in dealing with

borderline patients. Because of the uncanny fit of projective

identification, therapists may have a difficult time sorting out where

the patient’s pathology ends and their own psychology begins. It is

not helpful to act on countertransference feelings; it only repeats the

trauma that patients have endured. Transfer of care, consultation,

supervision, and personal therapy can help clear up these difficulties!

252


Inpatient Management

Though this section is included in this chapter, the principles discussed

here are applicable to all hospitalized patients with personality

disorders. The majority of patients who need admission have a

borderline personality organization, regardless of diagnosis. In

practice, it is Cluster B patients that are hospitalized most frequently.

Hospitalization can have different meanings in the context of treatment.

For many, it is seen as a setback and failure of outpatient treatment.

Patients may feel useless for not managing on their own, and therapists

feel as if their efforts have been in vain. However, it may also indicate

increasingly adaptive behavior. Patients who feel overwhelmed and

ask for hospitalization demonstrate good judgment, especially

compared to patients who act out their feelings by abusing substances,

harming themselves or being sexually promiscuous.

Regardless of how admission is arranged, patients arrive in a state of

crisis. The inpatient unit becomes a holding tank, an environment

providing the external structure for internal deficiencies. Patients can

easily regress because they feel they will be cared for while in hospital.

Others now have a responsibility for them. Additionally, their

maladaptive style of relating to others is heightened due to their

emotional stress, with splitting and projective identification being

the predominant defenses they deploy to help gratify their needs. Under

the conditions of admission, defensively motivated behaviors appear

sooner and more dramatically than in individual outpatient therapy.

Splitting in an inpatient setting involves the entire multidisciplinary team.

Staff members may find themselves defending and supporting certain

patients in increasing opposition to their colleagues. Patients overtly

encourage this by idealizing certain individuals and complaining to

them about others, or more covertly, with projective identification

working on different members simultaneously.

Patients have a knack for detecting and reactivating preexisting

conflicts in their caregivers (again, the fit of projective identification;

this phenomenon is also seen with manic patients). Conflict between

staff members can become quite heated and cause devastating long¬

term results. The chaotic internal world of borderline patients becomes

reenacted in their external world. For example, some staff members

may focus on preserving the patient’s autonomy, and recommend

privileges that conflict with the safety concerns of the other members.

253


In order to minimize this, the following steps can be taken:

• educating the staff about the dynamics of these defenses

• regular meetings to discuss progress and setbacks

• sharing the content of all contact with the patient

• special meetings to discuss countertransference feelings when the

staff is becoming noticeably split

The last step can be particularly difficult. Often a team will notice that

one member feels uniquely able to understand a patient and is

uncharacteristically permissive, or alternatively, is denigrating and

harsh. It is very difficult to bring such an observation to attention.

Therapists experience numerous reactions, but not every nuance is

due to the patient. When members of a treatment team are familiar

with each other they begin to accept that they have countertransference

reactions and that identifying them will help unify treatment efforts.

Repeated failures to provoke expected reactions in others helps

patients internalize new “objects” and increase their stability.

The goals of an inpatient stay are to provide support, curb the direct

expression of impulses and strengthen ego function. Interventions may

be required to prevent harmful acting out or acting up, including

medication, restraints or seclusion. Additionally, superego function may

need to be strengthened in ways that further the best interests of

patients, such as giving reality-based advice.

With the demands of their daily routine temporarily removed, patients

have a tendency to regress in hospital. This is seen in various ways:

wearing pyjamas all day, chatting with other patients all night, sleeping

until late morning hours, asking staff or patients to make phone calls

or run errands, finding ways to prolong hospitalization, etc. This can

be limited by short admissions, adherence to ward routines as a

condition of admission, and setting firm limits on behavior.

The majority of patients can be managed with brief stays of three or

four days. Indications for longer-term treatment are:

• repeated failures of brief hospitalization and outpatient treatment

• associated Axis I conditions (e.g. anorexia nervosa)

• escalating violent or self-destructive behavior

• severe or psychotic symptomatology

• a chaotic environment that provides no social support

• accelerated or intense inpatient treatments

• diagnostic uncertainty requiring longer observation and evaluation

254

Croup Therapy


Group therapy can be a useful form of treatment with borderline

patients, either alone or combined with individual psychotherapy.

Groups allow borderline patients to diffuse their intense affects and

direct them at more than one member. A group can provide a safe

holding environment. It can offer, in a sense, a new family or a

benevolent transitional object, where identification and introjection

can take place. This fosters increasing maturity and a diminution of

the use of primitive defenses. Interpretations made on a group level

may be better tolerated than those given in individual therapy. A group

setting also allows patients to explore new ways of dealing with people

in a protected environment.

Because borderline patients lack a stable self-image, it is ideal to have

group members who can provide positive role models. Such a group

would contain a number of higher-functioning members with

heterogeneous disorders.

Short-term inpatient groups can be successful when a “here and now”

focus is maintained to work on practical goals such as support,

stabilization and limiting regression. A group consisting of recently

discharged moderate-to-low functioning borderline patients is not likely

to provide a therapeutic milieu.

Simultaneous participation in individual and group therapy, while not

standard practice, supports patients through difficulties brought on by

the group process. For example, confrontation or scapegoating by

the group can be very anxiety provoking and discouraging.

A stable therapeutic figure helps patients contain emotions that might

otherwise cause them to leave (e.g. feelings of deprivation or

competition). Diluting transference manifestations between individual

and group sessions can be a benefit for therapists.

Alternatively, group therapy can be difficult with borderline patients.

Their direct expression of anger can cause others to see them as

unpredictable, offensive and disloyal. This can effectively divide the

members and this “split" can dominate the group. When this occurs,

borderline patients are capable of acting out on this sense of rejection.

Suicide attempts, venomous personal attacks and other forms of

interpersonal sabotage may result and destabilize the group.

255


Cognitive Therapy


• Mistrust and suspiciousness — “The world is against me.”

• Distorted perceptions — “People are deceptive and manipulative.”

• Vulnerability — “I am powerless to control my life.”

• Worthlessness — “I am unlovable.”


The automatic thoughts in BPD create a vicious cycle for patients.

Seeing the world as a malevolent place, they feel powerless to get by

on their own strengths. They feel inherently unlovable and cannot turn

to others. Convinced the world is out to get them, they have no sense

of security and cannot tolerate autonomy or dependence.

A key cognitive feature of BPD is called dichotomous thinking. Events

and people are distorted into only two categories: good or evil; love or

hate. Dichotomous thinking perpetuates patients’ internal and external

conflicts, magnifying their already low sense of self-efficacy and further

decreasing motivation.

Borderline patients can be difficult to engage. They lack the

introspection and patience to participate in the collaborative

empiricism needed for cognitive therapy.

Cognitive approaches begin with modification of dichotomous thinking.

This can be done by hypothetically assigning characteristics to people

at both ends of the spectrum of a given quality, for example, reliability.

A borderline patient will list impossibly high expectations for a reliable

person and describe an unreliable person as the embodiment of evil.

By then looking at real people in their lives, patients can begin to see

that others can be mainly, mostly or usually reliable. As dichotomous

thoughts decrease, control over impulsive behavior becomes possible:

Recognition of dichotomous thinking and the impulse to act on it

Listing of alternatives and pros and cons in achieving a goal

Implementing the response that yields the greatest benefit

Working towards a goal provides a structure that develops a clearer

sense of identity. This gives patients the confidence to experiment by

expressing themselves in a proactive and assertive manner, instead

of being victims of fate who have neither strengths nor supports.

256


Pharmatotherapy

Though there is no definitive drug treatment for personality disorders,

over ninety percent of borderline patients still receive prescriptions.

This finding illustrates the widespread overlap of borderline

symptomatology with Axis I disorders, and the possibility of multiple

diagnoses. However, there are other parameters that need to be

considered. Doctors may prescribe medication when feeling

pessimistic about psychotherapy. Patients in crisis may see a

prescription as tangible proof (a transitional object) that a doctor

cares about them. Some patients ensure that they get prescriptions

by exaggerating their symptoms or seeing several doctors. For this

reason, it is prudent to prescribe medication for clearly defined target

symptoms for a specific time period. Because of the risk of overdose,

small amounts of medication should be given and, where faced with

an option, the least toxic drug should be used (e.g. avoid tricyclic

antidepressants where possible).

Every major group of psychoactive medication can be used to target

symptoms:

Antidepressants: Patients frequently receive antidepressants, though

studies have shown an unpredictable response.

• SSRIs have been found to decrease impulsivity and the frequency

of self-harm. Some SSRIs have been indicated for control of bulimia.

Additionally, they have a large margin of safety in overdose.

• MAOIs have been shown to be more effective than TCAs, but their

use involves dietary restrictions to avert hypertensive crises.

Mood Stabilizers: Lithium, Valproate and carbamazepine have been

used primarily for reducing behavioral dyscontrol and impulsivity.

Anxiolytics: These medications are frequently sought by borderline

patients to “take the edge off their mood. Benzodiazepines pose

considerable addiction risks as well as potentially worsening impulse

control through disinhibition.

Antipsychotics: Use of these medications for short-term control of

psychosis and persecutory delusions is warranted. Additional benefit

may be derived from their sedative effects. Tardive dyskinesia is a

risk with long-term administration, particularly in older female patients.

257



Benjamin (1993) emphasizes the following factors in the childhood

experiences of patients with BPD:

• a family situation so chaotic that it resembled a soap opera; fights,

legal difficulties, substance abuse by one or both parents, affairs, etc.

• traumatic abandonment which involved periods of time that were

excruciatingly dull alternating with episodes that were dangerous,

intrusive and unpredictable (such as sexual abuse)

• linking the aloneness with being a bad person, as if the patient had

done something to deserve the punishment, abuse, desertion, etc.

• a family that fostered dependency over autonomy, leaving patients

with a tendency to undermine themselves when things are going well

Benjamin reiterates many of the treatment suggestions previously listed

in this chapter. Focusing the patient’s energy in the direction of

independence and strength via a firm and well-explained treatment

contract is a key therapeutic factor. Once perceived abandonment is

understood to be the root of self-destructive behaviors, maladaptive

patterns become more amenable to discussion rather than action.

Case Example

Tara Bull is a forty-three-year-old married woman. Her pleasant

demeanor is at odds with the scars visible on her forearms. When

asked about them, she recounts the many times in her life she has

been treated unfairly and sought a way to deal with her anguish. She

came from a broken home and was often blamed by her mother for

the marriage ending. Her mother had a succession of boyfriends, most

of whom were emotionally abusive towards her mother, and some of

whom were sexually abusive towards her — she can recall two but

thinks there were more. After being blamed for her father’s departure,

she vowed not to do anything that would disrupt her mother’s

relationships. She concealed the abuse, and took on many duties that

were more appropriate for her mother. Whenever she did well at an

activity or showed promise in a subject at school, she was ignored by

her mother. What did get attention for Tara Bull was her eventual truancy,

school failures and criminal charges (for misdemeanors only). She

recalls her mother only being at her side when she was at her (Ms.

Bull's) lowest. Even at the time, she was aware of repeating her mother’s

“mistakes.” This upbringing led her to become a self-proclaimed “misery

junkie” who thrives on hearing the misfortunes of others, which is made

possible by her current position as a crisis line counselor.

258


Course

BPD manifests itself prior to the demonstration of diagnostic criteria.

As children, borderline patients frequently had difficulties in school,

particularly with concentration, and possibly had learning disabilities.

Friendships may have been jeopardized or terminated because of

behavioral dyscontrol, bringing about early social alienation.

In adolescence and early adulthood, the symptoms of the disorder

flourish. Patients often do not complete their education or vocational

training. With dissolution of theirfamily of origin, or upon leaving home,

they become involved in relationships that perpetuate and worsen

their difficulties. Substance abuse is common, perhaps as a means of

calming their intense feelings. The vast majority of patients diagnosed

with BPD manifest consistent symptomatology over time. Few patients

are rediagnosed with other disorders, though other conditions can

develop in addition to this personality disorder.

It is in late adolescence or early adulthood that patients usually come

to medical attention. First visits are frequently precipitated by DIRs.

From this point on, BPD usually runs a rocky course punctuated with

attempts at self-harm, hospital admissions, difficulties in relationships

and emotional instability. The consumption of healthcare resources

can be enormous. Emergency room visits, with resuscitation and

detoxification, in addition to hospitalization, demands for outpatient

therapy and multiple prescription medications, all add to the cost. This

is in addition to the lost productivity caused by sick days and other

absences from work. The treatment of BPD is a long process that

often requires hospital admission and crisis intervention.

Despite this pessimistic picture, BPD appears to lessen in severity

within a decade of the first hospitalization. Several studies have

documented higher levels of functioning and stability in jobs and

relationships over this time. Despite the wear and tear on therapists in

this first decade, it may be that patients incorporate something from

each caregiver or hospital stay and integrate this over time.

Suicide attempts are the most worrisome complication. Though this is

often a primitive method of securing treatment and attention, repeated

attempts are a risk factor for completing suicide, which happens in up

to a tenth of borderline patients. Additionally, morbidity is increased

by failed attempts that leave patients with lifelong disfigurement due

to scars or burns, and handicaps such as brain damage or paralysis.

259


Referentes



Edition





L. S. Benjamin



G. Gabbard


Edition








N. McWilliams






R. Pies



F. Pine

Supportive Psychotherapy: A Psychoanalytic Perspective

Psychiatric Annals 16, p. 526-529, 1986

260


Referentes for Pharmatotherapy

E. F. Coccaro & R. J. Kavoussi

Fluoxetine and Impulsive Aggressive Behavior in Personality-

Disordered Subjects

Archives of General Psychiatry 54(12): p. 1081 - 1088, 1997

R. A. Dulit, M. R. Fyer, G. L. Hass et a!

Substance Use in Borderline Personality Disorder

American Journal of Psychiatry 147: p. 1002 - 1007, 1990

J. G. Gunderson

Pharmacotherapy for Patients with Borderline Personality

Disorder


R. M. Hirschfeld

Pharmacotherapy of Borderline Personality Disorder

J. Clin. Psychiatry 58(supplement): p. 48 - 53, 1997

H. P. Kapfhammer& H. Hippius

Pharmacotherapy in Personality Disorders

J. of Personality Disorders 12(3): p. 277 - 288, 1998

P. S. Links, M. Stiener, I. Boiago et al

Lithium Therapy for Borderline Patients: Preliminary Findings

Journal of Personality Disorders 4: p. 173- 181, 1990

P. H. Soloff

Pharmacological Therapies in Borderline Personality Disorder,

Borderline Personality Disorder, Etiology & Treatment

J. Paris, Editor

American Psychiatric Press Inc., Washington D.C., 1993

in

P. H. Soloff, J. Cornelius, A. George et al

Efficacy of Phenelzine and Haloperidol in Borderline Personality

Disorder


R. J. Waldinger & A. F. Frank

Transference and the Vicissitudes of Medication Use by

Borderline Patients

Psychiatry 52: p. 416 - 427, 1989

261


Fill-in-the-blank Personalities:

Fatal Personalities

Instinctively Attract

Act I

Seemingly out of nowhere, a talented, attractive and highly available

borderline drops into the plot. A glimpse of her tortured past is given,

but through a series of clever and evasive maneuvers in script writing,

the details are concealed. She quickly gets the attention of a roving

narcissist, and lavishes on him the attention that his dependent

wife and schizoid child are not supplying in sufficient quantities for

his hypertrophied ego.

Act II

Idealization runs rampant. They live. They love. They frolic. They

Cluster B all over each other. They do things even a paranoid couldn’t

imagine, or a schizotypal wouldn’t even foretell.

Act III

Eventually things get a little rough. He needs to get back to reality,

she just needs more of him. He levels with his obsessive-compulsive

friend, who draws up a twelve-step plan for her emotional

independence, but it is of no avail. Erratic job performance eventually

comes to the attention of his avoidant boss, who after empathically

hearing all the details, is forced to hand out a suspension.

Act IV — Option 1

Admitting his stupidity to his wife

causes a re-emergence of her

histrionic side — the very

qualities that drew them together

in the first place. They pool their

antisocial qualities and devise

a plan to rid themselves of his

lover.

Act IV — Option 2

Events escalate to a histrionic

pitch. He realizes life without his

borderline lover would be dull,

if she allowed him to have any.

Together, they make a pact not

to exploit each others’

antisocial qualities, and live

happily ever, or at least until the

next time he has a free

weekend.

262

Review Questions

1. The term borderline refers to:

a. a DSM-IV personality disorder

b. an ICD-10 personality disorder

c. a subtype of schizophrenia

d. a concept of personality organization

e. a song by Madonna


2. Which of the following behaviors is consistent with the DSM-IV for¬

mulation of BPD?

a. becomes irritable or difficult to deal with when asked to something

he or she does not want to do

b. resents helpful input from others regarding how he or she might do

something better

c. claims that he or she is treated unfairly by others (without justifica¬

tion)

d. mocks, sabotages or scorns those in positions of authority

263



1. Options a and d are obviously correct based on the material presented

in this chapter. Option e is also correct.

Option c is correct and the material is found in the Schizotypal Per¬

sonality Disorder chapter. Recall that a syndrome encompassing a

thought disorder and occasional behavioral peculiarities but without pro¬

gression to a clear state of psychosis is called latent, pseudoneurotic

or borderline schizophrenia.

Option b is partially correct. The ICD-10 contains a diagnosis called the

emotionally unstable personality disorder which is further subdivided

in an impulsive type and a borderline type. The five criteria in the

borderline subtype correspond to DSM-IV criteria 1, 2, 3, 5 & 7.

The use of the term “borderline” has been criticized by Millon. The name

of the disorder is not descriptive, as are most of the other Axis II diag¬

noses (e.g. Dependent PD, Paranoid PD). Millon suggests other terms

that would be suitable replacements: cycloid, ambivalent, erratic, impul¬

sive, quitoxic and labile (the last term being his preference).

2. All of the options listed can reasonably be seen to be within the prov¬

ince of borderline behavior. These descriptions are paraphrased from the

diagnostic criteria for the negativistic (passive-aggressive) person¬

ality disorder, with which BPD has a considerable overlap.

Other personality disorders sharing a considerable overlap with BPD are:

histrionic, narcissistic, antisocial and dependent.

References



Wiley and Sons, New York, 1996



American Psychiatric Association, Washington, D C., 1994


Pocket Guide to the ICD-10 Classification of Mental & Behavioural Disor¬

ders


264


The Nartissistit Personality

265



Name:

Occupation:

Appearance:


Favorite Song:

Motto:

James Pond

Window dresser for a fashion store

Silk suit, cubic zirconium cufflinks &

tie pin, alligator shoes

Walks friend’s Afghan in order to

meet women

King of the Road

After me, you come first


Before Session:


During Session:

Fantasies Involve:



Brings to Session:

Preens with a portable mirror

GQ; tells others he will be featured in

the next issue

Starts each sentence with, “I . . . ”

Wonders what he’s like in bed

Self-appointed fashion consultant

Acts as if the session is being filmed

A discount coupon for his store


“A FAME CAME"

Admiration is required in excessive amounts

Fantasizes about unlimited success, brilliance, beauty, etc.

Arrogant

Manipulative

Envious of others

Grandiose sense of self-importance

Associates with special people

Me first attitude

Empathy is lacking for others

266

Introduction

The Nartissistic Personality

Narcissus was a mythological figure who scorned the love of others.

One of the many heartbroken maidens had a prayer answered by the

goddess Nemesis, “May he who loves not others love himself.”

Narcissus fell in love with his reflection in a pool. Unable to leave it, he

became fixed in a long gaze, pined away and died. The flowers

underneath his body were given his name. The narcissistic personality

disorder is based on this myth. It is characterized by grandiosity, lack

of empathy and a need for admiration. Some key names associated

with the understanding of this disorder are:

• Freud (1914) — brought the mythological term into common usage,

referring to narcissism in two ways: primary narcissism — an early

stage of self-absorption; and secondary narcissism — an ego-ideal

that embodied a person’s aspirations at a later stage of life.

• Reich (1930’s) — through his analysis of resistance, recognized

that patients protected themselves with character armor; he used

the term phallic-narcissist to refer to individuals who were selfassured,

arrogant and protected themselves by attacking others first.

• Jones (1913) — wrote a book called “The God Complex,” describing

patients who were overtly grandiose, judgmental and aloof; they also

overestimated their abilities and had fantasies of omnipotence; if such

patients decompensated, they commonly expressed the delusion of

being God.

• Kohut (1971) — a pioneer of self-psychology, he saw narcissistic

individuals as requiring responses from people in the environment,

which helped them maintain their self-esteem and sense of cohesion.

• Kernberg (1967) — conceptualized the narcissistic personality as

one outcome a borderline personality organization; this involved

primitive defense mechanisms, but with a higher level of ego functioning.

The narcissistic personality disorder (NPD) was first added to the

diagnostic nomenclature in the DSM-lll. Though it had long been of

interest to psychoanalysts, it was Kernberg’s description of the

behavioral characteristics that influenced the diagnostic criteria.

NPD is less thoroughly validated as a diagnosis than other personality

disorders. The ICD-10 has no corresponding diagnosis (narcissistic

type is not included as a specific personality type). Many of the

diagnostic criteria require introspection by patients, as well as significant

levels of inference from clinicians. Narcissism itself is observable to

varying degrees in everyone and is adaptive under many circumstances.

267


Media Examples

Narcissists are frequently cast as main characters, and especially as

leaders in books, movies and plays. They have a “tragic flaw” which is

either corrected or punished. In such portrayals, the main character

“just doesn't get it,” usually due to vanity, despite being surrounded by

good friends, abundant opportunities or an unnoticed love interest.

Notable examples can be seen in:

• Groundhog Day — Bill Murray portrays a weather reporter sent to

cover the festivities in a town called Punxsatawney, PA. Snide and

conceited, he gives a good demonstration of narcissistic behavior at

the beginning of the film. As punishment, he must relive the same day

until he mends his self-serving ways.

• The Fisher King — Jeff Bridges portrays a disc jockey/radio show

host who launches into a vitriolic tirade against yuppies who frequent

a particular bar. His final remark about them “having to be stopped” is

misinterpreted by an impressionable caller, leading to disastrous

results. His self-serving demeanor and use of the program as a vehicle

for personal commentary exemplifies narcissistic behavior.

• Indecent Proposal — Robert Redford plays the part of a cocky,

high-rolling billionaire who satisfies his lust by paying a married woman

a million dollars to spend one night with him. Though suave and

debonair, he is shallow and ultimately cannot hold her interest.

• Apocalypse Now — Robert Duvall superbly plays the part of the

narcissistic Lt. Col. Kilgore. His erect bearing, strutting walk, and

omnipotent demeanor add to the performance. Kilgore is a surfing

fanatic and demands an impromptu demonstration for his enjoyment.

Duvall played another narcissistic military officer in The Great Santini.

Other narcissistic characters (to varying degrees) are seen in:

• Citizen Kane — the role played by Orson Welles

• Patton — the role played by George C. Scott

• Star Trek (Original Series) — Captain Kirk

• Bugs Bunny Cartoons — Foghorn Leghorn

• American Gigolo — Richard Gere character

• Twelfth Night (Shakespearean Comedy) — Malvolio

• A Few Good Men — Marine Colonel played by Jack Nicholson

• Jurassic Park — island owner portrayed by Richard Attenborough

• Rain Man — the Tom Cruise character, Charlie Babbitt

• Sliding Doors — Gwyneth Paltrow’s (original) boyfriend

268



Narcissistic patients, like other Cluster B personalities, revel in the

attention they receive in interview situations. Especially in the opening

few minutes, when patients are given free “reign” (pun intended) to

speak their minds, interviews go quite smoothly. Narcissistic patients

take the ball” and run with it quite well. Every nuance regarding their

presenting complaint is related as essential information.

Narcissistic patients like to surround themselves with “special” people.

An interviewer paying undivided attention soon becomes the “best

therapist in the hospital.” The interview is used as an opportunity to

reaffirm and enhance an already inflated sense of self-importance.

Even as the bombardment of information proceeds, there is often a

rehearsed or detached quality to the interview. Narcissistic patients

talk “at” you instead of “to” you and make little eye contact.

Difficulties arise when the patient’s grandiosity is confronted with reality.

Patients can become hostile under such conditions and suffer a

narcissistic injury, even leading to a narcissistic rage. Responding

with heated emotion, patients devalue interviewers for not having

sufficient experience or intelligence to understand them. If this state

does not pass quickly, rapport can be re-established with appeals to

patients’ grandiosity:

• “It seems that others do not appreciate your abilities.”

• “Tell me more about your accomplishments in this area.”

• “You really seem to be headed somewhere.”

Developing rapport with narcissistic patients can be difficult. Collusion

with their idealized self-perception prevents a check with reality,

impeding an assessment. Empathically addressing reality, or the

consequences of narcissism, can detract from the interview by evoking

a grandiose repair of threatened self-esteem.

Nardssistit Themes

• Condescending attitude • Readily blame others

• Dwell on observable assets • Conspicuous lack of empathy

• Hypersensitive to criticism • Highly self-referential

• Exploit others for the gain they can provide for the patient

• Difficulty maintaining a sense of self-esteem

• Many fantasies, but few accomplishments

269


Etiology

Biological: NPD does not appear to be genetically linked to other

disorders. Temperamental factors may include a high level of energy,

overconscientiousness, increased sensitivity to unverbalized affect,

or a lack of tolerance for the anxiety caused by aggressive drives.

Psychosocial: NPD has not been as extensively investigated as other

personality disorders. Because it lacks a genetic link to Axis I

conditions, or a major impact on society (e.g. crime, disproportionate

health care costs), research has not been as abundant. Other factors

to consider are:

• narcissism is a component of several other personality disorders

• NPD can be difficult to validate due to subjectivity of the diagnostic

criteria

Early theories focused on erratic, unreliable caretaking that caused

an early fixation at a stage where narcissism is a developmental phase.

Kernberg views narcissism as a pathological process involving a

psychic hunger or oral rage, caused by indifferent or spiteful parenting.

However, some positive aspect of the child (e.g. a talent) or the

environment may allow an escape from parental threats or indifference.

This “specialness” facilitates a sense of grandiosity that blankets and

splits off the real self, which contains envy, fear and deprivation.

Kohut conceptualized narcissism not as a pathological deviation, but

as an arrest in development. The seeds of NPD are sown when

caretakers do not validate a child’s responses. This empathic failure

causes the child to develop an idealized image (imago) of the parents,

and not one based on real limits.

Many theories have postulated some form of parental deprivation,

although empirical evidence is lacking for this view. For example,

experiments in which little monkeys were taken away from their mothers

did not produce narcissistic monkeys, but ones that were sad and

withdrawn, with poor physical and social development. Reports are

consistent for children similarly deprived.

Other theories posit that children who are treated specially, or at least

differently than others, may develop NPD. Such children may be

narcissistic extensions of their parents, and function to maintain

esteem or as a replacement for something from their parents’ life.

270

The Narcissistic Personality

Epidemiology

Accurate estimates are lacking, with prevalence estimated to be less

than 1% of the population. In clinical populations, prevalence may be

as high as 3%. There is a gender difference, with men being diagnosed

almost three times as often as women. Apparently this diagnosis is

uncommon in Europe.

Ego Defenses

Major ego defenses in NPD are idealization and devaluation.

Defenses used to a lesser extent are projection and identification.

Narcissistic patients display idealization as opposed to primitive

idealization, which is seen in other disorders. The distinction is one of

degree. Narcissistic patients generally idealize others within the limits

of human capabilities, but do not endow people or objects with

supernatural powers. Kohut used the term grandiose self to refer to

the superiority that characterizes the inner world of the narcissist.

While ego defenses are unconscious processes, the grandiose self

may be outwardly projected. Narcissistic patients are consciously

preoccupied with issues of rank, power and status. They are constantly

attuned to what is considered “the best” or “Number One.”

Similarly, devaluation does not occur to the extent that people or objects

are considered “all bad,” or as having powers that are magically

destructive. Narcissists strive for perfection, and are critical of

themselves if it is not achieved. If the devalued self is projected onto

others, then they are seen as inadequate, incompetent or unworthy.

These defenses operate differently than in the process of splitting.

The idealization in NPD has more stability than in BPD, for example.

People and objects may be idealized for a lengthy period of time.

However, since perfection is the desired goal, disappointment and

devaluation are inevitable. This too has a greater longevity than with

the defense of splitting. Devalued objects are eventually discarded in

the search for a more suitable replacement. Splitting involves a more

rapid oscillation between these extremes.

Narcissistic patients increase their self-esteem by identification with

idealized organizations or people. With the process of identification,

patients extend the aura of perfection to include themselves.

271



A pervasive pattern of grandiosity (in fantasy or behavior), need for

admiration, and lack of empathy, beginning by early adulthood and

present in a variety of contexts, as indicated by five (or more) of the

following:

(1) has a grandiose sense of self-importance (e.g. exaggerates

achievements and talents, expects to be recognized as superior without

commensurate achievements)

(2) is preoccupied with fantasies of unlimited success, power, brilliance,

beauty, or ideal love

(3) believes that he or she is “special” and unique and can only be

understood by, or should associate with, other special or high-status

people (or institutions)

(4) requires excessive admiration

(5) has a sense of entitlement, i.e., unreasonable expectations of

especially favorable treatment or automatic compliance with his or

her expectations

(6) is interpersonally exploitative, i.e., takes advantage of others to

achieve his or her own ends

(7) lacks empathy: is unwilling to recognize or identify with the feelings

and needs of others

(8) is often envious of others or believes that others are envious of

him or her

(9) shows arrogant, haughty behaviors or attitudes

Reprinted with permission from the DSM-IV.



Narcissism can be an associated feature of several other conditions.

Some of the features of hypomania overlap with NPD. These include:

grandiosity, a sense of entitlement, increased goal-directed activity,

and involvement in risky yet pleasurable activities. The distinction can

be made on the basis of NPD lacking the mood symptoms, and having

a long-standing rather than episodic course. The grief, shame and

withdrawal after a narcissistic injury are similar to some of the criteria

for a major depressive episode, or if of longer duration, a dysthymic

disorder. In NPD, there is an obvious precipitant, and the lack of

severity and duration seen in mood disorders.

Substance abuse, especially with stimulants (cocaine,

amphetamines), can produce a clinical picture resembling NPD.

272


NPD can also closely resemble delusional disorder, grandiose type.

Delusional disorders tend to have a circumscribed focus, without obvious

impairments in behavior or ability to function. NPD is a life-long condition

with several other interpersonal manifestations.


Narcissism itself is a normal feature in human development. Infants

are egocentric in that they see the world as revolving around them.

As development proceeds, children discover there are other people

in the world, and priorities other than their own gratification. Children

and adolescents often have narcissistic traits that do not necessarily

lead to NPD. Gabbard (1994) gives an excellent synopsis of how

narcissism is viewed differently depending on life cycle stage. He

makes the cogent point that our culture itself is narcissistic. He

illustrates this point with examples of our obsession with glamour,

competitive sports, and how “winning forgives everything.”


Appearance:

Behavior:

Cooperation:

Affect:

Speech:

Thought

Content:

Thought

Form:

Perception:

Insight &

Judgment:

Suicide/

Homicide:

Often immaculately groomed; may have expensive

(or expensive-looking) jewelry and accessories

Often assumes a rigid or authoritative posture; may

caress their belongings or parts of their body

Cooperative as long as interview proceeds according

to their wishes or expectations

Can range from withdrawn to animated; feelings are

readily expressed and varied, but may seem “put on”

Often well-modulated and articulate

Related to grandiose sense of achievement, power,

aspirations, connections and knowledge; can be

plaintive and derogatory towards others

No characteristic abnormality; tend to overelaborate;

may be tangential or circumstantial


Impaired; are aware of others’ poor treatment of them

and of difficulties in relationships; react strongly when

confronted with their own contribution

Consider in conjunction with Axis I disorders; not often

dangerous; risk increases with a narcissistic injury

273


Psychodynamic Aspects

Before exploring the inner world of narcissistic patients, it is important

to be aware that there are descriptions of distinct types of narcissistic

characters. The two poles at each end of the continuum of interpersonal

behaviors regarded as narcissistic have received various labels:

Type 1

Oblivious, Thick-Skinned

Overt, Egotistical, Grandiose

• Arrogant

• Craves attention

• Disregards the feelings and

reactions of others

Type 2

Hypervigilant, Thin-Skinned

Covert, Dissociative, Vulnerable

• Self-effacing

• Diverts attention

• Highly sensitive to the signals

from others; easily hurt

Source: Adapted from Gabbard (1994)

The DSM-IV criteria describe the more flagrant behaviors and

characteristics from of Type 1 category. The distinction between the

two types is useful to help integrate the disparate views provided by the

two main contributors to NPD, Kohut and Kernberg. It also helps with

conceptualizing the range of outcomes from the various etiologic factors

mentioned previously. To these two types, Millon (1996) adds the

following: unprincipled (deficient social conscience), amorous,

compensatory (repairing early life deprivation) and elitist.

Parental deprivation and erratic caretaking are no doubt important in

the development of NPD. These factors, however, are nonspecific and

could be etiologically significant in any personality disorder. For this

reason, other explanations and theories will be presented.

Kohut was a major contributor to self-psychology. The term selfobject

is used to refer to people, who, while remaining external and separate

(object), provide a source of gratification for the person (self). The

soothing, affirming and approving function of the selfobject persists

throughout life, though in mature relationships, other people provide

more than just gratification.

In NPD, patients have a pathological need for selfobjects to help them

maintain a cohesive sense of self. This need is so great that everything

other people offer is "consumed” (orality or oral rage). This leaves

narcissistic patients unable to develop relationships with others beyond

this need. There is no capacity for empathy, sharing, or loving others.

Narcissistic people function this way because they were treated in a

274

The Nardssistit Personality

similar manner by their caregivers. To a certain extent, all children

become a narcissistic extension of their parents. This helps facilitate

development through processes like introjection and identification.

Object relations theory postulates a tripartite self in NPD:

• the true self, which is deprived and hungry

• the false self, being loved for special accomplishments

• the idealized self, living up to the expectations of caregivers

Parents who are too invested in using children as narcissistic

extensions transmit the sense that love is given for playing a role.

Under such circumstances, children learn that gratification comes from

others, and comes from being “perfect” or fulfilling the expected role

perfectly. The person’s emotional reactions are not considered or

reinforced as important. This facilitates a false self as the predominant

manifestation in NPD. The evaluative process by which behavior is

judged becomes introjected, and is experienced as criticism.

Narcissistic patients are inwardly critical and constantly strive for

perfection, which is is also projected onto others who then are

admonished for not living up to the patients’ own standards. The internal

world of NPD is also made up of the real self, which contains

unconscious feelings that were denied expression. Patients feel empty,

inferior and fragile. Being a narcissistic extension invokes feelings of

deprivation and falseness.

Patients strive to be perfect in all aspects of their lives, aspiring to the

idealized image (Kohut’s imago) of their parents, who did not encourage

a more realistic sense of self. Regardless of the degree to which there

is a conscious awareness, narcissistic patients protect their fragile

self-esteem by avoiding situations in which they may be vulnerable.

Grandiosity guards against feeling painful affects, making it difficult to

point out as a defense.

Narcissists envy the successes of others, and are particularly attuned

to whether something can be obtained to further their own cause.

Innate aggression may explain why some narcissistic patients destroy

the work, or good things, of others. Behavior in NPD is a defensive

compensation for fragility. While dependent on others for their self¬

esteem, narcissists are vain, contemptuous and “pseudo-selfsufficient.”

Expressions of gratitude are avoided to prevent an

awareness of needing others. There is an overall numbness towards

the feelings of others, and a lack of awareness that things can be just

“good enough” instead of having to be perfect.

275



Unlike patients with many of the other personality disorders, narcissistic

patients do present for help. They are aware of something going awry

in their relationships, but rarely see themselves as the common

denominator. A typical situation involves a patient presenting in a

dysphoric state, usually after a narcissistic injury or a DIR.

Therapy is often sought as a boost to reestablish self-esteem. Several

themes may be present in the initial meeting, with patients looking for

a “qualified professional” (or the “department head”) to:

• carefully listen to the minute details of the presenting complaint

• collude with the devaluation of the other party

• reinforce that the right thing was done by the patient in the situation

• assuage whatever guilt might be present

• help patients to perfect themselves, rather than to gain an understanding

of who they are and how they interact with others

Therapy with narcissistic patients presents difficulties. NPD involves

a particularly defensive character structure that is reinforced by the

way in which society views success. The traditional benchmarks of

psychological health — being able to work and to love — may be

difficult to set as therapeutic goals. Highly narcissistic individuals can

do extremely well in certain occupations. Additionally, they can find

partners with personality structures that complement their own, and

enjoy comfortable but emotionally compromised relationships.

A typical difficult case might involve a bloated, recently fired CEO who

wants “some kind of therapy” because he isn’t sleeping well, and can’t

seem to deal with his dismissal. His company was part of a recent

merger, and the new CEO was someone he bulldozed over on his

way to the top many years ago. His marriage ended one year ago,

and he is currently involved with his secretary. He drinks excessively,

but does not see this as a problem. In the past, he picked up a lot of

important business tips in bars, and hopes to find something he can

use to take revenge for his “predicament.”

The goal in treating NPD is to help patients accept themselves without

boosting their grandiosity or facilitating the devaluation of others. This

process may take several years. One of the difficulties encountered is

that psychotherapy is a learning situation. Narcissistic patients often

avoid novel situations that highlight their ignorance or deficiencies,

preferring instead to be in environments where they have some status.

276

The Nartissistit Personality

Kohut and Kernberg are the major contributors to the contemporary

understanding of the etiology and treatment of NPD. Their complex

theories diverge in many areas, possibly because they developed their

approach with different types of narcissistic patients. Since each

approach has its own merits, an awareness of both enhances the

flexibility with which NPD can be handled. McWilliams (1994) uses a

plant analogy. Kohut’s concept is a developmental one, in which a

normally growing plant is deprived of sunlight and water. Kernberg’s

concept is a structural one, in which the plant has an aberrant part.

Kohut theorized that parental empathic

failures were the main cause of

narcissism. Therapy centers on the

repetition of this failed relationship in

transference reactions such as the need

for affirmation (mirror transference),

idealization (idealizing transference),

and imitating the therapist (twinship transference). Kohut emphasized

the fragility of narcissistic patients and advocated a gentle approach:

• taking therapeutic material at face value, ignoring the message that

what patients actually feel is different than what they express

• taking responsibility when patients are feeling upset

• avoiding what may be seen as criticism, stressing the positive aspect

of experiences; highlighting progress when it is made

Kohut accepted the patient’s need for idealization as normal, and,

returning to the plant analogy, sought to provide sunlight and water.

Kernberg views greed, and the devaluation of

others, as defensive operations that require tactful

confrontation and interpretation. Both positive and

negative transference reactions are considered

early on, with envy being a particular focus. A

cognitive understanding is sought to show patients

how their defenses prevent them from receiving help.

Kernberg’s plant requires a pruning.

Kohut’s approach may work best with the Type 2 or hypervigilant

narcissist, with Kernberg’s being more suitable for Type 1. These two

approaches to therapy are not mutually exclusive. One approach may

benefit certain patients at a given time, and with progress, the other

becomes more valuable. Attention to transference, countertransference

277


and the effectiveness of trial interpretations, will indicate which approach

is more useful. Combining these approaches yields useful therapeutic

guidelines. Narcissistic patients are exquisitely sensitive to shame. A

remark considered critical in early sessions (or at any point) can lead

to termination. The gentle, accepting approach advocated by Kohut

fosters a therapeutic alliance. Recognizing and admitting to

imperfections not only presents an empathic failure, but the patient

internalizes a more realistic and humane attitude.


Transference reactions in NPD are strong. The therapist is either

idealized as wonderful or devalued as incompetent. These reactions

are like those seen in BPD, but have more stability. A frequent pattern

involves idealization of the current therapist, with devaluation of those

from the past. Patients experience these perceptions as if they were

based on objective evidence. What sets the transference

manifestations in NPD apart from other personality disorders is that

patients show little interest in why they have these reactions. Attempting

to explore these issues is seen as indulging the therapist’s needs, and

superfluous to the therapy. Narcissistic patients “ventilate” in sessions,

using the therapist as an audience. Kernberg used the term satellite

existence to refer to the patient’s oblivious reaction to the therapist.

Transference reactions in NPD specifically undermine therapy and

arouse strong countertransference reactions. Therapists who identify

with the idealized transference can be seduced into a “mutual

admiration society.” This arrangement is short-lived because

narcissistic patients need others only for their gratification. Inevitably,

devaluation results. The subsequent barrages evoke feelings of

irritability and hostility. It can be difficult to resist taking punitive action

against patients. With the lack of interpersonal involvement, boredom

is a common countertransference reaction.


• find out what the agenda is in seeking therapy

• be cautious about making remarks that may be seen as critical; frame

or “couch” questions and statements to sound benign

• acknowledge errors, but do not be overly self-critical, as this reinforces

patients’ superior view of themselves

• encourage patients to openly express their needs, and to ask others

what their needs are

• monitor countertransference; avoid gratification or punishment

278


Pharmatotherapy

Narcissistic patients can experience mood swings that correspond to

their defensive structure. While the effusiveness accompanying

idealization rarely seems to need medication, the dysphoria of a

narcissistic injury frequently brings about treatment with an

antidepressant. If a major depressive episode develops, the focus in

prescribing should be to treat target symptoms. Narcissistic patients

are adept at persuading doctors to give them medications that may

be ill-advised, especially benzodiazepines and opioids. They are

vulnerable to hypochondriacal preoccupation; pain (psychic or

physical) is poorly tolerated, and impels patients to seek medication.

Croup Therapy

Convincing patients to participate is the main obstacle in group therapy

for NPD. Often, the suggestion is seen as a rejection, or projected as

the therapist being incapable of treating the patient. This switch can be

facilitated by beginning individual therapy first, and when the alliance

is strong enough, continuing in a group format. Another recommendation

involves simultaneous participation in both types, ideally with the same

therapist. Each mode of therapy can complement the other, as

narcissistic patients tend to run from their mistakes and hide from

those who are aware of them. However, this practice may be seen as

an affirmation of specialness, and make group members not afforded

this arrangement feel left out.

Narcissistic patients often dominate group settings, and take up a

disproportionate amount of time airing their concerns. While they may

enjoy the larger audience, the other members are soon resented for

taking any of the group’s attention. Narcissists rapidly seem to forget

that they have any difficulties, and often take up the role of co-therapist.

Their sense of entitlement makes them prone to transgress group

rules, especially contact with members outside of sessions. Limiting

the group membership to one NPD can help minimize this.

Narcissistic patients stir powerful transference feelings in group

settings, and instigate considerable interaction. This can facilitate an

active “here and now” confrontation, visible to group members. An

additional benefit of group therapy is the dilution of transference and

countertransference. Feedback on a group level can be a powerful

learning experience, and lessen the desire to terminate therapy when

confronted.

279


Cognitive Therapy


• Self-Righteousness — “I did it correctly. I always do.”

• Grandiosity — “Can you meet my standards?”

• Exploitation — “I’ll find someone with better skills next time.”

Cognitive therapy can be used to address three major features of

NPD: grandiosity, hypersensitivity to criticism and lack of empathy.

The all-or-nothing aspect of grandiosity is examined. Patients are

encouraged to limit their comparisons to within themselves, not to others.

Enjoying activities is stressed, instead of focusing only on attaining

goals, i.e. “I can enjoy ordinary things.” Systematic desensitization

can help lessen hypersensitivity to criticism. Patients can learn to be

more discriminating when receiving feedback. They can learn to control

their emotional responses and look for positive elements, i.e. “Other

people can have helpful ideas.” The failure to develop empathy may

need to be overtly pointed out by asking about an awareness of the

feelings of others. With role-playing exercises, emphasis can be placed

on how someone else might feel, notjust react, in a situation. Alternative

ways of treating others are examined, e.g. “Other people have feelings

that are important.”


Benjamin (1993) hypothesizes the following factors in NPD:

• the unconditional, selfless adoration of at least one family member

who consistently catered to the wishes of the patient

• absence of concern for the welfare of others

• the fear that any imperfection will have devastating consequences

Benjamin (1993) draws upon the work of both Kohut and Kernberg in

outlining a therapeutic approach to NPD. Kohut's ideas in particular

are facilitating collaboration, particularly the therapist’s ability to admit

to an occasional lapse in understanding. However, pattern recognition

comes about with timely, tactful and accurate confrontation. A key

aspect to therapy with narcissistic patients is to point out the burden

that comes with expecting unconditional adoration (as in continuing

to please a parent whose esteem depends on the success of his or her

children). Another focus is to learn ways of not being vulnerable to

others in needing their constant attention and approval. Patient can

benefit from understanding that the goals they seek are unattainable

and maladaptive — a heavy price in terms of health, happiness and

quality of relationships is paid for these relentless, self-indulgent quests.

280


Case Example

Course

NPD has often run a lengthy course by the time patients seek help.

Narcissism may have certain advantages in early adulthood, and is

also associated with the tendency to leave therapy. As a result, patients

often do not engage in treatment until later in life. By this time, they

have a firmly established pattern of using and discarding other people.

NPD is frequently disguised under other complaints, usually physical

or marital. Narcissistic patients have difficulty surrendering their

physical assets to time. They resist aging, in some cases by putting

themselves in jeopardy with extramarital affairs or strenuous activities

to “stay young.” They do not easily forgive others, nor celebrate the

successes of those around them, particularly if their own

accomplishments are being surpassed in some manner. When

motivation is sufficient, therapy can bring about changes that enhance

relationships.

281


Referemes



Edition





G. Gabbard


Edition





O. Kernberg

Severe Personality Disorder: Psychotherapeutic Strategies

Yale University Press, New Haven, 1984

H. Kohut

The Analysis of Self: The Psychoanalytic Treatment of NPD

International Universities Press, New York, 1971

N. McWilliams









R. Pies



282

InnerSpate


The interpersonal frontier... this is the saga of the voyager

Nartissus, on a five year journey to seek a way out of the

Egotentrk Universe

Episode 1

Narcissus has a rendezvous with Comet

Kohutek, encountering an empathic

betazoid species who mirror the prime

directive.

Episode 2

Full battle stations as

Narcissus grapples with

Darth Kernberg, and

must make use of the

ship’s defensive

capabilities to avoid a

photon interpretation.

283


Enterprising

Personalities

Captain

Nartissist

Mr.

Obsessive

Dottor

Histrionic

284

Review Questions

The Nardssistit Personality

1. How is NPD differentiated from delusional disorder, grandiose

type?

2. What “narcissistic” function do delusions serve?



1. Delusional Disorder involves non-bizarre delusions of a least one

month’s duration. While a delusion generally dominates the thoughts

and actions of the patient, behavior is not obviously odd or unusual.

Patients with grandiose delusions are convinced that they have special

relationships with famous people, superior knowledge, extraordinary

powers or inflated self-worth. Differentiation is made on the basis that

these beliefs are not of delusional intensity in NPD. In a sense,

delusional patients believe they have attained their goals, while the

narcissistic patient still yearns for them. Interpersonally, narcissistic

patients seek to impress others, are preoccupied with envy and are

manipulative. Delusional patients tend to focus more on the nature of

their “gift” and actions that are related to it. For example, a patient with

the delusion that she has developed a cure for a rare illness is more

concerned with contacting various government agencies than in

impressing those around her.

2. Delusions serve important psychological functions for patients in

whom they occur. They can be understood in terms of fulfilling an

unconscious wish or psychological need. One of the best explana¬

tions of delusions is that they displace'onto the environment specific

feelings (such as hate) that are unacceptable on a conscious level.

Historical information about delusional patients often reveals their own

experience with hostility in early relationships. This becomes internal¬

ized as a model for future relationships, and in adulthood, this hostility

is projected onto the external world. This helps satisfy an internal emo¬

tional need, but results in false convictions about the environment.

Delusions are maintained because they help bolster the low self-es¬

teem of patients. In a primitive way, delusions provide meaning for

the lives of those who suffer from them. Patients who were previously

isolated, hopeless and felt they had little purpose in life can have some¬

thing to rally around. Grandiose delusional themes can be related to

two of Erickson’s Life Cycle Stages.

• Initiative vs. Guilt

• Industry vs. Inferiority

Central Issue

Achievement

Achievement

Theme of Delusion

Grandiosity

Grandiosity

Reference

D. J. Robinson

Brain Calipers: A Guide to a Successful Mental Status Exam

Rapid Psychler Press, London, Canada, 1996

286

The Avoidant Personality


287



Name:

Occupation:

Appearance:


Favorite Songs:

Motto:

Mike McMeek

Model for “before” picture in

weightlifting ads

Matches clothes to office wallpaper

Has dog introduce him to others

Born to be Mild; If You Asked Me To

I gotta be . . . anyone but me


Before Session:


During Session:

Fantasies Involve:



Brings to Session:

Followed Schizoid’s path; hoped

they might meet

Reads nothing so as not to

disappoint others

Discusses detours, off-ramps & exits

Reincarnating Dale Carnegie as his

uncle

Protects car from Antisocial

Spends time with head in lampshade

Invisible Man comic book


"AURICLE"

Avoids activities

Unwilling to get involved

Restrained within relationships

Inhibited in interpersonal situations

Criticism is expected when in social situations

Lower than others (self-view)

Embarrassment is the feared emotion

288

Introduttion


The avoidant personality disorder (APD) is characterized by inhibition,

introversion and anxiety in social situations. Some key names

associated with developing the concept of this disorder are:

• Kretschmer (1925) — described a “hyperaesthetic shut-in” character

type, which resembles the current concept of the avoidant personality.

• Fenichel (1945) — described the phobic personality, a conceptual

forerunner to the avoidant personality disorder.

• Horney (1945) — wrote about “interpersonally avoidant” personalities

who withdrew into solitude due to the strain of relating to others.

• Millon (1969) — first used the term avoidant to refer to an activedetached

pattern of interaction in which individuals desired relation¬

ships, but withdrew to avoid the possibility of being hurt.

• Burnham, Gladstone & Gibson (1969) — described a “need-fear

dilemma,” whereby avoidant personalities felt a strong need for people

but feared being destroyed through abandonment.

Avoidant personality disorder was first included in the DSM-III from

Millon’s description. The DSM-lll-R criteria were changed to correspond

to the concept of a phobic character disorder. The DSM-IV emphasizes

hypersensitivity, fear of rejection and feelings of inadequacy, in addition

to the avoidant behavior.

The concept of APD has been criticized for having too much overlap

with the schizoid personality disorder, despite their assignment to

different clusters. The main distinction is that schizoid personalities

do not desire close relationships; avoidant personalities do, but fear

rejection.

Other studies have found considerable overlap between APD and the

dependent personality disorder. APD has been previously described

as the inadequate personality disorder (discussed in the Other

Personality Topics Chapter).

APD shares considerable overlap with social phobia, generalized

type. Patients have an increased incidence of other anxiety disorders,

including panic disorder with agoraphobia. APD is often diagnosed

in conjunction with other Axis I and II conditions.

The psychoanalytic concept of schizoid encompasses avoidant,

schizoid and schizotypal personality disorders. The ICD-10 contains

a related diagnosis called the anxious (avoidant) personality disorder.

289


Media Examples

Avoidant characters are often cast as latent heroes. They long for

love and acceptance and, upon receiving it, develop their potential

like Popeye eating a can of spinach. Plots frequently involve an extro¬

verted character coaxing out an introverted (avoidant) one. The

extrovert is subsequently rewarded with a loyal friend or lover who

often has some special ability or hidden talent.

Examples can be seen in the following films:

• Superman (comic series, movies in 1978, 1980, 1983, 1987) —

Clark Kent, the other identity of Superman, is a mild-mannered news¬

paper reporter. His self-effacing manner, bumbling antics and love of

Lois Lane (at a distance) are good examples of avoidant behavior.

• Always — Brad Johnson plays the role of a junior pilot who aspires

to become a waterbomber. He slowly develops a relationship with the

girlfriend of a deceased pilot. His “Aw, shucks, ma’am” approach and

reticent manner are avoidant qualities.

• The Mask — Jim Carrey portrays an “Everyday Joe” banker who

can’t set aside his inhibitions to live out his romantic fantasies.

• Four Weddings and a Funeral — Hugh Grant portrays Charles, a

clearly avoidant fellow, who is strongly attracted to a woman he meets

at a series of weddings. He cannot tell her he has feelings for her, as

amply demonstrated in a scene where she announces her intention

to marry another (clearly narcissistic) man. He is equally inept at telling

another woman he dislikes her and, through his ineffectual style,

becomes engaged to her.

• The Wizard of Oz (1939) — The cowardly lion, lacking the courage

to become the King of Beasts, sums up his dilemma with, “If I only had

the nerve.”

• Threesome — Eddy, the shy, sensitive roommate, exhibits some

avoidant behaviors in the process of sorting out his sexuality.

• The Accidental Tourist — William Hurt portrays a travel writer who

displays a mixed bag of personality traits, some of them avoidant.

• Zelig — the lead role played by Woody Allen.

290



Avoidant patients may or may not pose difficulties in interview situa¬

tions. When some notion of a “guarantee” of acceptance is given,

they become more amenable to sharing information and emotional

experiences. This acceptance is usually present to a greater degree

in clinical situations than in social situations. Patients may be quite

open in interviews, making it difficult to gauge the degree to which

avoidant behavior is present under typical social circumstances.

Empathic acceptance of patients’ sensitivity and past suffering gener¬

ates rapport. Once a sense of trust and a protective atmosphere are

established, the interview will readily proceed. A detailed history of

various emotional traumas often ensues. Patients frequently express

feelings of being ashamed about many aspects of their lives. In order

to maintain the interview, it is important not to convey that these concerns

are silly or trivial, even if the patients identify them as such. Confrontation

will result in a retreat that reduces the effectiveness of the interview,

though the usual avoidant behaviors will become more apparent if this

occurs.

Some patients are extremely sensitive and anxious when interviewed.

Unfamiliarity with clinical situations or past upsetting experiences may

provoke reticent behavior. Again, while the content of the interview

suffers, the process provides valuable information. Under such cir¬

cumstances, it may be possible to gather only essential information,

deferring the details until rapport has been established.

Avoidant Themes

Feelings of being defective

Low tolerance for dysphoria

Self-criticism

Exaggeration of risks

Shyness

Fear of rejection

Hypersensitivity to criticism

“Love at a distance”

Predominant social anxiety

“Actively” socially detached

Unduly set back by minor failures or disappointments

Will become intimate with those who pass the test for safety

Outwardly appear disinterested, inwardly are hypersensitive

Abrupt topic changes away from personal matters

Epidemiology

Prevalence is estimated to be less than 1 % of the general population,

with an equal frequency in men and women.

291


Etiology

Biological: APD does not have a clear genetic etiology. Studies of

temperament have found that some people have a predisposition to

marked social avoidance when faced with unfamiliar situations.

Introversion also has been found to be a hereditary factor.

Anxious and inhibited patients share some of the biological features

of generalized anxiety disorder, particularly hyperarousal of the sym¬

pathetic nervous system. Tachycardia, pupillary dilation and laryngeal

tightness are common physical signs. Baseline levels of cortisol may

also be abnormally high.

The hippocampus and limbic system may be involved in inhibiting

behavioral responses. Cognitive processing abnormalities may be

present, as evidenced by both decreased habituation and decreased

flexibility when presented with novel situations.

Psychosocial: While shyness may have a genetic or constitutional

origin, psychosocial factors mediate the extent to which it is expressed.

Intuitively, it would seem that children who were belittled, criticized

and rejected by parents have decreased self-esteem, resulting in social

avoidance. As children grow, these experiences are reinforced by their

peers, perpetuating self-criticism and avoidant behavior. Through the

cognitive process of generalization, patients come to expect similar

treatment from everyone. Millon’s developmental perspective of APD

is in accordance with this scheme.

Alternatively, children may find that timidity helps cope with raging

impulses. Fears that expression of their anger can have destructive

consequences leads to a pattern of avoidance. Situations where guilt,

anger or embarrassment may be provoked, along with a strong and

unpleasant emotional response, can promote avoidant behavior.

As with the paranoid personality, avoidant traits can develop in re¬

sponse to having developmental handicaps such as sensory impair¬

ments or a disfiguring illness. There is a common thread in paranoid

and avoidant reactions in that they share an alertness to the possibility

of external threats. An equal emphasis on, or awareness of, personal

limitations may modify emotional expression in these circumstances to

produce avoidant rather than paranoid traits. An example of this can

be seen in the movie The Man Without a Face.

292


Ego Defenses

Ego defenses in APD are generally higher-level or more mature

defenses (described in the section on neurotic defenses in the

introductory chapters). Chief among avoidant defenses is repression,

which prevents ideas and feelings from reaching consciousness. Other

defenses used are:

• Inhibition — an evasion of conflict, either among internal agencies

(e.g. id versus superego) or externally with other people.

• Isolation — separating an idea from the accompanying affect.

The psychological processes and defenses used in phobic disorders

are similar to those in APD. When a forbidden wish or impulse threatens

to emerge or to bring on real or imagined punishment, three

mechanisms of defense are recruited:

• Displacement — shifting anxiety from an unconscious idea or object

to an external one (which often bears some symbolic link).

• Projection — externalizing the source of harm or punishment.

• Avoidance — a conscious attempt to control anxiety.


A pervasive pattern of social inhibition, feelings of inadequacy, and

hypersensitivity to negative evaluation, beginning by early adulthood

and present in a variety of contexts, as indicated by four (or more) of

the following:

(1) avoids occupational activities that involve significant interpersonal

contact, because of fears of criticism, disapproval, or rejection

(2) is unwilling to get involved with people unless certain of being

liked

(3) shows restraint within intimate relationships because of the fear of

being shamed or ridiculed

(4) is preoccupied with being criticized or rejected in social situations

(5) is inhibited in new interpersonal situations because of feelings of

inadequacy

(6) views self as socially inept, personally unappealing, or inferior to

others

(7) is unusually reluctant to take personal risks or to engage in any

new activities because they may prove embarrassing



293



APD has considerable overlap with social phobia, generalized type.

APD involves a wider range of situations that cause anxiety, a perva¬

sive difficulty in relationships, and is egosyntonic. It can be

distinguished from generalized anxiety disorder in that APD patients

lack overt anxiety when not in social situations. Agoraphobia has a

more direct focus on fearing situations in which escape, or obtaining

help from others, may not easily be available. Anxiety may result in

occasional panic attacks or panic disorder.

Avoidant behavior can be seen in mood disorders, schizophrenia

and other psychotic disorders. Disorders with real or perceived

changes in appearance (e g. anorexia nervosa and body dysmorphic

disorder) often cause patients to restrict social contact.

Substance use disorders, particularly use of sedative/hypnotics,

alcohol, or cannabis can lead to introversion and avoidant behavior.

General medical conditions (e.g. hypothyroidism) also need to be

considered.


Appearance:

Behavior:

Cooperation:

Affect:

Speech:

Thought

Content:

Thought

Form:

Perception:

Insight &

Judgment:

Suicide/

Homicide:

None characteristic; not concerned with latest

fashions

May be anxious initially, with hand wringing and

agitation; may appear hypervigilant


Restricted/flat initially; wider range and animation

seen as comfort increases

No characteristic abnormality; restricted by anxiety

Hypersensitive to surroundings; express anxiousness

about relationships; may have ideas of reference


circumstantial, vague


Partial; are aware of anxiety and hypersensitivity;

may have limited insight into avoidant behavior

Increases in conjunction with an Axis I disorder;

not generally dangerous to themselves or others

294


Psythodynamif Aspects

The central dynamic in APD is that of shame, which involves a sense

of not living up to an internal standard or ego ideal. It carries the

connotation of being “bad,” leading to feelings of impotence or

helplessness. Guilt is the conviction of violating an internal rule (a

prohibition of the superego) and the concern with punishment.

While a constitutional predisposition to feel shame may exist, it is

reinforced and perpetuated through environmental experiences.

Shame becomes a reaction within the first year of life and is especially

evident during toilet training. Internalizing a variety of shameful expe¬

riences (e.g. emotionally expressive caregivers who are hostile or

intolerant) leads to a diminished sense of self-esteem and a conviction

of being “defective.” Accompanying the low self-esteem is a painful

sense of dysphoria, which develops not only from feeling rejected but

also because of the sense of being defective.

Patients generalize their experience with critical and rejecting care¬

takers, and assume other people will react similarly. To avoidant

patients, revealing anything of themselves leaves them vulnerable.

They fear that should someone get to know them, their deficiencies

will become obvious, bringing on criticism and ultimately rejection. The

resulting dysphoria is especially hard to bear because to an avoidant

person the rejection appears justified.

Avoiding potential harm from others becomes the central behavior in

APD. Though patients have an awareness that relationships can be

satisfying, they engage in social, emotional and behavioral strategies

to protect themselves. Patients even avoid thinking about things that

may bring on dysphoria. They frequently find diversions to occupy

their time. For example, television, movies and live theater offer a

semblance of human interaction while keeping them at emotionally

safe distances. These outlets facilitate another form of escape: wishful

thinking and an active fantasy life. Avoidant people do not have enough

faith in their abilities to bring about change, and hope that some event

or relationship will appear as magically as it does in fictional works.

Another method of coping is to adopt a fagade to attract others and

camouflage weakness. One of the most popular ways this is achieved

is through substance abuse, particularly alcohol. A common descrip¬

tion of an alcoholic personality is a person who is “shy, isolated,

irritable, anxious, hypersensitive and sexually repressed.” (Kaplan, 1994)

295



Avoidant patients are generally well suited to the process of psycho¬

therapy with a supportive-expressive approach. Initially, a supportive

approach may encourage patients to take a closer look at the multi¬

tude of “escapes” they have developed over time. This is facilitated by

empathizing with their sensitivity to social situations and their quick

sense of rejection. With time, expressive approaches become possi¬

ble when connections can be made between developmental experi¬

ences and their impact on current functioning.

As rapport develops, patients can be asked about the specifics of

their reactions. This is especially helpful when done in a “here and

now” manner with transference reactions. Patients can be encouraged

to verbalize their feelings instead of avoiding them.

Two types of avoidant personalities have been described and may

indicate differing treatment approaches:

Type A

Type B

constitutionally or temperamentally overanxious; more

likely to have had a varied (and potentially normal)

attachment history; may benefit from behavioral

interventions, social skills training and exposure

therapy

narcissistically vulnerable; more likely to have had

shaming or intolerant parents with negative

attachment experiences; may benefit from more

traditional psychotherapy (see NPD).


Avoidant patients enter therapy with the same trepidation as other

relationships. To whatever extent they are concerned that others will

see through them, they are especially anxious about being transparent

to a “professional.” They may expect to be magically helped, or try

even harder to deflect attention away from their perceived defects.

Patients may ingratiate themselves with their therapist, doing anything

to please and avoid confrontation. Avoidant patients desperately

evaluate social interactions for any hint of acceptance or rejection.

Since an “expert” is involved, undue weight may be put on any aspect

of the patient-therapist interaction. The major countertransference

reaction involves collusion with the guarantee of acceptance patients

seek. Therapists may find themselves stifled in not wanting to hurt or

offend patients.

296



• A good deal of effort may be required to interest patients in therapy;

empathy and a supportive approach increase comfort.

• Don’t make promises or overtures that are unrealistic or not likely to

be found elsewhere; avoid becoming overprotective.

• Be attuned to the possibility of substance abuse.

• Encourage patients to take a more active role in relationships.

Pharmacotherapy

Because of the overlap with anxiety disorders, and the continual

exposure to social situations, avoidant patients may require anxiolytics.

Benzodiazepines are often sought because of their effectiveness and

quick onset of action. However, their addiction potential, and the chronic

nature of the difficulties encountered due to personality variables, make

these medications advisable for only short-term crises. Other

medications that may be efficacious in alleviating anxiety:

• MAOIs, with phenelzine being the best studied member of this group

• Tricyclic antidepressants, buspirone and beta-blockers

Recent studies have been consistently demonstrating the effectiveness

of the SSRIs in reducing anxieity symptoms. Research investigating

the anxiolytic effects of newer antidepressants such as venlafaxine

and nefazodone is still pending.

Medication can be used to reduce moderate-to-severe symptoms to

help prepare patients for cognitive-behavioral interventions such as

social skills training, relaxation training and graded desensitization.

Group Therapy

Avoidant patients can be ideal group members and benefit consider¬

ably from this type of therapy. Much as in individual therapy, supportive

approaches are necessary in the early stages. Therapists may need

to be protective and see that patients are not pushed by the rest of the

group. Overt encouragement will often be beneficial.

Avoidant patients have difficulty speaking in public. When doing so,

they are self-effacing and reluctant to involve others. These features

can be directly addressed in a group setting. Secondary benefits, such

as developing a more appropriate style of dress and an awareness of

social trends, can help patients fit in more smoothly outside the group.

297


Cognitive Therapy


• Avoidance — “I am defective. How could anyone like me?”

• Rejection — “If someone rejects me, I must be inadequate.”

• Criticism — “I’ll never amount to anything.”

• Misinterpretation — “If people think I’m useless, it must be true.”

• Discounting praise — “Someone who likes me must not know me.”

• Catastrophizing dysphoria — “If I feel down, it will overwhelm me.”

• Giving Up — “I’m going to lose anyway. Why should I bother?”


The effectiveness of any form of psychotherapy increases appreciably

for avoidant patients if they confront situations actually causing them

anxiety (as opposed to imaginary). This makes a combination of

cognitive and behavioral therapy an ideal form of treatment for APD.

Patients demonstrate the same cognitive, emotional and behavioral

patterns towards the therapist as they do towards others. Transfer¬

ence manifestations can be dealt with in a “here and now” manner in

order to develop a working alliance. This can be done as soon as an

emotional change is observed during a session. It takes considerable

effort and perseverance to encourage avoidant patients to open up.

They fear that when their reactions and behaviors are revealed, the

therapist will no longer be interested in treating them. Only when

patients feel comfortable enough to discuss their reactions to the

therapist, can the cognitions that pervade their relationships be ex¬

plored.

Cognitive therapy requires the recording of dysphoric thoughts and

feelings. Patients actively avoid such experiences both between and

during sessions. For this reason, an early intervention is to focus on

the elements involved in the avoidant process. In order to do this,

socratic questioning (guided discovery) can be used to help patients

agree that, in general, avoidance will not help achieve their goals.

Situation where potential for rejection exists

Automatic negative thought/distorted cognition about self

Dysphoric emotion

4*

Avoidant behavior reduces dysphoria

298


As patients become familiar with this scheme, they can start to look at

their reactions in therapy, instead of discussing something that hap¬

pened recently. When this happens in a “here and now" manner,

patients are prompted to share their feelings (“I’ll have a mental

breakdown”). As they develop a tolerance for dysphoria, they can test

out their predictions and dysfunctional beliefs.

Some of the behavioral techniques used in the treatment of anxiety

disorders can be useful in APD, especially exposure therapy. Patients

first make a list of threatening situations in order from least to most

threatening. Exposure occurs either by using imagination (systematic

desensitization) or real situations (in vivo or role playing). A list of

feared consequences is constructed for each situation. Generally,

patients catastrophize the outcome, and observations made during the

exposure supply evidence to contradict their predictions. In the treatment

of phobias, relaxation training occurs prior to contact with the feared

object. This may be beneficial for use in APD as well. A lifetime of

avoiding relationships and social situations can leave patients lacking

certain skills. Formal instruction can be given in areas such as

assertiveness training, personal management, and sexuality. Other

pointers can be given informally, such as attending to non verbal cues,

making conversation and increasing awareness of current trends.


Benjamin (1993) proposes that unlike many other personalities,

avoidant patients were given sufficient nurturance and developed social

bonds as children. This preserves their wish for relationships as adults.

Caregivers were thought to place undue emphasis on the opinions of

those outside the home and on cultivating a notable social image.

Any deficiencies were subjected to constant derision, and if in public,

were emphasized with humiliation (teasing, ostracism, etc.). Despite

this, the avoidant patient remained loyal to the family as the principal

source of support. In this way, the patient developed the sense that

he or she was flawed, would not succeed outside the home, and should

avoid others. Benjamin warns that while avoidant patients often do

well in therapy, there can be a strong pull exerted by their families to

not share “secrets.” Even in the absence of this interference, patients

are usually reticent to share personal information for fear of “blaming”

the family. She warns that that simply relating well to the therapist is not

a sufficient gain in therapy; patients must appreciate the impact of

their interpersonal patterns in a way that they make changes in their

everyday relationships.

299


Case Example

Mike McMeek is a twenty-eight-year-old single, unemployed man. He

decided to work for a year after high school instead of going to college.

Unfortunately, things haven’t gone his way and he has yet to make

plans to further his education. He showed promise in a number of

jobs, but ultimately could not make the transition to positions of

responsibility. In one situation a burger chain planned to promote him

to shift manager. This was just before a major holiday, and Mr. McMeek

could not arrange a schedule that met staffing needs. Though he offered

to work double shifts himself, this was seen as lacking leadership potential

by his employer. Despite being offered his old position “back on the

line,” he declined because he felt he would be seen as a failure by his

family.

Upon using a guest pass in a local gym, he was “discovered” and

started a modeling career. To his questionable fortune, he impressed

the company running an ad campaign as looking like the prototypic

“ninety-nine pound weakling” (though he weighs in at a trim one-fiftyfive).

This made him the “before” picture in a series of nationally run

fitness ads. Not only did this solve his financial difficulties, but it allowed

him to embarrass his parents who were often critical that he hadn’t

made anything of himself (which would increasing their stature in the

community). Unfortunately, his fame has made it even more difficult for

him to find a relationship because he is now tainted with the aura of

unavailability, which has only increased his social isolation.

Course

Avoidant patients can also be conceptualized as being observers of

life instead of participants. They lead their lives hoping and wishing

for better, yet are harshly self-critical when they make a move to

achieve their goals. While shyness can be adorable and even adaptive

early in life, it becomes a serious impediment later in life, when

competition and assertiveness are rewarded. Avoidant patients often

work below their level of ability. They have difficulty speaking in public,

exercising authority and delegating tasks — all qualities required for

professional advancement. Additionally, a self-effacing demeanor and

hypersensitivity to criticism do not generally work well as leadership

qualities. APD is one of the character structures most amenable to

therapeutic intervention. If patients can endure the initial relational

difficulties in therapeutic situations, they can integrate their tolerance

for dysphoria into a more assertive approach to relationships.

300


References



Edition


L. S. Benjamin






G. Gabbard


Edition





H. Kaplan, B. Sadock & J. Grebb, Editors

Synopsis of Psychiatry, Seventh Edition


N. McWilliams









P. Pilkonis, in J. Livesley, Editor



301


First Date Checklist

□ 5 packages of breath mints

□ Flowers

□ Bone for dog

□ Odor eaters (new)

□ Chocolates (good ones)

□ Cab fare home (plus tip)

□ Catnip for cat

□ Engagement ring

□ Triple-checked address

□ Food critic’s review of restaurant

□ Conversation piece

□ Two watches to avoid being late

□ Picture of someone’s baby

□ Book of 1000 compliments

302


Review Questions

1. How does the avoidant personality disorder differ from the schizoid


2. What diagnosis is most applicable to the clinical situation illustrated

below?

303



1. Millon was the first to use the term “avoidant," which was recognized

as a diagnostic entity in the DSM-lll. He felt that the phenomenon of

being “socially detached” warranted further investigation.

On the surface, both avoidant and schizoid individuals are “pleasure

deficient” and socially detached. Millon draws the distinction between

being passively (schizoid) and actively (avoidant) detached. While the

interpersonal behavior of these two personality types is similar, their

temperament, personal histories, cognitive styles and coping strategies

are quite different:

Schizoid

• chronic underactivity

• deficit in affective expression

• cognitive slippage

• interpersonal indifference

Avoidant

• chronic overactivity

• disharmonious emotions

• cognitive interference

• interpersonal mistrust

It has been commonly reported that the major difference between these

two personality disorders is that in SzdPD, relationships are not desired

whereas they are in APD. Further to this, avoidant personalities have

been described as being “hypersensitive, shy and insecure” while

schizoid personalities are “indifferent, aloof and cold.” (Trull, 1987)

Successive refinement of the criteria for APD has given it a clear

demarcation from SzdPD. However, as Benjamin (1993) points out,

social phobia, dependent personality disorder and avoidant

personality disorder have a considerable degree of overlap.

References




L. S. Benjamin

interpersonal Diagnosis and Treatment of Personality Disorders


T. J. Trull, T. A. Widiger & A. Frances

Covariation of Criteria Sets for Avoidant, Schizoid and Dependent

Personality Disorders

American Journal of Psychiatry 144: p. 767 - 771, 1987

2. Santaclaustrophobia!

304


The Dependent Personality


Biographiial Information

Name:

Occupation:

Appearance:


Favorite Song:

Motto:

Anita Lott

Food Banker & Pet Hotelier

Just Take Me t-shirt under a big

fuzzy sweater

Confines dog to prevent elopement

Stand By Me

Don’t leave home without me


Before Session:


During Session:

Fantasies Involve:



Brings to Session:

Sees another therapist

Autographed self-help book from

yet another therapist

Describes nightmares after seeing

Home Alone

Confining therapist to her home

Sits in car when Avoidant not there

Sits next to therapist; records

session with a portable tape

recorder

Nightly dinner invitation

Mnemonit for Diagnostic Criteria

"NEEDS PUSH"

Needy — other people assume responsibility for major areas of life

Expression of disagreement with others is limited

Excessive need for nurturance and support

Decision making is difficult

Self-motivation is lacking

Preoccupied with fears of being left to care for self

Urgently seeks another relationship when a close one ends

Self-confidence lacking

Helpless when alone

306

Introduttion


The dependent personality disorder (DPD) is characterized by

submissive behavior and excessive needs for emotional support.

Some key names associated with describing this disorder are:

• Freud (1923) — thought that excessive dependency was caused

by a fixation at the oral stage of psychosexuai development.

• Abraham (1924) — described “oral-receptive” characters, who

believed that a mother-substitute would care and provide for them,

thereby reinforcing inactivity and an aversion to meaningful work.

• Fenichel (1945) — observed that dependent patients consistently

found a “nursing mother” in their relationships.

• Horney (1950’s) — described a “compliant type” of character.

• Millon (1969) — described a submissive type of personality, later

reclassified as passive-dependent, in which the person remained

passive and looked to others to provide pleasure.

• Bowlby (1969, 1977) — saw the dependent character arising from

experiences that caused doubt about availability of the attachment

figure, causing an anxious or clinging attachment secondary to fears

of losing this person.

Dependent traits have long been described in a denigrating manner.

As phenomenology and classification systems developed, dependent

characters were seen as having a moral defect and described as being

weak-willed, ineffectual and docile.

The dependent personality disorder was first categorized during World

War II as an immature reaction to military stress, manifested by

helplessness, passivity or obstructionism. This description was carried

over into the DSM-I, where it was classified as the passive-dependent

subtype of the passive-aggressive disorder. In the DSM-II, DPD was

covered under the inadequate personality disorder (discussed in

the Other Personality Topics Chapter).

Millon’s description formed the basis for the first distinct inclusion of

DPD, which appeared in the DSM-lll. There were only three criteria in

this initial description, which grew to nine in the DSM-lll-R. Dependent

behavior is particularly evident in borderline, avoidant and histrionic

personalities, as well as in mood and anxiety disorders. For this reason,

DPD is often diagnosed in conjunction with other disorders. The ICD-

10 contains a category also called the dependent personality disorder,

which shares a considerable overlap with DSM-IV criteria.

307


Media Examples

Dependent characters are natural sidekicks. Their loyalty and devotion

to the main character often add an endearing touch to stories.

Occasionally, they rescue those who have gone out on a limb to take

a chance that they were not willing or able to take themselves. In

other instances, they become empowered, and take control over their

abusive/controlling/repressing spouses/bosses/friends.


• What About Bob? — Bill Murray portrays a highly dependent patient

who cannot bear feeling abandoned as his therapist leaves for a

vacation. He tracks down the location of the cottage and ingratiates

himself with his therapist’s family to avoid having to leave. He won’t

even leave his goldfish behind!

• Dr. Watson — In many aspects, Watson remains dependent on

Sherlock Holmes. Though a physician, he automatically subjugates

his practice to join in on anything that arises in Holmes’ detective work.

• Rocky — Rocky’s wife, Adrian, played by Talia Shire, is a dependent

character. Mousy and shy, she seems like an incomplete person

without him and requires him to bring her out of her shell.

• Death Becomes Her — Bruce Willis plays a hapless pawn tied to

two narcissistic women. He starts out as a plastic surgeon, but stays

in a destructive relationship too long, loses his license to practice, and

ends up as a cosmetician for a funeral home. He barely saves himself

from a fate of eternal subservience.

• Forrest Gump — Forrest maintains a dependent relationship with

his childhood friend, Jenny. He remains resolutely faithful to her and

is forever hopeful that they will be together. His tolerance of her long

absences, promiscuity and poor treatment of him demonstrate some

of the dependent personality characteristics.

• All in the Family (1970’s television) — Jean Stapleton portrays an

excellent dependent personality as Edith “Dingbat” Bunker. She

tolerates an incredibly chauvinistic husband who uses her as a stepping

stone for his own diminished self-esteem. The mindlessness of this

character and her willingness to allow her husband to think for her

embody key aspects of DPD.

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Dependent patients usually are quite easy to interview. They readily

respond when given attention, and are cooperative. While anxiety may

be a complicating factor initially, this can be assuaged through gentle

persistence. Rapport is developed by showing empathy for their needs

and by understanding how they have put their faith in others.

Open-ended questions are often answered appropriately, with

elaboration on their close relationships. Dependent patients are overtly

concerned with pleasing people. They are very attuned to the

expressions and gestures of others. Because of this, they are quite

malleable in interview situations. They can readily detect impatience

if their answers to open-ended questions do not appear to satisfy the

interviewer. They respond equally well to closed-ended questions and

do not usually object to an interruption or segue.

Difficulties can develop if patients get the sense they are not doing

what is expected of them. Under such circumstances, they may give

complete control to the “authority” of the interviewer. They resign

themselves to answering questions, but may not contribute

spontaneously. It is common for patients to form an immediate

attachment with interviewers, and to ask for advice and follow-up

sessions. They openly lament having to start over with someone new.

Dependent patients are very sensitive about their submissiveness.

They readily misconstrue exploration as criticism and will frequently

become tearful. Confrontation of any type frequently brings on tears

and a plea for help. For this reason, initial interviews can be more

successful by looking for, rather than pointing out, dependent themes.

Dependent Themes

• Neediness

• Work below level of ability

• Rarely live alone

• Continually seek advice

• Subordinate themselves • Volunteer for unpleasant tasks

• At risk for substance abuse, overmedication and abusive relationships

• Continual involvement in relationships; may endure a difficult one or

quickly find another upon its dissolution

• May have a “somatic orientation,” i.e. expressing their difficulties in

terms of physical complaints rather than emotional pain

• “Center of gravity” lies in other people, not the patient

• Make few or no demands other than for belonging and acceptance

309


Etiology

Biological: Temperamental features consistent with DPD are

submissiveness and low activity levels. There may be a stronger

tendency for monozygotic twins to display dependent behavior than

dizygotic twins, indicating that there is a genetic contribution.

Biological factors play a role in DPD. Children who are born with or

develop serious illnesses can regress and become overly dependent

on caretakers. If the illness is of sufficient duration or severity, normal

individuation may not occur. Because of the illness, autonomy is not

encouraged, which becomes egosyntonic for everyone involved in

the process.

Some studies have demonstrated an association between medical

illness and premorbid dependent traits. Other findings have postulated

a relationship between dependency and a general predisposition to

disease. Dependent traits become more pronounced after the onset

of serious illnesses and may be particularly common after head injuries

where both judgment and physical capabilities are affected.

Psychosocial: There are studies to support experiences of both overand

underindulgence in the upbringing of dependent patients.

With respect to underindulgence, prospective studies have found a

higher incidence of dependent traits among children who come from

impoverished backgrounds. Overcontrolling caretakers and inhibition

of emotional expression are common historical features seen in this

model of DPD.

Children who are indulged by overbearing and overprotective parents

can clearly develop dependency needs. Another feature of these

families is criticism or punishment following attempts at autonomy.

Children may fear their burgeoning independence will mean a loss of

love from attachment figures. In this way, dependent parents who are

overinvested in their children perpetuate the dependency they instill.

Although the oral phase of development is considered the fixation

point of dependent patients, it is more likely that the above patterns

persisted throughout development. The concept of orality is used to

refer to the hunger for attachment, rather than any reference to feeding

habits. Social and cultural factors require consideration. Additionally,

DPD may be more common in the youngest child in a line of siblings.

310


Ego Defenses

Various ego defenses are used in DPD:

• Idealization — other people, particularly partners, are seen as allpowerful

rescuers who provide protection and make decisions.

• Reaction Formation — dependent behavior may be the transformation

of aggressive or hostile feelings (see the Obsessive-Compulsive

Personality Chapter for a more detailed description, pun intended).

• Projective Identification — patients induce feelings of guilt and

indebtedness for their efforts to perpetuate relationships.

• Inhibition, Somatization and Regression are also used.


A pervasive and excessive need to be taken care of that leads to

submissive and clinging behavior and fears of separation, beginning

by early adulthood and present in a variety of contexts, as indicated

by five (or more) of the following:

(1) has difficulty making everyday decisions without an excessive

amount of advice and reassurance from others

(2) needs others to assume responsibility for most major areas of his

or her life

(3) has difficulty expressing disagreement with others because of fear

of loss of support or approval

Note: Do not include realistic fears of retribution.

(4) has difficulty initiating projects or doing things on his or her own

(because of a lack of self-confidence in judgment or abilities rather

than a lack of motivation or energy)

(5) goes to excessive lengths to obtain nurturance and support from

others, to the point of volunteering to do things that are unpleasant

(6) feels uncomfortable or helpless when alone because of

exaggerated fears of being unable to care for himself or herself

(7) urgently seeks another relationship as a source of care and support

when a close relationship ends

(8) is unrealistically preoccupied with fears of being left to take care of

himself or herself



311


Epidemiology

Estimates of the prevalence of DPD vary considerably among studies.

In clinical populations it is diagnosed in approximately 3% of patients.

There is a gender difference, with women being diagnosed three times

as often as men, though it is important to keep cultural and social

factors in mind before making this diagnosis.


Dependent traits can be seen in several Axis I conditions, as well as

in other personality disorders. A major depressive episode may cause

a patient to fear being alone and have an exaggerated need for others.

Dependent behavior may also be present in dysthymic disorder, with

the presence of a relationship modulating the dysphoria of this disorder.

In both these disorders, mood symptoms are prominent and episodic.

In DPD, patients are generally content when in a relationship, and

exhibit mood symptoms only with the loss or threatened loss of an

attachment.

Anxiety is also a prominent feature in DPD. Patients with phobias

often exhibit dependent behavior by needing a certain person around

to help calm them. Agoraphobia in particular has an overlap with

DPD. The distinction can be made by the generalized fear of being

alone in DPD; it is not limited to certain situations such as finding an

escape or obtaining help. Agoraphobic patients can happily lead an

independent existence apart from their specific fears.

Similarly, patients with panic disorder can become frantic without

someone around them for reassurance and comfort. Sometimes other

people can be seen as “good luck charms” whose presence reduces

the frequency or severity of attacks. Patients with panic disorder often

have accentuated dependency needs. The episodic nature of the

attacks in panic disorder and the otherwise independent functioning

between attacks helps separate these conditions.

Dependent patients are prone to somatizing, particularly in families or

cultures where attention is not given to emotions. Somatization disorder

and hypochondriasis in particular may perpetuate relationships and

ensure a passive, dependent role for patients.

Dependent patients usually do not have complaints as widespread,

or a focus as far developed, as those seen in somatoform disorders.

312


The orality of DPD can manifest itself in substance abuse. While

any drug can potentially be involved, alcohol and benzodiazepines in

particular can provide a soothing, anxiety-dissolving substitute for

attachment. Dependent patients may also turn to food as a substitute

for love and develop bulimia nervosa or obesity.

Commonly, in a shared psychotic disorder (folie a deux), the person

in whom the delusion is induced or transmitted has a dependent

relationship with the “primary case.” Occasionally, in delusional

disorder, erotomanic type, the lives of patients can be tied to those

on whom they are fixated.


Appearance:

Behavior:

Cooperation:

Affect:

May be less than stylish; often low esteem is reflected

in dowdy or frumpy clothing; often baggy, neutral or

bland colors; favor cozy or soft-feeling apparel

May be anxious with a new or skeptical interviewer;

behavior may include hand wringing, tremor, or holding

own hand or an object for comfort


Usually demonstrate an appropriate range; a genuine

sense of despair is conveyed with their fears

Speech:

Thought

Content:

Thought

Form:

Perception:

Insight &

Judgment:

Suicide/

Homicide:

No characteristic finding; may reflect anxiety

Passivity, letting others make decisions; express few

opinions; egosyntonic reliance on others

No characteristic abnormality; may be circumstantial,

vague, or overelaborate

No characteristic abnormality; consider medical

cause or substance abuse if findings are present

Partial; aware of dependence on others, but often do

not consider it a problem; often unaware of the extent

to which their lives are hampered; do not wish to

face or discuss dependency issues


disorder; not generally dangerous to others or

themselves; risk increases with substance abuse or a

general medical condition

313



Psychodynamic theories regarding dependent behavior initially

emphasized a disturbance or fixation at the first stage of psychosexual

development, the oral phase. Though this is now considered an

antiquated concept, it still provides a useful framework.

At the beginning of the oral phase, the infant is in a passive-dependent

relationship with the world. Gratification of oral libidinal needs, referred

to as oral erotism, is achieved by being fed, and upon satiation, falling

asleep. Later, when teeth develop, more aggressive features appear.

Known as oral sadism, this phase is connected with biting, devouring,

spitting, etc. The term oral character refers to adult analogues of

these development stages. Such people depend on others to provide

for them (DPD) or give them love and attention (NPD). In a sense,

they want to be “fed”, but demonstrate varying degrees of need from

others, and of willingness to give in return for this connectedness.

Some psychoanalysts divide the oral character into a passivedependent

type (more consistent with DPD) and an active-dependent

type (more consistent with HPD).

Though it may not be intuitively obvious, envy and jealousy are oral

traits. Hostility and aggression often occur in dependent behavior:

• “You look after me.”

• “You make the decisions.”

• “You tell me what to do.”

• “You’re in charge.”

This was recognized in the initial classification of dependent behavior

as being a subtype of passive-aggressive disorder. Dependent

behavior may be a compromise or a cover (reaction formation) for

deeper aggressive impulses. Patients may earn “credits" through their

services and use them to induce guilt in others. People the patient are

still “controlled,” but by a more subtle and acceptable process.

It is also common to find overcontrolling parents in the families of

dependent patients. Much as in the development of BPD, attempts at

autonomy were not reinforced and may even have been punished. A

less dramatic variant may have involved rewarding dependent

behavior. Another consistent feature is a low level of emotional

expression in families. This may leave patients seeking physical

demonstrations of affection, because verbal ones are not given.

314


Attathment versus Dependenty in DPD

DPD criteria include pathologic degrees of both attachment and

dependency behaviors. Attachment behavior in DPD achieves and

maintains closeness to a person who is seen as more capable. It is

usually aimed at a specific person and increases a patient’s sense of

security. Dependency involves reliance on others, diminished selfconfidence

and a lack of autonomy. It is a diffuse process that involves

seeking protection, help and approval.

Attachment dimensions of DPD are:

• seeking a secure base

• needing affection

• desiring closeness with an attachment figure

• protesting separation from attachment figures

• fearing the loss of an attachment figure

Dependency dimensions of DPD are:

• diminished self-esteem

• submissive behavior

• need for approval

• requiring care and support

• requiring advice and reassurance


Dependent patients are usually eager to get involved in psychotherapy.

They ingratiate themselves by taking whatever is offered in terms of

appointment times and frequency. They become model patients, rarely

canceling appointments or arriving late. Therapists are treated with a

sense of admiration bordering on awe. Regardless of the content of

sessions, the process of therapy suits dependent patients’ needs quite

well. Having a strong, competent professional to turn to for

understanding and support for an indefinite time period appears to be

the answer in itself. Idealization in DPD is more subtle and enduring

than that seen with other personality disorders, particularly BPD and

NPD. Patients are tolerant of the lapses, oversights and mistakes of

their therapists. As long as the continuity of therapy is not in question,

such occurrences do not bring about the rage or anger that

accompanies the devaluation seen in Cluster B disorders.

The difficulty in psychotherapy is in conveying to patients that the

goal must be to examine and alter dependent behavior, not indulge it

315


to make up for other deficiencies. The therapist, like a catalyst in a

chemical reaction, cannot be part of the final solution. In order to be

successful, the therapeutic process needs to tactfully and empathically

frustrate patients’ wishes, and then explore the fantasies and antecedents

of dependent behavior. This often takes place by denying requests for

advice, extra sessions or overt help with practical matters.

Psychodynamic psychotherapy aims to uncover what is being masked

by the continual search for a caretaker, and what frightens patients

about independence.

In some cases, acknowledging progress invokes fears of separation

and termination of therapy. Patients may begin to emphasize their

difficulties, or actually regress in order to prolong the attachment to

the therapist. A time-limited approach may help deal with this situation.

If a certain number of sessions is agreed upon at the outset, the anxiety

of termination can be discussed early in the therapy. This can also be

used at a later point if progress is not being made. Some patients may

not be able to tolerate breaking the attachment to their therapist and

require indefinite though infrequent sessions.


Transference reactions involve idealization and the fantasy that the

all-knowing therapist has all the answers. Frequently, patients expect

to be “spoon-fed” and do not realize that their involvement is necessary

for improvement. Patients expect therapists to satisfy their longing for

a nurturing figure. They may assist this process by flattery, giving

presents and imitating the therapist to achieve solidarity.

Countertransference reactions to the clinging and passivity of patients

can be quite strong. It may feel as if all that is really needed is a “swift

kick” to get things back on track. Subservience and ingratiating behavior

may cause an avoidant collusion with patients regarding sensitive areas

and issues of termination.


• Be tactful and gentle when focusing on dependent behaviors.

• Convey that the work of therapy is to identify and explore impediments

to a more independent lifestyle.

• Advice, favors and gratification of other needs will not be beneficial.

• Be an example of independent functioning for patients to model.

316

Pharmacotherapy


Dependent patients exert a strong “pull” on their physicians to do

something to help them. This, combined with a frequent mixture of

mood, anxiety and somatic complaints, can result in patients receiving

medication for their problems.

Dependent patients are eager to please and will do things that may

not be in their best interests to comply with the treatment prescribed

for them. They may not complain of side effects, may take medication

for longer time periods than is advised, and may become “dependent"

either psychologically or physically. A prescription can become a

transitional object, or have some other significance to the patient.

Because dependent behavior can be a feature of many conditions, a

careful diagnostic assessment is essential when it is the presenting

symptom. Axis I disorders have specific pharmacologic treatments;

there is no medication to cure dependent personality traits.

Still, dependent patients receive prescriptions as a result of either their

own initiative or their physician’s. It is important to consider the risks of

certain medications when they are used:

• benzodiazepines — addiction, memory impairment, disinhibition

• antidepressants — impaired sexual function, risk in overdose

• antipsychotics — tardive dyskinesia, dystonic reactions, akathisia

Overall, dependent patients may benefit from a trial of medication if

they are particularly symptomatic, or develop an Axis I condition that

is a clear departure from their personality traits.

Croup Therapy

Groups can be an excellent therapeutic modality for dependent

patients. Some group members may gratify the wish for advice,

sympathy and enduring attachment. Other members will confront such

yearnings and behaviors. This facilitates learning and gives patients

encouragement to attempt more independent solutions. The group is

an ideal place to experiment with new ways of interacting. Group

therapy can also be a place for dependent patients to hide. By idealizing

other members (and the therapist), they may become perennial

favorites and remain in groups far longer than is advisable. Membership

in the group is not the ultimate solution for their interpersonal

deficiencies.

317


Cognitive Therapy


• “I am inadequate and helpless. I can’t handle things on my own.”

• “I must find someone to care for me and protect me”


The structure and time-limited approach in cognitive therapy can be

very helpful in DPD. A frequent misconception is that therapy tries to

bring about a completely independent existence. Patients are prone

to dichotomous thinking: either they are entirely dependent, or entirely

on their own. Autonomy with enduring emotional connections to others

is a more encouraging goal for patients. Often direct examination of

dependent behaviors and attitudes overwhelms patients, who may be

unaware that this is their main issue. By use of guided discovery

and socratic questioning, patients become aware that assertiveness,

problem solving and effective decision-making could benefit their lives.

The practical, directive approach in cognitive therapy may foster an

early reliance on the therapist. Once patients are committed to therapy,

setting limits is useful in helping them discover their desire to be looked

after. For example, if the homework assignment is not done, or patients

have nothing to contribute to the agenda, they should not be allowed

to deflect the responsibility for what is done in that session onto the

therapist. The standard cognitive approach is to provide an agenda if

the patient does not. But in DPD, pointing out to patients that

submissiveness is part of their problem may generate active

involvement on their part. Setting goals with an increasing gradient of

independence is an important intervention. In behavior therapy, these

goals are addressed by using graded exposure, possibly with the direct

involvement of the therapist.


Benjamin (1993) views the development of the dependent patient as

starting out in a normal fashion. As a child, the patient accepted

nurturance and learned to trust and count on others. The difficulties

began when the infant was not “weaned” from this protective

environment and allowed to explore the world on his or her own.

Parents of dependent patients are thought to either enjoy the extended

closeness to their children or be overly concerned that problems will

arise if the child’s demands are not met completely and immediately.

In particular, Benjamin (1993) hypothesizes that over time, relentless

318


nurturance leads to dedicated submission. In trying to protect their

children, parents instead become controlling, which engenders feelings

of inadequecy. As the child grows, his or her incompetence in

development tasks draws the attention of others, resulting in ridicule.

The dependent’s lack of confidence is the most pronounced among all

of the personality disorders. This only serves to drive the patient back

to the parents, often with feelings of having failed at tasks outside the

home. In general, overwhelming parental control is a consistent feature

in the histories of dependent patients. They see no other option than to

submit, which can be as much a feature of a controlling family as it can

be an excessive need for nurturance and protection. As outlined

previously, dependent patients are usually quite cooperative with therapy.

The difficulty comes in facilitating recognition of their enmeshment

with other people. Benjamin (1993) proposes that a key factor in therapy

is to get patients to recognize that the opposite of being submissive

can be to “separate” rather than “control.” Patients often pay a price

for their submissiveness, and if they can learn to become more

assertive, their true wishes can be attainable.

Case Example

Ms. Lott is a forty-four-year-old woman who is currently in her third

marriage. She has custody of the four children from her first two

marriages and has had two children with her current husband. She

describes her house as “Kid Central” and for most part enjoys the

constant activity generated by her children and their friends. She readily

admits spoiling her children, and in fact has not taken a vacation for

years so that there is always money for new toys. At times she feels

taken advantage of by her neighbors because her house always seems

to be the one where parties and sleepovers occur. When she asks for

a favor from her friends, she feels so indebted that she will repay the

effort ten times over.

Course

Dependent behaviors, while adaptive early in life, can cause serious

limitations for adults. In some situations, dependent patients exist

happily in a symbiotic relationship with someone who “needs to be

needed.” Psychotherapies can be quite effective, once patients

understand that the therapist is not there to solve their problems for

them. When patients develop an awareness of the limitations caused

by their dependence, and see that autonomy holds advantages for

them, they can work successfully towards this goal.

319


Referentes



Edition





L. S. Benjamin



G. Gabbard


Edition


R. Hirschfeld, M. Shea, R. Weise & J. Livesley, in

The DSM-IV Personality Disorders, J. Livesley, Editor








N. McWilliams






R. Pies



320

Dependent's Apartment

(from first date with Avoidant Personality)


321


Social Phobia Convention

This is just a temporary bandaid cure. You’ll need

years of therapy later in life to completely recover.

322


Review Questions

1. How does the concept of masochism apply to DPD?

2. Which of the following options could be an explanation for the

illustration below?

a. masochism

b. altruism

c. fetishism

d. catatonia

e. dependent personality disorder

323



1. Masochism, though often used in a sexual or moral sense, is used

in personality literature to describe a relationship characterized by

suffering, passivity and deference to the dominant partner. This has

considerable overlap with the passive submissiveness demonstrated

by dependent patients.

These two concepts differ in that masochistic personalities appear to

be unconsciously programmed to fail. They so often undermine

themselves that this condition was referred to a the self-defeating

personality disorder in the DSM-lll-R (as a proposed personality

disorder). Masochistic personalities often do not indulge in pleasurable

activities and may appear as if they are poverty stricken.

Despite the overlap in some of the behaviors, these disorders were

delineated through quite different formulations. In earlier writings on

dependent personalities, a social judgment was often included on their

weak wills, deficient motivation and the ease with which they are

seduced into undesirable activities. Dependent personalities will go to

considerable lengths to preserve relationships and are generally happy

when involved with someone.

Masochistic personalities are less successful at finding satisfactory

relationships. They are seen as desiring a moderate amount of anguish

in their relationships. Self-denial is quite apparent; enjoyment or

indulgence is actively prohibited. In contrast to people with DPD,

masochistic personalities often alienate those who could be supportive

or helpful. They also seek a moral triumph by torturing others with their

own pain. As opposed to enjoying pain and suffering, masochists endure

these feelings in order to achieve a greater good (altruism) or to avert

a worse outcome that their mistreatment.

Reference




2. All of the options listed are possibilities. Catatonia is a term applied

to a diverse number of postural and movement disorders. The motor

disorders can include both increased and decreased levels of activity.

The illustration could be a depiction of a catatonic stupor.

324

The Obsessive-Compulsive

Personality


325



Name:

Occupation:

Appearance:


Favorite Song:

Motto:

R. Lloyd Micron

Molecule counter for a chemical co.

Starched underwear and socks

Has sent dog to obedience school

every year for 8 years

You II Do It My Way

There are rules about making rules


Before Session:


During Session:

Fantasies Involve:



Brings to Session:

Washes hands before and after using

restroom

Arranges magazines alphabetically

Quotes an etiquette book

Not flushing the toilet

Repairs hole in chair with pocket¬

sewing kit

Demands watches be synchronized

A bottle of the cologne Obsession


"PERFECTION"

Preoccupied with details, rules, plans, organization

Emotionally restricted

Reluctant to delegate tasks

Frugal

Excessively devoted to work

Controls others

Task completion hampered by perfectionism

Inflexible

Overconscientious about morals, ethics, values, etc.

Not able to discard belongings; hoards objects

326

The Obsessive-Compulsive Personality

Introduction

Hallmarks of the obsessive-compulsive personality disorder (OCPD)

are rigidity, perfectionism, orderliness, indecisiveness, interpersonal

control and emotional constriction.

Some key names associated with concept of this disorder are:

• Esquirol (early 19th century) — wrote about this personality type

• Freud (1908) — linked obsessive behaviors to difficulties during the

anal stage of development, and defined the anal triad, consisting of

parsimoniousness, orderliness and obstinacy (mnemonic — poo).

• Jones (1919) — described a sense of time pressure, frugality with

money and preoccupation with cleanliness.

• Abraham (1921) — elaborated on Freud’s view and added several

features to the list of typical behaviors.

• Schneider (1923) — described the anankastic personality as kempt,

pedantic, proper, constrained and insecure.

• Reich (1933) — described obsessive characters as “living machines”

and also noted them to be indecisive and plagued with doubt.

• Lazare (1966) — conducted studies contributing to the DSM criteria;

in addition to Freud’s triad, other defining characteristics were: emotional

constriction, perseverance (in the face of undue obstacles), rejection

of others, rigidity and a strong superego.

• Janet, Rado, Erikson (Erik), Salzman and Shapiro — all made

contributions to the description and understanding of this disorder.

The obsessive-compulsive personality disorder is often confused with

the similarly named obsessive compulsive disorder (OCD), which is

classified on Axis I as an anxiety disorder. Though some of the early

theories did not distinguish a personality style from this clinical disorder,

these conditions are phenomenologically distinct. An obsession is

defined as “a recurrent thought, impulse or image,” and a compulsion

as “a repetitive behavior or mental act.” Patients with OCPD do not

experience distinct obsessions or compulsions. Their thoughts and

behaviors are egosyntonic, and therefore are not recognized as

excessive or unreasonable, as they are in OCD.

This disorder was initially called the “compulsive personality disorder”

in the DSM-I and again in the DSM-III (for the sake of brevity, the term

obsessive is used in this chapter). In the ICD-10, it is called the

anankastic personality (Greek for “forced”). This differs from the DSM-

IV description by leaving out parsimony, and adding the features of

indecisiveness and the need to plan activities in unalterable detail.

327


Media Examples

Obsessive characters are frequently cast as harsh, mean-spirited

“control freaks.” They have a tragic flaw that the plot sets out to punish

or correct. Typical examples include domineering bosses, know-it-alls,

workaholic spouses and loners on a mission.


• Terms of Endearment — Shirley MacLaine won an Oscar for her

portrayal of a clearly obsessive woman who channels her libido into

gardening, and ends up with a backyard that threatens to overtake

the house. She is a repressed busybody who repeatedly tries to

dominate her daughter’s life.

• Dragnet (movie version) — Dan Aykroyd plays the nephew of Joe

Friday, the character from the original television series. Aykroyd’s grim

manner, humorlessness and interest in “just the facts” are examples of

obsessive behavior.

• Star Trek (original series) — Mr. Spock is the obsessive’s obsessive.

He is ruled by logic and rarely betrays even a glimpse of emotion.

Many humorous moments are provided by his perplexity at the range

of human emotional responses.

• Remains of the Day — Anthony Hopkins turns in a marvelous

performance as Stevens, the head butler of an English country estate.

He exists only to serve his employer, and remains singularly focused

on his work. In one scene, he refuses to leave his post during a

luncheon, while his father passes away in the same house. In another,

he seeks out a former housekeeper (who had a romantic interest in

him), only to explore the possibility of her returning to his place of

employment. His perfect reserve and absence of emotional expression

keep him from exploring the possibilities of life and love.

• Moby Dick — the role of Captain Ahab (the whale too)

• The Odd Couple — the role of Felix, played by Tony Randall

• Gorky Park — Inspector Arkady Renko, played by William Hurt

• The Mosquito Coast — lead role played by Harrison Ford

• Mo’ Better Blues — Bleek, played by Denzel Washington

• A Christmas Carol — Scrooge, a Dickens classic

• Seven — detective played by Morgan Freeman

• The Untouchables — Kevin Costner’s portrayal

328



Obsessive patients can be difficult to interview. They usually relate

the history in a pedantic, circumstantial manner. In order for the

presenting complaint to be understood, a myriad of other details leading

up to the current situation are given. Hearing patients out usually will

bring them back to the issue at hand, but this can take considerable

time. Trying to narrow the focus can bring about a hostile reaction, as

patients feel compelled to supply all possible information. Additionally,

obsessive patients are very attuned to control issues, and will try to

dominate the interview.

A good deal of the history is related in a “news” as opposed to “weather”

fashion. Events are explained in a detached, objective manner devoid

of any emotional flavor. Pointing this out is a precarious technique.

Patients pride themselves on their objectivity; asking about what they

are experiencing emotionally may bring about only a blank stare. In

some situations you may need to label expectable feelings for the patient

to identify. If not, a detour such as the following may result:

Q: "What feelings did you have while speaking with your colleague?”

A: “It was my feeling that this person was incompetent. I could have

done the job in a much more efficient manner.”

In a psychotherapy assessment, it may be appropriate to go back

over this statement and explain that this was a thought, not a feeling.

In other settings, doing this risks that the majority of the affect

expressed will just be anger directed back at the interviewer.

It can be difficult to develop rapport with obsessive patients. Showing

empathy for their suffering means that they have not solved their

problems. It may be more productive to attempt to understand their

“dilemma.” Try to use patients’ exact words when rephrasing and

reflecting, or semantics may become the focus. Wait until the issues

are clear before summarizing, as patients tolerate interruptions poorly.

Obsessive Themes

• “Misses the forest for the trees”

• Humorless; lacks spontaneity

• Sees prime goal as the accomplishment of work

• Emotional constriction

• Cerebral rigidity and inflexibility

• Indecisiveness

• Hoards money, objects, etc.

• Fixated on details

• Few leisure activities; can’t relax

329


Etiology

Biological: There is little information available describing possible

genetic links or physiologic findings in OCPD. No less a proponent

than Freud, however, thought that obsessive individuals had a “rectal

hypersensitivity.” Research studies have not found a genetic link between

OCD and OCPD.

Psychosocial: The classic etiology of OCPD is a difficulty arising

during the anal stage of psychosexual development (roughly ages one

to three). As children approach the age of two, toilet training becomes

a major focus of the interaction with parents. Here, the “production”

part of a natural process is treated as something unpleasant by parents.

Children that are indoctrinated into toilet training too early (before the

rectal sphincter is physiologically mature), or too harshly, end up in a

power struggle with caregivers.

This is often the first intrusion of socialization into the infant’s otherwise

unrestrained existence. Achieving continence involves submitting to

parental expectations on demand, and being judged on the outcome.

When children fail at the task, overambitious or demanding parents

evoke feelings of being bad and dirty. Issues of cleanliness, timeliness,

stubbornness and control can reasonably be seen as linked to this

stage of development. Failing to produce on schedule, with an

immediate perception of disappointment, arouses feelings of anger

and aggression. The ego recruits defenses to dissipate the strong affects

generated by their parents’ censure.

Erikson’s autonomy vs. shame and doubt stage overlaps Freud’s

anal stage. Here, in order to gain parental acceptance and avoid

disapproval, children may feel the need to renounce their autonomy.

In doing so, they focus on the specifics of what pleases their parents.

Parents who are cold, distant or obsessive themselves may give the

impression that nurturance is contingent on good behavior.

OCPD appears to be more common in the oldest child in a family,

who may have had more responsibility than the younger ones. Lastly,

cultural influences are etiologically significant. North American society,

in particular, rewards independence, hard work, orderliness and

punctuality. Particularly in men, the suppression of emotions and typical

attitudes of “deal with it” and “just do it” reinforce that an obsessive

style leads to success.

330


Epidemiology

The prevalence of OCPD is estimated to be 1 % ofthe general population,

with a slightly higher figure for patient populations. There is a gender

difference, with men being diagnosed at least twice as often as women.

This disorder is also found more frequently within professions requiring

meticulous attention to detail and strict dedication to duty.

Ego Defenses

The ego defenses in OCPD block expression of unfulfilled dependency

wishes and strong feelings of anger directed at caregivers.

• Isolation (of affect) separates or strips an idea from its accompanying

feeling or affect. This is the predominant defense contributing to the

obsessive component. An idea is made conscious, but the feelings

are kept within the unconscious. When this defense is used to a lesser

degree, three others mechanisms may be used:

• Intellectualization — excessive use of abstract thinking

• Moralization — adherence to morality to isolate contradictory feelings

• Rationalization — “rational” justification of unacceptable attitudes

• Undoing involves an action, either verbalization or behavior, that

symbolically repents or make amends for conflicts, stresses or

unacceptable wishes. This is the predominant defense contributing to

the compulsive component.

• Reaction Formation transforms an impulse into the diametrically

opposite thought, feeling or behavior. This is frequently seen as a

counterdependent attitude in which obsessive patients eradicate

dependency on anyone. Similarly, maintenance of a calm exterior

guards against an awareness of angry feelings. For example,

orderliness is a reaction formation against the desire to play with feces

or to make a mess.

• Displacement redirects feelings from a conflict or stressor onto a

symbolically related, but less threatening, person or object. “Kicking

the dog” or “shooting the messenger” are examples of this defense.

In OCPD, anger or aggression towards parents is unconsciously

forbidden, so substitutes (human, canine and otherwise) are targeted

for these feelings. This is also the predominant defense involved in

the formation of a phobia.

331



A pervasive pattern of preoccupation with orderliness, perfectionism,

and mental and interpersonal control, at the expense of flexibility,

openness, and efficiency, beginning by early adulthood and present

in a variety of contexts, as indicated by four (or more) of the following:

(1) is preoccupied with details, rules, lists, order, organization, or

schedules to the extent that the major point of the activity is lost

(2) shows perfectionism that interferes with task completion (e.g., is

unable to complete a project because his or her own overly strict

standards are not met)

(3) is excessively devoted to work and productivity to the exclusion of

leisure activities and friendships (not accounted for by obvious

economic necessity)

(4) is overconscientious, scrupulous, and inflexible about matters of

morality, ethics, or values (not accounted for by cultural or religious

identification)

(5) is unable to discard worn-out or worthless objects even when they

have no sentimental value

(6) is reluctant to delegate tasks or to work with others unless they

submit to his or her way of doing things

(7) adopts a miserly spending style toward both self and others; money

is viewed as something to be hoarded for future catastrophes

(8) shows rigidity and stubbornness




Features of OCPD, particularly frugality, concern with perfection, and

a stilted personality, overlap with those of other personality disorders.

Affective constriction also can be seen in a major depressive episode.

Feelings of guilt can also impel patients to try and undo a perceived

wrong. The heightened productivity of hypomania can overlap with the

drivenness seen in OCPD. However, other features of a mood disorder

are conspicuously lacking in OCPD, as obsessive patients strive to

suppress variations in mood and affect (although later in life, obsessive

patients are prone to depression).

Some general medical conditions (especially epilepsy) cause

personality changes that resemble OCPD. Substance-induced

disorders must always be considered in the differential diagnosis.

332

OCD versus OCPD


Despite the similarity in names, these are phenomenologically distinct

conditions. Key features to distinguish between the two are:

Feature

Central

Concept

OCD

Recurrent, intrusive

thoughts and/or

behaviors/mental acts

OCPD

Enduring preoccupation

with perfection, orderliness

and interpersonal control

Subjective

Experience

Egodystonic;

recognize irrationality

of mental events and

behaviors

Egosyntonic until close

relationships are affected

or defenses break down

Impact on

Daily Routine

Mentation

Time consuming;

interferes with

ability to function

Aware of forced

nature of thoughts,

recognize them as a

product of own mind;

resists compulsions

Defend traits and methods

as being effective and

justified by productivity

Thoughts lack quality

of intrusiveness; behavior

occurs automatically, with

most processes remaining

unconscious

Manifestations Often involves themes Pervasive throughout

Anxiety Marked; anxious dread Not usually evident

Etiology

Biological

Features

Treatment

Growing evidence

for genetic factors

Abnormal CT & PET

scans; some structural

abnormalities found

SSRIs/clomipramine

used with good results

Psychosocial influences

predominate

None consistently present

Psychotherapy in various

forms

OCD and OCPD were initially formulated as one disorder, hence the

similarity in name. There are conflicting opinions about the degree to

which OCPD exists prior to the onset of OCD. Currently, there is more

evidence against this association. OCD is associated with other Cluster

C personality disorders more frequently than with OCPD.

333



Appearance:

Behavior:

Cooperation:

Affect:

Speech:

Thought

Content:

Thought

Form:

Perception:

Insight &

Judgment:

Suicide/

Homicide:

Traditional clothing; “square” or “nerdish"; prim and

proper; colors usually conservative; neatly groomed

Paucity of movement; body language not

expressive; few gestures or facial expressions

Often try to control interview; can pose difficulties

Low degree of variability; if expressed, often show

anger or indignation

Monotonous; lacks prosody and inflection

Detailed description of events; need to tell whole

story in logical sequence; lacks emotional content

No characteristic abnormality; often circumstantial,

overelaborate, or metaphorical

No characteristic abnormality; attentive to fine details

Often limited; have considerable difficulty in seeing

the value of emotions, or changing workaholic attitude

Usually not a concern; however, breakdown of

defenses with substance abuse, an Axis I disorder or

situational crisis can release feelings of rage


The central dynamic in OCPD is that of feeling like an unloved child.

This may occur in reality, due to aloof and demanding parents, or may

simply be a perception. Regardless, obsessive patients did not grow

up feeling loved or wanted by their caretakers.

While the classical etiologic construct focused on the anal stage, it is

highly likely that parents who were, or at least seemed, harsh and

controlling, would have been this way during all development stages.

Being forced to “perform” during toilet training, and submit to other

experiences, engenders feelings of anger and destructive fantasies.

Parents who are unreasonably controlling squash unacceptable

behavior, as well as the expression of anger and aggression.

Attachment to caretakers is sought, though dependency needs remain

unfulfilled. A psychodynamic understanding of OCPD involves the

defensive handling of anger and dependency needs, both of which are

consciously unacceptable to patients. As children, obsessional patients

were often praised for what they did, as opposed to who they were.

334


Behavior is then shaped in an effort to receive the reward of parental

approval. The notion of “being seen and not heard” is transmitted, with

the result that children behave like little robots. Feelings in general get

relegated to the realm of weakness, guilt, shame and being “bad.” This

leads to an overinvestment in thinking, and rational or logical approaches.

Patients are uncertain what will be accepted, since their automatic

reactions and behaviors do not seem to be suitable. This leaves a

strong sense of self-doubt, expressed later in life as ambivalence.

Obsessive patients are notoriously indecisive, ruminating continuously

to avoid making a wrong decision.

Fleeting parental approval for “proper” behavior leads to the desire

for permanent approval, by being perfect. The demands of parents

are incorporated into a punitive and harsh superego. Patients believe

that by developing into a seamless, flawless, high achiever, they finally

will be loved and accepted. This leads them to follow a series of hollow

pursuits. They are driven beyond their own interests to succeed, but

lack a genuine desire for the activity. The fuel for this fire is placation

of the superego. There is a double irony in the relentless pursuit of

these accomplishments. First, patients only get a transient increase in

esteem, since the motivation for their achievements is to please others.

Secondly, despite obsessive patients’ apparent autonomy, they actually

have little freedom from their superego, which is a persistent and harsh

critic.

Patients fear “out of control” situations and compulsively seek to

maintain control, both over themselves and others. Internally,

compulsions undo or repent for an unconscious sense of having

committed a crime (e.g. the acts parents disapprove of and the

aggressive feelings generated). Externally, obsessive patients control

their relationships, because out of their unconscious dependency

needs arises the fear that attachment to others may be tenuous. When

patients were not in control of past relationships, painful consequences

resulted.

Obsessive patients’ libidinal wishes are punished as if they were crimes

actually committed. For this reason, they may avoid situations where

they might even think about life’s baser elements. As a result, they may

be overly moralistic and lacking in imagination. Rational thought,

discipline and orderliness bolster a sense of self that has been reduced

by perpetual self-criticism.

335


Psythodynamii Therapy

One of the first challenges involved in treating OCPD is interesting the

patient in therapy. Frequently, a crisis or loss needs to occur to cause

enough emotional pain for patients to seek help. A lesser stress usually

brings about their usual coping mechanism of working harder or finding

a bigger challenge.

The principle of psychic determinism is difficult to convey. Obsessive

patients believe they are in complete control of their lives. Even the

existence of unconscious or hidden wishes conflicts with their

pragmatic approach to life. Conveying an explicit interest in helping

obsessive patients can help secure a commitment to therapy. Patients

are used to dubious acceptance by authority figures, and a warm and

accepting attitude can help develop rapport.

Occasionally, patients will seek therapy to help with a specific choice.

An “expert opinion” is sought to give concrete help with the decision,

not to explore the underlying ambivalence. If any lasting gains are to

be made, requests such as these are best not addressed directly.

Control issues become evident in early sessions. Patients may seek

to dominate by talking continuously. They may devalue early

observations and comments as being things that they already knew.

Other attempts at control may be seen in resistance to schedule

appointments, or taking lengthy time periods to settle their account.

An early difficulty involves the rambling, detailed descriptions of events

brought to therapy. While frequently articulate, obsessive patients

convey little to no feeling with their narrative accounts. This “droning

on” actually serves to keep themselves, and others, in the thick of a

smoke screen that covers feelings. This may be particularly evident

when a strong affect threatens expression. Asking patients to focus

on and describe their feelings helps tackle intellectualization. This

question may need to be repeated regularly. In some cases, patients

may need help in labeling emotional states.

There is a strong effort to become a “perfect” patient. Sessions will be

attended on time and rarely cancelled. Patients will work very hard at

bringing material they think interests the therapist. In some cases,

patients go to great lengths to show that they are getting better. It is

important to resist mechanistic explanations from patients by pointing

out the difference between intellectual insight and emotional insight.

336


A major therapeutic intervention involves getting patients to discuss

their transference reactions. Frequently, these are reported as non¬

existent. It is crucial to pay attention to the last thing patients say before

leaving, especially as they gather their belongings when the session is

“off record.” This has been referred to as an exit line and is characterized

by heightened transference feelings. The defense of reaction formation

is used to turn aggressive thoughts into ones that sound kind. Expres¬

sion of concern about their therapist’s health or wishes for a happy

vacation may indeed be the converse.

Exploring a feeling of frustration with the therapist or the therapy

becomes a stepping stone to acknowledging and expressing anger.

Over time, the goal of therapy is to modify the superego. In doing so,

patients can develop an awareness of their feelings, and integrate

them without an accompanying sense of shame.


Because the defensive structure in OCPD inhibits an awareness of

emotions, patients are not conscious of their transference reactions.

Unconsciously, they project their superego, experiencing their therapist

as a demanding and judgmental parent. While patients reenact the

role of the dutiful child, there is an undercurrent of irritability and

opposition. Frequently, this becomes obvious with exit lines and the

therapist’s vacations. Obsessive patients also project their high

expectations onto therapists, and then feel ashamed for not living up

to their standards of proper conduct.

Countertransference generally consist of two reactions. The first is

boredom with the excessive amount of intellectualized, rationalized

material. It is a common experience to feel distanced and to have

difficulty focusing on obsessional rambling. The second is a temptation

to badger or ridicule patients’ affective constriction. Feelings of

impatience can be brought about by the disparity between conscious

cooperation and unconscious opposition.


• Expect a considerable amount of intellectualized material.

• Aggressively pursue patients’ feelings (by interrupting if necessary);

encourage discussion of transference reactions.

• Clearly destructive compulsive behavior (food, sex, drugs, alcohol,

gambling) may need to be treated prior to starting psychotherapy.

337


Pharmacotherapy

OCD has received a good deal of attention in terms of research, effective

treatment interventions and public awareness. What was once thought

to be a rare disorder has been found to exist in up to 2% of the

population. It has been very satisfying for clinicians and patients alike

to see the understanding of this condition advance so rapidly.

Unfortunately, OCPD is not altered by the medications that are effective

in OCD. The neurochemical nature of the obsessions and compulsions

are quite different in these disorders. Patients with OCPD do not usually

seek medication. Receiving a prescription feels to them like a reminder

that they have a problem they couldn’t solve, which is a potent

deterrent. Obsessive patients may also be very attuned to side-effects.

They may be a “hard sell” and request to read a PDR (U.S.) or CPS

(Canada) prior to accepting medication. Should side effects impair or

give the impression of impairing productivity, patients will stop the

medication quickly.

Benzodiazepines cause disinhibition in some patients. In crisis

situations, the controls that keep anger in check may be lacking. A

combination of alcohol and benzodiazepines, while always a bad idea,

may be a particularly destructive combination in OCPD. Some

compulsive behavior can be the result of an impulse control disorder.

Usually these conditions are treated pharmacologically with

anticonvulsants, antidepressants, lithium, buspirone or propranolol.

Croup Therapy

Obsessive patients can benefit from group therapy and be valuable

additions to the group membership. Their work ethic and reliability are

qualities for other patients to model. Use of relatively mature ego

defenses provokes less of a disturbance in the group process.

Confrontation of long, detailed obsessive explanations in a “here and

now” fashion may be better tolerated in a group setting. Obsessive

patients can be encouraged to take risks and decrease indecision.

Difficulties arise in groups when obsessive patients try to “fix” problems

for others. A myriad of advice, suggestions and plans are offered when

other patients discuss their difficulties. Initially, little is offered to the

group, as OCPDs wish to be seen as perfect patients. This is not often

resolved until they are confronted by the group. In order to satisfy their

competitive urges, patients take on the role of co-therapist and try to

assume some measure of control over the group.

338


Cognitive Therapy


• “It must be perfect. I’ll have to do it myself.”

• “There is a right and wrong way to do everything.”

• “There are rules to be followed and punishments for breaking them.”

• “If I don’t control things, chaos will result.”

• “I will dwell on this decision until I make the right choice.”


The aim of cognitive therapy in OCPD is to explore the consequences

of patients’ automatic assumptions, and then alter them to facilitate a

more realistic, humane lifestyle. Selection of a goal, based on the

presenting complaint, will have greater success if it involves the patient

directly (e.g. “I’m never satisfied with my work” instead of “people

around me don’t work hard enough”). Examination of the dysfunctional

thought record reveals themes involving the cognitive errors of

dichotomous thinking, magnification, overgeneralization and “I should”

statements (Shapiro, 1965).

“I need to be perfect, • I defer tasks to avoid failing

or I am not worthy” • I should be meticulous

(central schema) • I must make the right choice

Each of these sequelae result from, and reinforce, the central schema.

Another intervention is to construct behavioral experiments to test the

validity of the cognitive distortions. A pitfall in this approach is that a

cognitive solution is offered for a cognitive problem, reinforcing

obsessive patients’ tendency to look for tidy formulas and overly

mechanistic explanations. Cognitive therapy strives to alter thinking

and behavior; psychodynamic therapies reawaken emotions and allow

them to guide thinking and behavior.


Benjamin (1993) identifies three major developmental contributions

to the etiology of OCPD (enumerated below):

1. As a child, the obsessive patient was persistently forced to behave

correctly and follow the rules. In general, his or her parents were not

warm and accepting of typical childhood behavior and instead coerced

the child to be orderly under the threat of criticism of punishment.

2. Little to no reward was given for success — avoiding punishment or

339


criticism was the best possible outcome. Attention was given only to

mistakes because success was expected and not worthy of praise.

Also, children may have been given considerable responsibility with

little to no authority (particularly for the care of younger siblings).

3. Affection, emotional expression and laughter were not common

household experiences. Patients learned to model only proper social

conduct, restraint and rational behavior.

Benjamin (1993) notes that engaging obsessive patients in therapy is

a challenge. While it is a common obsessive “theme” to defer to

authority (as in psychotherapy), this only further restricts the patient’s

access to emotional experiences. Some patients will undermine

therapy by spending longer hours at work, thereby being “unable” to

attend their appointments.

A friendly, collaborative atmosphere is a goal in therapy with OCPDs,

it will not be present initially. Benjamin (1993) indicates that couples

therapy may be a particularly useful intervention. She notes that control

issues often dominate the obsessive’s choice of a spousal partner

(with DPD, HPD and PPD being the most common matchups).

Difficulties in sexual relations due to control issues are common in the

relationships of obsessive patients, and present another means of

engaging them in therapy.

Much of the obsessive’s perfection-seeking behavior is geared at

seeking the approval of a relentlessly critical parent (internalized as a

harsh and punitive superego). Many patients fantasize about a family

conference (confrontation) where:

• the parents will be given irrefutable proof of their child’s deficient

upbringing

• an apology will be given

• the parents will punished by the realization of the degree to which the

patient has suffered

Such an intervention is rarely warranted, and is very unlikely to achieve

the desired aim. Instead, it is more helpful for patients to come to the

realization that they do not have to be perfect in order to be happy and

successful. Change is more likely once they see the origins of their

behavior, and understand that it was previously adaptive, but is too

extreme in their present circumstances. Developing empathy for the

self as a child is a key step in acquiring this perspective.

340

Case Example


R. Lloyd Micron is a thirty-seven-year-old married man. He has done

very well in his position as a chemical engineer. He runs his department,

family and personal life with a finely-tuned sense of efficiency.

Mr. Micron comes from a long line of scientists. Rather than typical

childhood toys, he was given items that would further his intellectual

capabilities. He has fond memories of learning how to use an abacus

and slide rule before he started kindergarten. His wish for a

programmable calculator was fulfilled only after he could demonstrate

to his father, a math professor, that he could solve complex problems

without one.

He reveled in science in high school, not so much because of his

family heritage, but because it provided something for him that he

could count on as being consistent. The laws of nature and

mathematical formulas were unvarying and comforting for him. He

studied feverishly in high school but lacked his father’s talent for pure

mathematics. His decision to pursue chemical engineering was made

to spite his father. While in his last year of high school, R. Lloyd failed

to win the city-wide mathematics contest, so he chose a discipline in

which his father had little experience.

Once he graduated, R. Lloyd redesigned many chemical processes

so that they were both more efficient and less expensive. He revels in

his reputation as a “molecule counter” at work. He is respected, but

not very popular with his staff and superiors (he has no peers). Despite

an awareness of his difficult childhood, he is recreating the same harsh,

results-driven environment for his children and trainees.

Course

Obsessive patterns require considerable energy to maintain. It is

common for patients to experience a mid-life depression when they

become aware that their efforts will not achieve their unrealistic goals.

Friedman and Rosenman developed the concept of behavior patterns

known as Type A and Type B. OCPD has considerable overlap with

Type A behavior, which is a risk factor for coronary artery disease.

Obsessive patients are at risk for developing stress-related medical

conditions and, in particular, psychosomatic illnesses because of their

workaholic lifestyle.

341


References


Diagnostic and Statistical Manual of Mental Disorders, 4th Ed’n





L. S. Benjamin


The Guilford Press, New York, 1993

M. Friedman & R. H. Rosenman

Type A Behavior Pattern: Its Association with Coronary Heart

Disease

Ann. Clin. Res. 3(6): p. 300 - 312, 1971

G. Gabbard


Edition








N. McWilliams






R. Pies



D. Shapiro

Neurotic Styles


342


Rules of Order for the Malignant Obsessive-

Compulsive Personality

• Being a Type A personality isn’t good enough; strive for an A+.

• If in doubt, think, Think, THINK it out.

• The inkblot test has no time limit. After giving your response, clean

up some of the mess.

• The more you do, and the faster you do it, the longer you live.

• If it’s worth doing, it’s worth over-doing, right now!

• The best reward for hard

work is more work.

• Encourage others to do

it by the book, your book.

• Perfection is the lowest

acceptable standard.

• You can get all the rest

you need when you’re

dead.

• The words no, choice,

and compromise are not

in your vocabulary.

• If you can’t change the

rules, change the game.

• There are others like you

in every organization —

find them!

• Burn the candle at both

ends, and in the middle!

343


Lady Macbeth Knows Dirt!

Having to worry about cleaning everything

from delusional blood stains to Arabian perfume,

Lady M certainly had her hands full! We obtained

her famous Dunsinane Castle formula and are

now pleased to bring

you our new household cleaner,

Out Damned Spot!, in honor of her ladyship.

Now available in tapulets.

344


Review Questions

1. Which of the following traits are consistent with the DSM-IV

description of OCPD?

a. expresses pervasive doubt and acts in an overly cautious manner

b. excessive pedantry and moral inflexibility

c. unreasonable difficulties in allowing others to perform tasks because

the task won’t be carried out correctly

d. limited expression of affection

e. does not give time or money to others when there is no perceived

benefit for them

f. repeated checking actions, such as locks on doors or the controls

on a stove

2. Match up the following impulse-control disorders to the players in

the following illustration:

a. kleptomania

b. pathological gambling

c. trichotillomania

d. pyromania

e. intermittent explosive disorder

345



Options a, b and c are from the ICD-10 description of the anankastic

personality disorder.

Options d and e are from the DSM-lll-R description of OCPD. These

criteria were deleted from the DSM-IV but are still valid observations

about obsessive patients.

Option f is more characteristic of the obsessive-compulsive disorder.

While repetitive actions are seen in OCPD, they are typically more

productive and not based on recurrent, unwanted, intrusive thoughts.

2. From left to right (descriptions are abbreviated from the DSM-IV)

• pathological gambling — the inability to stop gambling when it becomes

a financial or personal liability

• kleptomania — repeated theft of items that are not of necessity or

taken for their value

• pyromania — purposeful firesetting that is not for monetary gain

• trichotillomania — repeated pulling out of one’s hair

• intermittent explosive disorder — repeated episodes of aggressive

activity where assault is committed or property destroyed

References


Pocket Guide to the ICD-10 Classification of Mental & Behavioural

Disorders






Diagnostic and Statistical Manual of Mental Disorders, Third Edition

Revised

American Psychiatric Association, Washington, D C., 1987

346


The Negativistic

(Passive-Aggressive)

Personality

347



Name:

Occupation:

Appearance:


Favorite Song:

Motto:

Maxine Sass

Somewhere in government

Wears black and white together

Makes dog carry its food home

By the Time I Get There, You Won’t

Need Me Anymore

I’ll teach you to teach me


Before Session:


During Session:

Fantasies Involve:



Brings to Session:

Arrives late, blames Obsessive for

changing therapist’s watch

Tears out interesting articles

Repeatedly interrupts therapist

Being gruntled

Forgets insurance card # every week

Acts out the showdown between Miss

Manners and the Terminator

Weekly notice of termination


"NOT A COPER"

Negative reaction when asked to do something unpleasant

Overestimates the demands of tasks

Tardiness — deliberate slowness when doing something unpleasant

Authority figures are ridiculed (without justification)

Criticism (constructive) is resented

Obstructs the efforts of others

Procrastinates

Evaluation of performance is unrealistically positive

Recall for obligations is faulty (forgets)

348

The Negativistu Personality

Introduttion

The essential feature of the negativistic (passive-aggressive) personality

disorder is resistance to external demands, often with pessimism and

moodiness. Some key names associated with developing the concept

of this disorder are:

• Kraepelin (1913) and Bleuler (1924) — described character types

who displayed negative attitudes, and were easily frustrated and

irritated

• U.S. Military Psychiatrists (W.W. II) — developed the term passiveaggressive

to describe an “immaturity reaction” to military stress

• Reich (1945) — described a character type who complained

continuously and exhibited a low tolerance for unpleasant situations

• Spitzer (1977) — considered this a “state” rather than “trait” condition

• Millon (1981) — made several revisions to DSM-lll-R criteria

The passive-aggressive personality disorder (PAPD) was first included

as a separate category in DSM-II. The criteria were refined up to the

DSM-lll-R, but the diagnosis was excluded from the DSM-IV. It is now

referred to as the negativistic personality disorder (NegPD) in

Appendix B, “Criteria Sets and Axes Provided for Further Study.” Prior

to this, PAPD was included in Cluster C.

There were two main difficulties surrounding inclusion of PAPD as a

separate diagnosis. First was the “situational reactivity” aspect, in that

passive-aggressive behavior was seen only under certain

circumstances, and was not as pervasive as the behavior in other

personality disorders. Second, the disorder was organized around the

single theme of resistance to external demands.

Media Examples

Negativistic characters are frequently cast as deceptively bumbling

anti-heroes bent on revenge or destruction. Common examples are

seen in institutions where people do not have a choice about being

there, such as army conscripts. Another common portrayal involves a

spouse forced to live with an ultimatum. Examples can be seen in:

• Columbo (T.V. detective show, 1971-77) — had the guilty party

practically begging to be arrested by wearing him or her down

• Gandhi (1982 movie) — the notion of “passive resistance”

• The War of the Roses — a comedy featuring some passiveaggressive

action between a couple in the midst of separating

349



Negativistic patients can be difficult to interview. In the process of

gathering information, clarification of certain historical points may

trigger resentment and evasiveness. Two areas that are particularly

fraught with danger involve asking patients to what degree they

consider themselves responsible for their difficulties, and what their

motivation was for a particular act. Trying to address the anger in their

response only brings about a higher level of hostility.

Patients seek help most frequently because they feel they have bad

luck and that others have let them down. They often seek support for

their problems, rather than an understanding of their contribution.

Exploring patients’ point of view, and expressing empathy for their

presenting complaints, helps develop rapport.

Negativistit Themes

• Procrastination

• Obstructiveness

• Indecisiveness

• Continual conflict with authority

• Constant victimization

• Says “yes” but acts “no”

• Forgets “accidentally, on purpose"

Presumed Etiology

Biological: There is no known genetic predisposition to NegPD.

Children who have mental or physical disadvantages can develop this

interpersonal style if consideration is not given to their disability.

Psychosocial: Passive-aggressive behavior may become established

as a reaction to caretakers who partially, and grudgingly, meet

dependency needs. In order to maintain attachment, children learn to

appear to be grateful for what they receive. Parents who are assertive

in providing what they think their children want can also foster such

behaviors. For example, overzealous parents who provide nutritious

but otherwise unappetizing lunches (e.g. leftovers instead of pudding

cups) may well encourage hidden hostility in their children. Openly

confronting the situation risks a withdrawal of support, so covert

behavior becomes necessary.

Early situations may involve the threat of harsh punishment, which

discourages children from accepting responsibility for their actions.

Another contributor is blocking the expression of anger, which forces

children to search for other means of dealing with this strong feeling.

350

The Negativistit Personality

Epidemiology

Passive-aggressive behavior itself is quite common, and has some

adaptive elements. Estimates of the prevalence of NegPD are 1%,

with no reported gender differences.

Ego Defenses

• Passive-Aggressive Behavior — an unconscious mechanism

whereby aggression is expressed indirectly; the resulting behaviors

(illness, procrastination, etc.) affect someone in addition to the patient.

• Hypochondriasis — hostile impulses become somatic complaints.

• Denial — Who me? Never! How dare you even make the suggestion!

• Rationalization — rational explanations are used to justify attitudes.

DSM-lll-R Diagnostic Criteria

A pervasive pattern or resistance to external demands for adequate

social and occupational performance, beginning by early adulthood

and present in a variety of contexts, as indicated by at least five of the

following:

(1) procrastinates, i.e. puts things off that need to be done so that

deadlines are not met

(2) becomes sulky, irritable, or argumentative when asked to do

something he or she does not want to do

(3) seems to work deliberately slowly or to do a bad job on tasks that

he or she really does not want to do

(4) protests, without justification, that others make unreasonable

demands on him or her

(5) avoids obligations by claiming to have “forgotten”

(6) believes that he or she is doing a much better job than others think

he or she is doing

(7) resents useful suggestions from others concerning how he or she

could be more productive

(8) obstructs the efforts of others by failing to do his or her share of the

work

(9) unreasonably criticizes or scorns people in positions of authority

Reprinted with permission from the DSM-lll-R.


351



Though patients successfully blame others, and get away with not

doing their share of work, they are at risk for developing mood

disorders, anxiety disorders and substance use disorders. The

lack of productivity and pessimism overlaps with dysthymic disorder

(DD). However, NegPD lacks the vegetative signs and hopelessness

of DD, and involves a desire to avoid taking action rather than

indecisiveness.

Anxiety is a common response when negativistic patients are forced

into a situation (e.g. military service, legal proceedings) where they

cannot get by with their usual tactics. The distinction in NegPD is that

symptoms are time-limited, have a circumscribed focus, and may be

more appropriately termed “fearfulness ” (because the cause of the

stress is known)


The MSE is usually unremarkable. At times, extreme resistance to an

interview may be seen as a thought disorder, such as thought blocking

or thought withdrawal. When provoked, patients can lash out and

appear to be have a Cluster B personality disorder. As in any interview,

inquiries about self-harm or harm to others must be made.


Negativistic patients exhibit two main conflicts. The first is a wish to

resume a dependent relationship. This is dealt with passively because

they lack the assertiveness to be direct about their needs. When these

unexpressed needs are not met (telepathy failure), patients become

frustrated and critical of those around them. The second conflict arises

when frustration is transformed into resentment. Again, in the absence

of assertiveness, resentment becomes expressed as procrastination,

revenge, sarcasm and sabotage.

NegPD is a blend of dependency and entitlement. Patients cannot

seem to remove themselves from relationships they find unsatisfying.

They live the saying, “I’d rather light a candle than curse the darkness”

in reverse. The term help-rejecting complainer is also an applicable

description. Finding an alternate route to express anger can protect

relationships deemed too tenuous for direct confrontation. Additionally,

negativistic behavior makes possible the expression of hostility and

frustration in a way that avoids having to take responsibility.

352

The Negativistic Personality


Individual insight-oriented approaches have relatively high failure and

dropout rates. Patients rarely present for help because their behavior

distresses them. They frequently look towards psychotherapy to support

their perceived disadvantaged position and coping mechanisms.

Obliging the demand for support may reinforce maladaptive behavior.

On the other hand, refusing to offer the support of therapy is likely to

be seen as a rejection. Themes of provoking anger in others come up

in the session material. When these are pointed out, patients often

respond with resentment. The frustration of dependency needs and

the suggestion of personal contribution to relationship difficulties set

the stage for an ongoing battle.

When patients evoke strong countertransference anger in therapists,

nonjudgmental exploration helps direct the search for similar behavior

in other relationships. Another technique is to make a connection with

patients’ desire to be excused from unpleasant tasks. When sufficient

rapport has developed, it will be particularly helpful to point out that not

receiving special treatment from an individual fosters resentment towards

that person.

Transferente and Countertransferente Reactions

Negativistic patients are usually unaware of their behavior. They

disavow feelings of anger and perceive only that others mistreat them.

Authority figures are treated with a mixture of both envy and contempt.

Countertransference reactions can be quite strong. Patients have an

uncanny knack for being able to hone in on weaknesses and exploit

them. Demeaning remarks, lateness and non-payment of fees are all

expectable. Denial of any awareness of the effects of these behaviors,

or the motivation behind them, is also typical.


• Expect a struggle when exploring patients’ perception of mistreatment.

• Use countertransference as information about how the patients

interact with others; identify discrete behaviors and precipitants.

• Avoid collusion with passive-aggressive behaviors, regardless of their

effectiveness or cleverness.

• If sufficient rapport exists, or all else fails, consider being completely

frank with patients about their behavior; the awareness may benefit

them, and demonstrates an overt approach to expressing conflict.

353


Croup Therapy

Group therapy is an effective modality for NegPD. The desire for

dependency and difficulty expressing anger are experiences to which

group members can relate. Problems arise when passive-aggressive

members contribute little, but sabotage or ridicule the efforts of others.

Early expression of feeling, as opposed to a reaction to the feelings of

others, is encouraged. Confrontation on a group level is a powerful

motivation for change.

Pharmatotherapy

Unfortunately, a medication to reduce negativistic behavior has not

yet been developed. Antidepressants and anxiolytics may be used.

Cognitive Therapy


• “If I don’t do what I want, someone will take advantage of me.”

• “If I get angry at someone, that person will punish me or leave me.”

• “People continually mistreat me and devalue my efforts.”

• “Nothing I do ever seems to come out right. Why bother?”

• “I shouldn’t have to do that. I deserve a break (every day)."


To get around obstructiveness, homework assignments can be given

in an “either-or” fashion. Either the assignment is completed, or the

reasoning that prevented completion is discussed. Once the patient’s

automatic thoughts are elicited, they can be constructed as hypotheses

fortesting. This helps involve patients in the process of collaborative

empiricism, and helps reduce their perception of therapists as controlling

figures. When evidence is lacking to support their cognitions, patients

are directed towards more valid explanations. Behaviors directed at

“getting even" with others are examined in a cost/benefit manner, with

an emphasis on exploring consequences.


Benjamin (1993) proposes the following features in the developmental

histories of negativistic patients:

• development initially started off quite well; nurturance was provided

and satisfied the child; in order for something to be missed, it must

have been given in the first place

• the above cozy arrangement was abruptly stopped and replaced with

354

The Negativistie Personality

demands that were excessive and did not take into account the continuing

needs of the child; at some point, most passive-aggressive patients

were unfairly treated and deprived of rewarding experiences

• expression of anger was harshly punished, resulting in the need to

seek indirect ways of expressing emotional upset; efforts at autonomy

that interfered with parental interests were also quashed.

The above environment leaves patients very sensitive to power and

control issues. Patients begin to defy their parents’ authority after initial

efforts to comply prove ineffective. Resentment develops, taking the

form of slowness, incompleteness, cynicism, procrastination and erratic

performance.

Much like borderline patients, negativistie individuals engage in

interpersonal behavior geared towards eliciting cruel, punishing or

rejecting responses from others. It takes a good deal of understanding

and restraint for the therapist to avoid being caught in this self-fulfilling

prophecy. In particular, Benjamin (1993) notes that handling of negative

transference in this disorder is a key factor in developing collaboration.

Case Example

Ms. Sass is a thirty-two-year-old married woman. She is seeking

“counseling” because it was recommended by her employer, the

vehicle licensing bureau. She was recently demoted from a supervisory

position due to complaints received from her coworkers and the public.

Ms. Sass was in charge of ordering specialized “vanity” plates for

customers. Such people, in her estimation, were needlessly wasting

money. She thought them to be rather self-absorbed and enjoyed

delaying the delivery of their plates for as long as possible. In order to

accomplish this, she developed a protocol for ordering plates that was

ridiculously detailed and asked for information that was unnecessary.

She was rather surprised by her removal from this section as she

thought the additional license plates customers had to purchase while

waiting for the personalized plates provided income for the bureau.

Course

Passive-aggressive patients generally do not lead happy existences.

They have frequent difficulties with anxiety, depression and somatic

complaints. Additionally, they have numerous and serious difficulties

in long-term, intimate relationships. Employment is another problematic

area, given the resentment directed at authority figures.

355


References


Diagnostic and Statistical Manual of Mental Disorders, Third

Edition Revised



Diagnostic and Statistical Manual of Mental Disorders, 4th Edition





L. S. Benjamin



G. Gabbard


Edition








N. McWilliams






R. Pies



356


The Fractionated Personality Disorder*

Morton Rapp, M.D.

The Multiple Personality Disorder (MPD), a malady in which “the

essential feature ... is the existence within the person of two or more

distinct personalities or personality states,”1 has gained much popu¬

larity in usage among members of the clinical community. This rela¬

tively new diagnostic entity has only been in vogue during the second

half of this century. It remained rare until the 1950’s, when scientific

advances in the area were bolstered by two critical discoveries: (1)

there’s a sucker born every minute, and (2) books describing MPD

were ultimately highly lucrative for the authors.

Controversy has always surrounded MPD as a diagnosis. Its support¬

ers claim that many patients who were subjected to severe child abuse

early in their lives tend to evidence MPD later on, and further, that

those who would challenge the validity of this may themselves suffer

from MPD. The author feels that this diagnosis has heuristic value

and presents here a related and ancillary disorder — the Fractionated

Personality Disorder (FPD).

Rationale:

In mathematics, every number has a reciprocal; for example, the

reciprocal of 2 is 1/2. It follows logically that if individuals exist who

have more than one personality, then there must be others with only a

fraction of a personality in order that the fundamental equilibrium of

the universe be maintained.

Empirical Base:

No studies have been performed to test the hypothesis of FPD. It was

felt that the intrusion of coarse methods such as standardized inter¬

views, or the intervention of psychiatric epidemiologists, would cheapen

the area of study — and ruin the author’s chances of success in

launching his forthcoming book(s) on this exciting new diagnostic entity.

Etiology:

The specter of child abuse underlies much of the FPD, as illustrated

in the following case:

M R., a 16-year-old teenager of Yuppie background, had been enjoying a successful

career as a malingerer until his 16th birthday. On that date, his father refused to buy

him a Jaguar Sovereign, stating that the family's second car, a 5.0 liter Mustang, would

have to do. The patient had a history of abuse at the hands of his father, namely being

forced to study and refrain from using LSD. M.R., upon hearing the Jaguar was a no

go, immediately stopped speaking and became a “1/3'' personality, characterized by

sleeping 14 hours per day and attending school one day out of three.

357


Clinical Features:

Despite a lack of systematic study, workers in the field of FPD have

identified a number of characteristic epidemiological features:

1. It afflicts all sexes.

2. It is more common in right-handed people.

3. In South-East Asia, it is more common in Asians, whereas in

Europe, it is more common in whites.

4. Its highest incidence is between ages two to ninety-four.

5. It is surprisingly common among people who are in need of a clinical

diagnosis to excuse some otherwise maladaptive behavior.

6. It has a high incidence among certain occupational groups (e.g.

hospital administrators). However, it is conspicuously absent in law¬

yers, suggesting that these professionals may have no personality

whatsoever.

Quantitative Ecology:

The diagnosis of FPD lends itself to easy quantification. For example:

p(FPD) = N + B<L/°)

where:

• p(FPD) is the probability of a clinical case suffering from FPD

• N is the number of current believers in the diagnostic entity

• B is the number of financially successful books on the topic to date

• L is the lurid nature of the FPD patient’s history, in luridity units

• D is the number of detractors of the diagnostic entity (IQ > 90)

One fruitful avenue for investigation might be to determine the smallest

fraction of a personality to be found in an individual (e.g. from a

clinician’s perspective, a one-eighth personality would be four times

more interesting than a one-half personality). As yet, there is no

evidence to support the existence of an Exponential Personality (where

the personality would be represented mathematically by two to the n,h

degree), or even a square root personality.

The author has described the presence of a diagnostic entity that

supplements the Multiple Personality Disorder — the Fractionated

Personality Disorder. The manuscripts for six books have already been

completed and copyrighted by the author. A major motion picture

loosely based on one of these volumes is slated for release next

summer at a theatre near you. Diane Keaton will star.

1 American Psychiatric Association, 1987, Diagnostic and Statistical

Manual of Mental Disorders, Third Edition Revised, Washington, D.C.

• © 1990 by Wry-Bred Press, Inc. Reprinted from the Journal ofPolymorphous

Perversity by permission of the copyright holder.

358

The Negativistu Personality

Review Questions

1. Which of the following behaviors is/are characteristic of negativistic/

passive-aggressive personality-disordered patients?

a. stubbornness

b. dawdling

c. inefficiency even when it is in the person’s best interests to be more

effective

d. easily frustrated and angry

e. marked ambivalence

2. Which of the following statements is most likely to be helpful in

therapy with negativistic patients?

a. “People really seem to be giving you a hard time.”

b. “Don’t you think you are exaggerating things a bit?”

c. “If you had taken your supervisor’s advice, things would have been

fine.”

d. “There appears to be a pattern developing here — everytime you

make a request to change your appointment that I cannot accommodate,

you miss the session anyway.”

359



1. Options a, b, and c are from the DSM-III description of the Passive-

Aggressive Personality Disorder, which was far less detailed that that

in the DSM-lll-R.

Option d is a feature suggested for inclusion in the DSM criteria by

Millon and is a particularly valid criterion for negativistic patients.

Option e is consistent with NegPD, but is also a key feature in other

personality disorders (e.g. OCPD, BPD) and is thus less specific.

2.

a. While this sounds like an empathic statement, but in NegPD, it only

reinforces a distorted perception of the requests made by others.

b. This is quite likely an accurate statement, it is too critical and will

most likely be perceived as blame by patients. Rather than helping

patients learn about themselves, statements like this will result in a

termination of therapy.

c. Giving advice to patients, even if comprising helpful suggestions,

rarely makes a difference. Being the arbiter of reality is not helpful with

nagativistic patients because of their potent difficulties with authority.

They do not generally receive the pleasure from sabotage that is more

characteristic of masochistic personalities.

d. Of the statements listed here, this is the most likely to be helpful. It

makes use of the negative transference between patient and therapist

in a “here and now” fashion. Searching for patterns in the behavior or

material from patients is a critical part of therapy. Making this

intervention an observation instead of a judgment makes collaboration

possible.

References


Diagnostic and Statistical Manual of Mental Disorders, Third Edition

Revised


L. S. Benjamin






360

Other Personality Topits


• Multiple PersonalityDisorder

• Masochistic and Sadistic Personalities

• The "Organic" Personality

• The Inadequate Personality

• The Asthenic Personality

• The Cyclothymic Personality

• The Explosive Personality

361


Multiple Personality Disorder

(Dissotiative Identity Disorder)

362

Dissociative Identity Disorder

Introduttion

Multiple personality disorder (MPD) was renamed the Dissociative

identity disorder (DID) in the DSM-IV. The essential feature is the co¬

existence of two or more distinct identities or personalities that take

control of an individual and cause deficits in the recall of information.

Some key names historically associated with this disorder are:

• Morton Prince (1906) — wrote an account of a patient with several

personalities called “The Dissociation of a Personality.”

• Eugene Azam (France, 1850’s) — described the symptoms of multiple

personality disorder in a patient named Felida X.

• Pierre Janet (France, 1880’s) — conceptualized and investigated

the process of dissociation.

• Freud and Breuer (1883-85) — proposed a model of mental

functioning in which traumatic memories were kept out of conscious

awareness by repression, as seen in their famous case, Anna O.

MPD is not considered a disorder of personality, but is included for its

heuristic value. It is categorized as a Dissociative Disorder and has

historically been classified under hysterical neuroses, dissociative

type. Renaming this condition re-emphasizes the psychological process

producing the different identities (dissociation), rather than the

observable manifestations (multiple personalities). The term implies that

a single person manifests different internal and external experiences of

the self.

DID is a fascinating condition, in which the varying identities or alters

can be sufficiently well-defined to be considered separate

“personalities.” The alters can have distinct names, sexual identities,

sexual orientation, voices, facility with foreign languages, handedness

and handwriting. Amazingly, each can have distinct illnesses, EEGs,

eyeglass prescriptions and even allergies!

The usual arrangement involves a dominant personality that is aware

of all of the fragments, though this is not always the personality that

seeks treatment. Alters appear to be variably aware of one another.

The total number of personalities has been reported to exceed fifty,

with the average being in the range of ten to twelve. Frequently, the

personalities have some connection with one another. For example,

all of the persons involved in a traumatic episode (victim, perpetrator,

witness, etc.) can be embodied by different personalities. Also,

dichotomous personalities (e.g. a good/evil pairing) are often present.

363


Media Examples

Multiple personality themes have often involved the duality of human

nature. A classic example is Robert Louis Stevenson’s Dr. Jekyll and

Mr. Hyde, which has been made into several movie versions. Many

other movies and books have been constructed around this theme.

Movie versions have been made from real cases, in particular:

• The Three Faces of Eve — a book by Drs. Thigpen and Cleckley

(the same Cleckley featured in the Antisocial Personality Chapter).

Interestingly, a book by Morton Prince’s recorded the case of a Miss

Beauchamp, whose three personalities were referred to as “the Saint,

the Devil, and the Woman.” These are the same three manifestations

of the character played by Joanne Woodward, who won an Academy

Award for her performance in the movie version of this book.

• Sybil — Sally Field won an Emmy for her portrayal of the character

from Flora Rheta Schreiber’s book. As an interesting aside, Joanne

Woodward plays the psychiatrist in this film.

Etiology

Biological:

• epilepsy or head injuries are present in up to a quarter of patients

• evoked potentials show clear characteristics for each personality

• non-dominant temporal lobe dysfunction may be present

• mood symptoms are often present in the host personality

• a genetic component may contribute to higher familial incidence

Psychosocial:

• frequent history of imaginary companions as children

• in almost all cases, severe psychological, physical, or sexual abuse,

or some other traumatic event occurred

• absence of support from significant others is thought to contribute to

the extensive use of dissociation to cope with trauma


Axis I:

• schizophrenia

• other dissociative disorders

• posttraumatic stress disorder

• mood disorders (e.g. bipolar — rapid cycling or psychotic features)

• substance use disorders (especially hallucinogens)

Axis II:

• borderline personality disorder

364


Axis Ill/Other

• brain tumors

• balingering/factitious disorder

• epilepsy, especially temporal lobe/partial complex seizures

The Dissotiative Self

Childhood sexual abuse, and in particular ritual or cult abuse, is the

most common etiologic factor in DID. The child, however, has a

constitutional predisposition to use dissociation as a defense, as

several other reactions could have occurred (e.g. repression, denial,

acting out, identification with the aggressor, etc.). McWilliams (1994)

notes that individuals who have a rich fantasy life, a penchant for

imaginative play, and a talent for creativity are more likely to dissociate

under the overwhelming stress of trauma or abuse. Ross (1989)

hypothesizes a cognitive map as follows:

the primary personality can’t handle the memories

the primary personality is responsible for the abuse

4*

it is wrong to be angry about the abuse

different parts of the self become separate selves

it a

• I never feel angry; she is the • I must be bad; this wouldn’t

bad one have happened otherwise

• She deserves to be punished

for being angry

• I

love my parents; she hates

them

Comment on MPD/DID

• I deserve to be punished for

being angry

• I can’t trust myself or anyone

else

The apparent prevalence of this disorder has increased dramatically

in recent years. This may well be due to an increased awareness and

sensitivity to dissociative states on the part of therapists. It is at times

very difficult to distinguish between the defenses of splitting and

dissociation, which lead to different diagnostic impressions.

On the other hand, this epidemic has sparked considerable

controversy, as well as evidence of improperly made diagnoses

(Merskey, 1992). The diagnosis of MPD may well carry a reduced

expectation for taking responsibility for one’s actions, making this

condition attractive to impulsive characters and malingerers.

365


Masothistit (Self-Defeating)

& Sadistic Personalities

The Masothistit (Self-Defeating) Personality

The term masochism is derived from the writings of Leopold von Sacher

Masoch (1836-1895). He was an Austrian novelist whose works

contained characters who derived sexual pleasure from being hurt,

abused, or humiliated. When the term is used in a sexual context, it is

called erotogenic or primary masochism. Freud used the term moral

masochism to refer to behavior that was self-damaging, which is the

focus of most psychiatric literature. Masochistic patients are notable

for repeating self-damaging relationships (repetition-compulsion).

Many other writers have described this type of personality, including

Krafft-Ebing (1882/1937), Reich (1933), and Kernberg (1988).

366

Masochistic & Sadistic Personalities

The DSM-lll-R included a self-defeating personality disorder in an

appendix as a disorder requiring further study. It was not validated as a

discrete personality disorder and was dropped from the DSM-IV.

Masochistic behavior itself is common and not necessarily pathological.

Suffering for some greater gain, or for the benefit of others, has a lot in

common with the ego defense of altruism, or more specifically,

altruistic surrender. Self-defeating behavior is manifested as being

accident-prone, self-injurious, martyr-like and self-righteous. Masochism

may develop as a strategy to secure or prolong attachment. Being

punished or teased may have been the only emotional connection a

child had with caregivers. A common cognition in this disorder is that

“an abusive relationship is better than no relationship at all.” Masochistic

behavior can be conceived as a blend of depressive and paranoid

behavior. While patients may feel worthless, they retain the hope that

this quality will bring sympathy and care from others. They share the

same perception of threat as paranoid patients, but instead, attack

themselves to ward off an attempt by others to do so.

The Sadistit Personality

The term sadism is named after the French writer Marquis de Sade

(1740-1814). It was initially used to refer to people who derived erotic

pleasure from inflicting cruelty on others. In a more generalized sense,

sadistic behavior involves the enjoyment of inflicting physical violence,

pain, humiliation and harsh discipline on others. Frequently, sadistic

patients were brutalized as children. This disorder is thought to result

from an amalgamation of sexual and aggressive drives.

The sadistic personality disorder also appeared in an appendix of

the DSM-lll-R, but was similarly not included in the DSM-IV. Sadistic

behavior is a large component of the observed behavior in antisocial

personalities, and to a lesser extent, passive-aggressive

personalities. Sexual sadism is diagnosed as a paraphilia, a type of

sexual disorder. Descriptions of a sadomasochistic personality

disorder exist, reflecting the coexistence of both elements in patients.

This is in keeping with the observation that most intrapsychic states

exist with their opposite. Examples of sadomasochism can be seen in

many plays, novels and movies.

Treatment involves psychotherapy, where patients can become aware

of their aggressive impulses and fear of/need for punishment.

367


The "Organit" Personality/

Personality Change Due to a General

Medital Condition

“Organic Personality Disorder” is an antiquated but still common term

used to denote a character change due to an identifiable illness or

incident. In a neurologic sense, the brain is often the passive victim of

disease processes occurring in other organs. Adding to this sympathetic

view is the sad reality that neurons in the central nervous system (brain

and spinal cord) do not regenerate themselves after an injury. The

most common conditions causing personality changes are:

Mnemonic — “PAST mfMf"

Poisoning (especially heavy metals)

AIDS/Neurosyphilis

Stroke (Cerebrovascular Disorders)

Tumors

Trauma

Huntington’s Disease

Epilepsy

Multiple Sclerosis

Endocrine Disorders

368

The "OrganU" Personality

Some cerebral insults affect many cognitive processes (intelligence,

memory, coordination, etc.). Other lesions affect personality almost

exclusively, with preservation of most other cerebral functions. Most

cases of this latter phenomenon involve the frontal lobes of the brain, a

condition known as the frontal lobe syndrome. Lishman (1998) lists

the most common characterological changes as: reduced volition and

social awareness, reduced tact and restraint, mildly euphoric mood,

irritable outbursts and impaired judgment. Overall, there is a coarsening

of personality features and an accentuation of preexisting traits.

Changes range from subtle to marked. In the majority of cases, patients

are unaware of their alteration in personality. While damage to specific

parts of the frontal lobes appears to cause particular findings, injury to

both frontal lobes (usually due to trauma) is particularly worrisome.

Parker (1996) identifies a condition known as the cerebral personality

disorder involving changes in mood, motivation and affective

expression following brain trauma. This term indicates that certain

brain centers (e.g. limbic system, prefrontal cortex) may be even more

responsible for personality changes than the frontal lobes. A fuller

description of personality changes due to brain insults is as follows:

• disturbance in emotional control

• impulsivity

• uncertain identity

• reduced confidence/self-esteem

• substance abuse

• inability to learn from experience

• reduced motivation

• social withdrawal

• angry outbursts

• diminished insight

• somatization

• insecurity/paranoia

Personality changes due to frontal lobe injury can be difficult to

diagnose because damage is usually diffuse and will not be visualized

on neuroimaging. Also, there are no incontrovertible neuropsychological

measurements of frontal lobe dysfunction. Lastly, other formal tests

of cognitive abilities can remain unaffected by insults that affect

personality. Lishman (1998) notes than on occasion, there have been

improvements in personality function following mild to moderate head

injury, namely reduced anxiety and increased sociability.

A number of Axis I disorders can arise due to head injuries:

posttraumatic stress disorder, obsessive-compulsive disorder,

phobic disorders, mood disorders, psychotic disorders,

somatoform disorders and dissociative disorders. There is also an

appreciable risk of suicide following head injuries.

369


The Inadequate Personality

The inadequate personality disorder (IPD) was included in the DSM-I

and DSM-II. The hallmark of this disorder is an ineffectual response to

day-to-day demands and the expectations of others. While patients

are aware of their shortcomings, they have neither the desire nor the

resources to change. They see their low level of achievement as part

of their nature, and in this sense, IPD is egosyntonic.

Other characteristics include:

• poor social judgment and adjustment

• low level of occupational performance and frequent job changes

• lack of stamina (physical, mental and emotional)

• low level of adaptation to societal demands

• poor ability to plan for the future

This description of this personality has an overlap with the criteria for

dependent, avoidant and schizoid personality disorders.

370


The Asthenic Personality

The asthenic personality disorder appeared only in the DSM-II. The

word asthenia derives from the Greek word for “weakness”. This term

is still used to describe someone of slight build or body structure.

The main features of this personality are:

• lassitude, lethargy, lack of will (abulia)

• lack of enthusiasm and the capacity for enjoyment (anhedonia)

• inability to withstand average/expectable stresses

This description shares considerable overlap with the features of

depression and the negative symptoms of schizophrenia.This

disorder was thought to have a constitutional origin. A more acute

“neurasthenic neurosis” has been described, which may now be

considered an adjustment disorder. An example of this personality

type can be seen in the H. T. Webster character called Caspar

Milquetoast, from the comic strip called The Timid Soul. The word

“milquetoast” refers to one who is easily dominated or intimidated.

371


The Cytlothymir Personality

The cyclothymic personality disorder (CPD) was included in the DSM-

I and DSM-II. The hallmark of this disorder was a fluctuation in mood

that occurred on a regular basis and was serious enough to affect the

person’s ability to function in social or occupational roles. In the DSM-

III, this condition became the cyclothymic disorder, a type of affective

disorder. In the DSM-IV, it is still listed under this name; however, the

category it belongs to is now called mood disorders.

The disorder resembles bipolar mood disorder except that the mood

symptoms in CPD occur with on a smaller scale. The “highs” are

hypomanic (not manic) in degree, and the “lows” do not meet the

criteria for a major depressive episode.

372


The Explosive Personality

The Explosive Personality Disorder appeared only in the DSM-II, though

the DSM-I had a category called the “emotionally unstable personality.”

This has also been referred to as the epileptoid personality disorder.

This diagnosis was given to patients who had volatile emotional responses

to minor upsets. When incited, patients raged with verbal barrages and

physical destructiveness.

This disorder was reclassified in the DSM-III as the intermittent

explosive disorder. In the DSM-IV, it is classified under the same

name as an impulse-control disorder. The DSM-IV criteria emphasize

occurrence of physical assault or destruction of property. This disorder

was changed to an Axis I condition because the loss of control was not

typical behavior for patients. Additionally, it is egodystonic. However,

the inter-episode personality characteristics have been variably

described. Some patients are well-adjusted, pleasant and calm.

Aberrations are only seen upon provocation over seemingly minor

events. Other patients appear to have aggressive, defiant and caustic

personality features that are present between explosive episodes. These

patients may be better considered as having either an antisocial or

narcissistic personality disorder in addition to the diagnosis of

intermittent explosive disorder.

373


Referentes



Fourth Edition




Third Edition Revised




Third Edition




Second Edition



Diagnostic and Statistical Manual of Mental Disorders





A. Freedman, H. Kaplan & B. Sadock, Editors

Comprehensive Textbook of Psychiatry, Second Edition



Comprehensive Textbook of Psychiatry, Fifth Edition



Synopsis of Psychotherapy, Eighth Edition


374


O. Kernberg

Clinical Dimensions of Mashochism

Journal ofthe American Psychoanalytic Association 36: p. 1005 -1029,

1988

R. Krafft-Ebing

Psychopathia sexualis

Physicians & Surgeons Books, New York, 1882/1937

W. A. Lishman

Organic Psychiatry: The Psychological Consequences of Cerebral

Disorder, Third Edition

Blackwell Science, London, England, 1998

N. McWilliams



H. Merskey

The Manufacture of Personalities: The Production of MPD

British Journal of Psychiatry 160: p. 327, 1992

R. S. Parker

The Spectrum of Emotional Distress and Personality Changes

After Minor Head Injury Incurred in a Motor Vehicle Accident

Brain Injury 10(4): p. 287 - 302, 1996

R. Pies



W. Reich

Character Analysis

Farrar, Strauss & Giroux, New York, 1933

C. A. Ross

Multiple Personality Disorder: Diagnosis, Clinical Features &

Treatment


375


Newhart Was Never Like This

The ideal group may well be composed of one of each of the DSM-IV

personality disorders. The following script shows typical, but hypothetical,

interactions between the different character types.

Narcissist: Before I begin talking about myself, would anyone here

like to say anything about me?

Obsessive: Nice try, but I

have to call the session to order first.

Passive-Aggressive: This is a group session, not a board meeting,

dufus.

Obsessive: What about circulating the minutes from last week’s

meeting? I have an indexed, collated and cross-referenced copy for

everyone right here.

Schizotypal: You’re such a yin force. Try some yang foods tonight.

I’ll make a list for you.

Therapist: We were all here. We’re well acquainted with what went

on.

Passive-Aggressive: That’s quite an alliteration!

Obsessive: Well, I still have my agenda to deal with (opens daytimer).

I’ve been reading a book called Thinking About Feelings.

Avoidant: Gee, that sounds really interesting. I wonder if it’s available

through my book club? I could use my bonus points to get us all a

copy, that is, if it’s OK with everybody.

Antisocial: (leaning towards Avoidant) I thought that, ahem, you know,

you promised those bonus points to me in exchange for. . .

Therapist: It seems that we’re forgetting the policy about contact

outside the group. What’s going on?

Antisocial: (glaring at Avoidant) My time and talent are worth money!

Besides, she needed a date for the Correspondence Course Reunion.

376


Passive-Aggressive: Liberte, Egalite, mais pas de Fraternite, mes

enfants.

Schizotypal: I’m sensing some bad karma right now. . .

Borderline: You Antisocial jerk! That’s where you were! I waited up

all night. I was so mad I got a headache and starting taking some pain

killers, and then I overdosed on them. You made me do it!

Narcissist: He’s not worth it. You should look for better men (preens

and then mutters audibly). No one ever overdosed because of me.

Therapist: I thought it was clear that group rules were meant. . .

Obsessive: To be obeyed and strictly enforced.

Antisocial: To be bent, and if need be, broken. There wouldn’t be

rules otherwise.

Schizoid: (freezes, then takes a renewed interest in shoelaces)

Uh huh.

Schizotypal: Natural laws are too complex for human understanding.

Passive-Aggressive: (shrugs) Whatever.

Borderline: For others to deal with.

Narcissist: To be open to interpretation.

Histrionic: I don’t know. I can’t remember. Can someone remind me?

A guy, maybe?

Paranoid: To watch out for.. .

or else.

Dependent: To get someone to explain them to you. I

need help.

Avoidant: Wha. . wha. . whatever you say. The thought of all those

new people just frightened me, and that Antisocial can be such a

charmer.

377


Passive-Aggressive: So tell us what else happened between you two,

or three, I guess it is now.

Histrionic: And don’t spare any details!

Therapist: We’re getting away from what Obsessive was saying.

Avoidant: I’m sorry, Obsessive. Did that make you feel.upset?

Obsessive: No, actually, I

never feel anything.

Schizotypal: Do you have a horoscope in that daytimer? What's a

non-sequitur anyway? I never took Latin, but I hear there’s voodoo in

Latin America.

Narcissist: I don’t think that’s important right now. What makes our

Obsessive and his book so special tonight? I could bring a book next

week. I’ve had a simply horrific week, and no time to air my concerns.

Schizotypal: I

sense a split in the karma right now.

Paranoid: Is that good or bad? Both, or neither? Can it be harmful?

Borderline: Men are all the same, always me, Me, ME. Well, what

about me? Guys seem so supportive at the beginning and then they

just don’t care. Women are the only truly nurturing beings. I hate all

men.

Dependent: You’re so right! I can’t remember all the times I’ve been

let down. You keep pouring yourself out and when you’re in need,

there’s nobody there. I need some support right now to talk about this.

Schizotypal: There is an abrupt positive force descending upon us

now.

Paranoid: But how long will it last? What happens next?

Borderline: I can’t believe it. .. you really and truly understand me.

Now that I think of it, you’ve always been there for me. Now that we

have each other, maybe we don’t need anyone else. (Gets up and sits

next to Dependent.)

378

Rapid Psyihler Press

Histrionic: (gushes) I’m glad you’re feeling better. I’m sooooo happy

for you. I’ll bring a card next week.

Obsessive: Shouldn’t you at least do a feasibility study first?

Paranoid: Or at least a blood test or something?

Narcissist: Why not consider other options ... I

somebody wonderful very nearby.

think you might find

Dependent: I wish I had the courage to just reach out like that.

Schizotypal: The celestial forces strongly oppose this union. The

gravitational pull exerted by a Dependent Moon can only slightly alter

the course of a Borderline Comet.

Passive-Aggressive: We all know it won’t work. What’s your opinion,

Schizoid?

Schizoid: If everyone here pairsup.I can be alone again.

Therapist: Our agreement was to talk about feelings, not live them

out!

Antisocial: Really honey, not so fast — just like you heard here. I

was planning to surprise you. The books were going to be a gift —

you know how you’ve always wanted to study Social Psychology. It’s

just that, urn, urn, what’s her name here, really gets going once you

give her a chance. I was on the way to the hospital when I met a few

old “business partners” and got side-tracked.

Avoidant: Well, it’s back to fantasizing about the personal ads for

me.

Therapist: We’ve got just a short time left. Maybe it’s time to check in

with Schizoid. What would you like to share with us today?

Schizoid:Uh.nothing.

Narcissist: What do I have to do to get some air time here? Bring a

book? Overdose? Say nothing and play with my shoelaces?

379


Paranoid: You’ve been dominating this group and my life for too long

now, Narcissist. Watch out!

Obsessive: Maybe we could make a schedule for next session. I’ll

bring my stopwatch.

Dependent: We could extend the time of the session — an eighthour

session would only leave sixteen in the day, and then there’s my

other groups...

Antisocial: Can we divide into little groups and change partners each

week?

Borderline: Sounds like you do that anyway.

Passive-Aggressive: Small things amuse small minds . . .

Histrionic: While the smaller ones take note! I read that in Cosmo.

You sure do learn a lot in those quizzes. Maybe we can all do one. I’ll

bring in some old issues next week.

Narcissist: Those quizzes are far too simple for this vapid sophisticate.

Obsessive: Sometimes I think you’re just so neurotic.

Passive-Aggressive: He sure is.

Narcissist: Well if I

am, so are you.

Therapist: Hold that thought, and we’ll start there next week.

380


Personality

Changes in

later Life

381


The elderly are becoming North America’s fastest growing age group.

Estimates for the American population indicate 12.5% were over the

age of 65 years in 1990. This group consumes over 30% of health

services. While up to 25% of this population suffers from some form of

diagnosable mental illness, they receive only about 7% of inpatient

psychiatric services and community/private practice services. Goldstein

(1991) makes the cogent point that this group is estimated to receive

half of the prescriptions written for benzodiazepines and other sedatives,

and may have less overall monitoring of their medications than younger

groups.

The study of how personality disorders change over time is certainly

an intriguing one, but an area that has received considerably less

attention than other research pursuits. Some of the reasons for this

are thought to be related to:

• difficulties in sorting out normal aged-related processes from the

evolution of a personality disorder

• the difficulty in applying Axis II diagnostic criteria to the elderly

• the continual modification of diagnostic criteria, which makes

longitudinal studies difficult; for example, a fifteen-year study initiated

in 1979 would have used DSM-II criteria to conduct protocols, which

would not correspond to the DSM-IV criteria established in 1994

• other diagnoses (e.g. depression, anxiety disorders) that have a higher

morbidity and are more pressing areas of for research

• difficulties in obtaining accurate epidemiological surveys

• the pessimism in some circles of the efficacy of treatment for elderly

personality-disordered patients

The DSM-IVDescription ofPersonality Disorders

In the DSM-IV general diagnostic criteria for a personality disorder,

criterion D states that “The pattern is stable and of long duration and its

onset can be traced back to at least adolescence or early adulthood.”

Personality disorders can be diagnosed in children or adolescents

when it appears that maladaptive traits are pervasive, persistent and

not related to a major clinical disorder or developmental stage. In order

to diagnose a personality disorder in an adolescent, symptoms meeting

the diagnostic criteria should be present for at least one year. It is

widely recognized that personality disorders are most prevalent in the

25 - 44 year age group. The apparent onset of a personality disorder

beyond this age should prompt a thorough investigation for a general

medical condition or substance use disorder.

382

Personality Changes in later Life

Difficulties in Using DSM-IV Axis II Criteria

The DSM-IV stipulates that the diagnosis of a personality disorder takes

into account an individual’s long-term pattern of functioning and that

particular personality features must be evident by early adulthood.

Unfortunately, there is no time frame given regarding the duration that

symptoms must be present for in order to constitute a diagnosis.

The DSM-IV also does not make a provision for late-onset personality

disorders, or the opposite situation involving the attenuation of Axis II

symptoms over time (i.e. past personality disorders). Loranger (1987)

has suggested that criteria should be met for a five-year time period in

order to make the diagnosis of a personality disorder.

It is crucial to assess personality symptoms in a “geriatric context.”

Abrams (1987) found a wide range of Axis II symptoms in elderly

populations, though few people met the full criteria for a particular

disorder. In particular, the elderly have different social and occupational

roles, so it becomes quite difficult to apply these “tests” in deciding if

certain behaviors warrant being called disorders.

Abrams (1990) points out the shortcomings of using dimensional (e.g.

trait) or categorical (i.e. discrete diagnoses) models in the elderly.

Because of the multifactorial changes that occur in aging, current DSM-

IV constructs may not be valid descriptions. For example, diagnoses

more applicable for the elderly might include depressive, euphoric and

hypochondriacal personality disorders.

Furthermore, the elderly do not have the same energy or opportunities

to behave in the ways outlined in the DSM-IV criteria. Promiscuity,

shoplifting, binge eating and impulse buying are less likely to be ways

in which the geriatric population would demonstrate character pathology.

Similarly, reduced energy, fewer social opportunities, repeatedly being

robbed or chronic pain would certainly influence a patient’s behavior

and could be mistaken for symptoms of a personality disorder.

McFlugh (1983) proposes that a meaningful model be constructed for

individual patients, which involves investigating symptom formation due

to situations and vulnerabilities occurring in the second half of life.

Research is also being conducted into biological markers (e.g. enzyme

levels) that can provide a standardized means of assessment.

383


Adult Psythologital Development

While physical growth (height, anyway) ends with the onset of adulthood,

emotional and psychological growth is by no means over. With time

and experience, genetic or constitutional factors have a greater chance

of being modified by environmental influences. Personality is not a

static entity, but continues to evolve in response to psychological, social

and cultural demands. Erikson outlined the three developmental tasks

of adulthood as being:

Intimacy vs. Isolation

The primary task in early adulthood is to establish and maintain an

enduring closeness to other adults (outside of the family of origin).

Intellectual and emotional maturity continue to develop, with the aim of

social integration.

Generativity vs. Self-Absorption

Generativity in this stage is usually manifested in guiding and providing

for future generations. It can be directed towards one’s children or to

society in general through various organizations.

Integrity vs. Despair

Acceptance of one’s life path is a key aspect of this stage. Integrity

involves a sense of having made a satisfying contribution. However,

there are few resources available for developing integrity and, unique

to this task, no clear goal to work towards. At this point in life, physical

capabilities are declining, illnesses become more severe, and one’s

peer groups diminish due to relocation, debilitation and death.

Developmental tasks in later life involve disengagement from established

social and occupational roles. One measure of psychological health in

elderly patients has been the acceptance of their inevitable death at

earlier ages (i.e. coming to this realization at age sixty instead of eighty).

Reactions in patients less accepting of this fate include phobias,

paranoia and sleep difficulties

Traits That Become More Pronounced With Time

• introversion

• hypochondriasis

• depression

Traits That Become Less Pronounced With Time

• impulsivity

• sociopathy

• hostility

384

Personality Changes in later Life

Personality Changes Over Time

Bienenfeld (1990) points out that one of the dominant tasks in later life

is to acknowledge one’s mortality. While the elderly do not lose their

generosity or caring for others, there is often a notable degree of self¬

concern, which can be mistaken for narcissism. At later stages in life,

many milestones have been passed and life obligations fulfilled. People

no longer have the commitments that took their time and energy earlier

in life, so they have the opportunity to focus on themselves. Richard

Gere aptly expressed this in the movie Primal Fear, when, regarding

people who save for a rainy day, he said “Well, it’s raining.” Often free

of social or career restrictions, the elderly are able to invest their money,

efforts and attention in the here and now. Additionally, a sense of

entitlement, self-importance, and a belief that one’s problems warrant

special attention are common enough that these behaviors alone do

not constitute a narcissistic personality disorder (Abrams, 1990).

Bienenfeld (1990) makes the observation that the above aspects of

narcissism, combined with a growing sense of “finitude,” contribute to

the almost universal behavior in the elderly of sharing reminiscences.

Abrams (1990) notes that emotional exaggeration and an excessively

vague and impressionistic style of speaking has been frequently noted

among elderly individuals. It is recommended that features other than

these be present before considering the diagnosis of HPD.

The high prevalence of mood symptoms in the elderly is an important

consideration in the diagnosis of a personality disorder. Differentiating

between personality traits and symptoms of depression poses a clinical

challenge. For example, dependency, feelings of helplessness,

exaggeration of somatic complaints and suicidal ideation are observed

in both elderly depressed patients and those with personality disorders.

Patients who develop depressive episodes later in life have a greater

chance of experiencing an incomplete recovery. The persistence of

mild-to-moderate depressive symptoms raises the clinical dilemma of

whether a mood disorder with prominent character pathology is present,

or a personality disorder was present initially and the patient has gone

on to develop secondary mood symptoms.

Abrams (1990) notes that depression in the elderly complicates the

assessment of personality traits by causing cognitive distortions,

inaccurate reporting, and modification of character traits. He suggests

that in the face of depressive symptoms, personality disorders should

be diagnosed sparingly.

385


The Longitudinal Course ofPersonality Disorders

It is important to keep in mind that each person is the product of unique

biological, social and psychological circumstances. Two patients with

the same personality disorder and the same degree of severity may

very well have taken very different paths that led to a common cluster

of behaviors. It is therefore very difficult to generalize about whether a

particular patient will exhibit the same interpersonal patterns at age

twenty, forty and sixty. Life experiences can worsen some symptoms,

improve others, or cause the emergence of new behaviors later. In

general, traits of personality-disordered patients have been found to

be stable over time. This is supported by the psychodynamic/

environmental viewpoint that personality is generally formed after a

critical period in life. The finding of long-term trait persistence supports

the genetic/constitutional viewpoint. Cluster B personality disorders

appear to change most with time because they require the greatest

amount of energy to maintain.

Personality Disorders That

Tend To Diminish With Time

•Antisocial

• Borderline

• Histrionic

• Narcissistic

• Passive-Aggressive

Personality Disorders That

Tend To Persist Over Time

• Obsessive-Compulsive

• Paranoid

• Schizoid

• Schizotypal

386

Personality Changes in Later Life

Treatment Planning for Elderly Patients

Diagnosis

Before a diagnosis can be accurately made, a number of factors need

to be considered:

• concurrent Axis I disorders need to be identified and treated before

personality pathology can be ascertained

• flexibility will need to be applied to many of the DSM-IV diagnostic

criteria in order to make them applicable to elderly patients

• collateral and longitudinal history is important to obtain

• late-onset personality disorders are a more likely diagnosis if all or

many of the symptoms are not typical behaviors for the patient

Psychotherapy

Psychotherapy with elderly patients involves less ambitious goals than

with younger patients. A lifetime of pathological relationships,

disappointments, unstable behavior, etc. is obtained from the histories

of personality-disordered patients. With a decline in energy and various

physical functions, patients do not have the same resources and outlets

available to cope with their frustrations. Somatization becomes more

common in the elderly as a means of expressing emotional upset. In

general, supportive approaches are advocated — the therapist should

focus on removing the barriers to a relationship with the patient.

387


Pharmacotherapy

Geriatric patients often receive large numbers of prescription

medications. This situation is compounded when they see several

specialists and/or do not consistently see the same general practitioner.

It is not unusual for patients to be taking between twelve and twenty

different medications. A rule of thumb is that if someone is on eight or

more medications, there is a high likelihood of a drug-drug interaction.

Iatrogenic illnesses also become more likely with a higher number of

medications.

The four main processes involved in pharmacokinetics are: absorption,

distribution, metabolism and elimination. All of these processes are

affected by age (e. g. due to reduced blood flow, slowed metabolism,

etc.). Psychiatric medications are usually highly lipophilic (absorbed

in fatty tissues). With age, the percentage of body fat increases, so

that medications have a greater volume of distribution throughout the

body. In general, dosages for elderly patients are started in the range

of one-third to one-half the usual adult amount, with increases being

made slowly. Because medication usually has a secondary or adjunctive

role in the treatment of personality disorders, particular discretion should

be exercised with elderly patients.

388


Personality and the Protess of Change

The study of personality encompasses a vast area of research and a

voluminous body of literature. The issue of which factors influence

personality, in which direction, and to what degree, has been the subject

of intense debate. Methodologically sound research findings include

widely disparate results on whether personality changes or remains

stable. Evidence abounds to support either finding, depending on what

is being measured and what specific definitions are being used.

Weinberger (1994) notes, at the end of an entire book on the topic of

personality change, that there appears to be widespread agreement

that personality remains flexible and can change until about the age of

thirty. Beyond this age, there is less of a consensus, though some

studies report that considerable change occurs throughout adulthood.

Examining this issue further, Weinberger (1994) delineates which factors

are likely to change and which are likely to remain stable. Returning to

the issue of temperament, Costa & McCrea (1990) factor analyzed five

key qualities or basic tendencies (often referred to as the big five)

that remain stable after the age of thirty (mnemonic — “canoe”):

•conscientiousness

• agreeableness

• neuroticism

• openness to experience

• extroversion

Costa & McCrea (1990) indicate that despite the relative stability of

these basic tendencies, their expression, called characteristic

adaptations, can and will change throughout adulthood. McAdams

(1994) developed the following model of personality structure:

Level 1

basic

tendencies

largely independent of environmental

influence; remain stable overtime

Level 2

characteristic

adaptations

habits, attitudes, relationships,

interests, etc.; these change with time

Level 3

existential

personality

this is how the person defines him- or

herself; this evolves constantly as the

person seeks change from within

389


Personality and the Protess of Psychotherapy

The preceding section was concerned with the stability or change seen

in personality occurring with life events and the passage of time.

Psychotherapy, of course, can be another agent of change. Eysenk

(1952) challenged the efficacy of psychotherapy, resulting in a huge

volume of work being done not only on outcome studies, but the process

of how change is effected. Starting with the work of Smith (1980), it

has been generally accepted that psychotherapy is effective and that

patients are better off receiving treatment than not. Weinberger (1994)

also sums up the considerable literature by saying that there is no type

of therapy that is clearly superior to others. Bandura (1961) and

Weinberger (1994) have attempted to delineate the factors involved in

therapeutic change:

Bandura

• counter-conditioning

• extinction

• discrimination learning

• reinforcement of desired behaviors

• punishment of undesired behaviors

• imitation of the therapist

or other role models

Weinberger

•working through the

transference

• developing a working alliance

• exposure to the sources of

interpersonal difficulty and

mastery of these situations

• attribution of improvement to

to the self rather than the

therapist

It is still a matter of debate

whether personality itself

changes or a person

learns to function more

adaptively. Either way,

evidence from the

literature, anecdotal

reports and clinical lore

report that therapy is

effective, and in many

cases depends most

strongly on the skills and

interest shown by the

therapist.

390

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Johns Hopkins University Press, Baltimore, 1980

J. L. Weinberger

Can Personality Change? in Can Personality Change?

T. F. Heatherton & J. L. Weinberger, Editors

American Psychological Association, Washington, D.C., 1994

392

Review Questions


1. Which item(s) from following list is/are consistent with the historical

perspective on the efficacy of psychotherapy with elderly patients?

a. Psychotherapy won’t work because the elderly do not have sufficient

“elasticity of mind” for new learning.

b. The length of time it takes to sort through all the personal history is

too long.

c. Personality style and defensive structure are fixed in the elderly and

not amenable to alteration.

d. Physical limitations and a reduced energy level interfere significantly

with treatment.

e. The stigma against psychiatry is particularly strong in geriatric

patients, which prevents their full cooperation.

f. Psychiatric symptoms are a normal part of the aging process.

2. Ms. Nosnibor is brought to see you. She is a seventy-four-year-old

never-married woman who worked as a microbiology technologist until

ten years ago. She lives on her own with her two Chows. Despite your

posted “No Smoking” signs, she enters your office with a lit stogie in

her hands. After you politely ask her to extinguish it, she drops it on the

floor and then says her back is too sore for her to bend over to get it.

Ms. N. was doing reasonably well until about one month ago. At that

time, she failed to be nominated into the “Hall of Phlegm” at work, a

honor she has been expecting at each retirees’ annual meeting. Since

that time, she has been suffering from constipation and headaches.

She goes into considerable detail telling you about the precise location

of each of her twenty-two headaches; your gentle interruptions do not

distract her from giving you an equally full account of her bowel habits.

When you ask her about other changes from a month ago, she tells

you she cannot finish her crossword puzzle, which she usually

completes before breakfast.

Your plan of action is:

a. Diagnose a narcissistic personality disorder and see her in a month.

b. Contact her old employer on her behalf and tell them all their culture

is in a petri dish.

c. Diagnose a dementing condition and refer her to a community support

organization.

d. Diagnose depression and start her on an antidepressant medication.

e. Give her a laxative and help her with the crossword puzzle.

393



1. All of these options have been given as reasons why psychotherapy

has traditionally been seen as an ineffective intervention in the elderly.

Meador (1996) indicates that there are four categories of challenges in

conducting psychotherapy with the geriatric population:

Caregiver/Patient Challenges

• unhappiness and anxious/depressive symptoms are part of aging

Family-Related Challenges

• family dynamics may limit the energy put into seeking treatment

Therapist-Related Challenges

• therapists may feel frustrated at the chronicity of the patient’s problems

Health Care Delivery Deficiencies

• limited/inadequate funds for psychotherapeutic interventions.

2. Option d is the best intervention.

Options b and e won’t help. Recall

that the elderly may often present

in a manner that appears to be

narcissistic in nature, but this does

not make NPD an applicable

diagnosis. A personality disorder

is rarely diagnosed in the presence

of depressive symptoms. Ms.

Nosnibor displays the following

features:

• precise onset of difficulties

• some loss of social skills

• rapid onset of symptoms

• somatic focus to her presentation

• emphasis on difficulties, particularly

cognitive changes

• short duration of symptoms prior to seeking help

These features distinguish depression-related cognitive dysfunction

(often called pseudodementia) from a dementing illness.

Reference

K. G. Meador & C. D. Davis

Psychotherapy, in Textbook of Geriatric Psychiatry, Second Edition

American Psychiatric Press Inc., Washington D.C., 1996

394


Index

Acting Up 33, 37, 248, 254

Adaptation 3,5

Affective State 121

disorders of 65,92

treatment 99,105

Aggression

treatment 94,99

Agoraphobia 289,294,312

see also Anxiety Disorders


(APA) 6,14

Alcoholic Personality

295

Alters 363

Anal

stage 30, 330, 334

triad 327

Anorexia Nervosa

see Eating Disorders

Anticholinergic Medication

see Psychotropic Medication

Antidepressant Medication


Antipsychotic Medicaiton

see Neuroleptics under

Psychotropic Medication

Anxiety 105

treatment 94,99

Anxiety Disorders

12,92, 115, 193,

244, 307, 352

see Agoraphobia, Generalized

Anxiety Disorder, Obsessive-

Compulsive Disorder, Panic

Disorder, Phobic Disorders,

Posttraumatic Stress Disorder

Anxiolytics


Approach-Avoidance Conflict

191

As-lf Personality

202,248,252

Asperger’s Disorder

122,170, 183-4

see also Pervasive

Developmental Disorders

Asthenic Personality Disorder

371

Atheoretical approach

6

Attachment 315

Attachment Theory

50-54, 133, 134

Attention-Deficit/Hyperactivity

Disorder (ADHD)

215

Autism/Autistic disorder

122, 165, 170,

172

see also Pervasive

Developmental Disorders

Axes (DSM) 8,9,13,21,22,

92

B

Bad Object 53

Behavior

disorders of 65, 92

Benzodiazepines (BZ)


Biological Markers

94

Biopsychosocial 77, 95

approach 69,70

management plan

79

model 78

Bipolar Mood Disorder

see Mania/Hypomania and

Mood Disorders

Body Dysmorphic Disorder

208, 294

see also Somatoform

Disorders

Borderline

defined 237

other uses of the term

237, 263

395


Borderline Personality

Organization

237, 248, 253, 267

Brief Psychotic Disorder

163, 169,245

see also Psychotic Disorders

Briquet’s Syndrome 219

c

Cathexis 172

Character 82

armor 267

Chemical Imbalances

102

Circumplex 63

Circumstantial Speech/

Circumstantiality

171,177

Clusters

see Personality Clusters

Cognition

disorders of 65, 92

treatment 94,99

Cognitive Therapy

58-60,69,70,89, 128,

154, 176-7,201,225,256,

280,298-9,318,339,354

automatic thoughts

59

cognitions 58

cognitive distortions/errors

60,69,70, 128,

154, 176,201,

256

cognitive shift

59

collaborative empiricism

59, 256

concepts 59

course of sessions

60

dysfunctional thought record

339

guided discovery

59,298,318

negative thoughts

59

reality testing

59

schema 59

socratic questioning

59,298,318

strategies 59

Comorbid Conditions

(Comorbidity)

96-97

Compulsion/Compulsive

Behavior 337

defined 327

Concrete Thinking

165, 175, 176-

177

Conduct Disorder

8,217-8,240

Conversion Disorder

78, 189, 192,208

see also Somatoform

Disorders

Counterdependent Attitude

331

Counterphobic Attitude

196

Countertransference

56, 126,

152, 175, 199-

200, 224, 252,

278,296,316,

337, 353

Cultural Factors 14, 15

Culture-Bound Syndromes

14, 15

Cyclothmia/Cyclothymic

Disorders 193, 245, 372

see also Mood Disorders

Cyclothymic Personality

Disorder 372

D

Defense Mechanisms

see Ego Defense Mechanisms

Delusion

defined 171,285,286

Delusion of Reference

171,183, 184

396


Delusional Disorder(s)

92, 137, 146, 147, 169,

273, 285, 286,313

Dependency 315

Depersonalization

165,170

Depression

78,92, 115, 120, 126, 127,

147, 163,245,272,312,

331,367, 371,372,393-4


Depressive Position 123

Derealization 170

Diagnostic and Statistical Manual

of Mental Disorders (DSM)

critique 9

defined 6

difficulties in applying to elderly

patients 382-383

DSM-II 6

DSM-III 6

DSM-III 6

DSM-lll-R 6

DSM-IV 7,84

Diagnostic Interviews

19

Diathesis 167

Dimensional Model

91,94,383

Dissociative Disorders

193,208,244,364,369


(DID) see Multiple Personality

Disorder

Disturbed Interpersonal

Relationships (DIRs)

50,51,102, 151,259

Double Bind 118,166

Dysthymia 115,163,193,

245,272,312,

352


Dysthymic Disorder

see Dysthymia and also Mood

Disorders

E

Eating Disorders

194,244,294

Anorexia Nervosa 123

Bulimia Nervosa 313

Ego 31,32

auxiliary 174

boundaries 175,239

observing 144

Ego Defense Mechanisms

acting out 33, 37, 196, 216,

248,251,253,

254,255

altruism 33, 61,323, 324,

367

anticipation 33,49

asceticism 33

Axis II coding 8

blocking 33

concept 32

controlling 33,38,216

denial 33,48,69,137,

143, 167, 192,

242.251.351

displacement

33,39,293,331

dissociation 33,38,192,216,

241,242,363,

365

distortion 33, 39, 69, 167,

242, 247

externalization

33

humor 33

hypochondriasis

33.351

idealization 33,40,119,167,

247,271,311,315

identification 33, 38, 61,255,

271,275

immature (category)

33

inhibition 33,41,293,311

intellectualization

33,41,69,119,

331

397


introjection 33, 39, 52, 53,

119,143,255,

275

isolation 33, 42, 293, 331

listed by use in individual

personality disorders

35

mature (category)

33,49

mnemonic 34

narcissistic (category)

33

neurotic (category)

33, 293

passive-aggression

33.42.57.351

projection

33.43, 55, 119,

137,140, 142,

145, 152, 167,

271,275,293

projective identification

33.44, 143, 145,

152, 155, 174,

175,200,216,

242, 250, 252,

253.311

rationalization

33.45.331.351

reaction formation

33.45, 137, 143,

311,314, 331,

337

regression 33,46, 49, 192,

200.311

repression 33, 36,192,195,

293

schizoid fantasy

33.46, 119, 167

sexualization

33.47, 192, 197,

200

somatization

33.47.311

splitting 33, 43, 53, 69,

143, 167,241,

242, 247, 250,

253, 365

sublimation 33,49

suppression 33, 36

undoing 33,48,331

Ego Psychology

31-33

structural theory

31

topographic theory

31

Egodystonic 160,373

Egosyntonic 4, 84,199, 310,

327, 370

Electra Complex

191

Electroencephalogram (EEG)

79

Emotional Reasoning

165

see also Cognitive Therapy

Encapsulation 147

Enuresis 215

Envy, primitive 221

Erotomania 313

see also Delusional Disorders

Explosive Personality Disorder

87

F

Factitious Disorder

244,365

Five Factor Models

83

Fixation 28

Folieadeux 142,313

Forme Fruste 91

Formulation 78

G

Gain

Primary

Secondary

Tertiary

198,207-208,

216

198.207- 208,

211,216,222

198.207- 208

398


Ganser’s Syndrome

219

Generalized Anxiety Disorder

(GAD) 159,163,292,

294


General Medical Condition(s)

(GMC) 169,194,294,

332, 364, 365,

368

personality change due to a

13, 368-369

Genital Stage 30

Good Object 53

Grandiose Self 271

Grandiosity 141,147,153,

214

delusional 147,273

malignant 213

self-referential 148,160

Group Therapy 61-62,69,70,

127, 155, 177,

201,225,255,

279,297,317,

338,354

clarification 62

confrontation 62, 70

co-therapist 70

therapeutic factors 61,62

H

Hallucination(s) 170,183,184

Help-Rejecting Complainers

201,252,352

Heterocyclic Antidepressants

(HCAs) see Psychotropic

Medication

Humor Index

Amulets 182

Anatomy of a Bond Adventure

231

Anatomy of a Romance Novel

206

Bistro

24

Cereal Killers

232

Chicken Crossing Road

71

Dependent’s Apartment

321

Dramatique

205

Eau D’Hermit

131

Eight Ball Cologne

230

Enterprising Personalities

284

Fatal Personalities Instinctively

Attract

262

First Date Checklist

302

Fractionated Personality

357

If You Love Something

112

InnerSpace

283

Lady Macbeth

344

Mutation of Ego Defenses

72-73

Nag-B-Gone

111

Newhart Was Never Like This

376-380

Parking Lot of the Personality

Disordered

23

Paranopoly 158

Personalities ’R Us

74

Rules of Order

343

Santaclaustrophobia

303

Shopping by Diagnosis

132

Social Phobia Convention

322

Sociopathy 101

229

399


Hypochondriasis

208,312

see also Somatoform

Disorders

Hypomania

see Mania/Hypomania and

Mood Disorders

Hysteria 187

Hysteroid Dysphoria

193

/

Id 31,32

ldea(s) of Influence

171

ldea(s) of Reference

148, 165, 171,

183,184

Identity Diffusion

175,242,248

see also Ego Boundaries

Illusion

defined 170,183

Imago 270,275

Imaginary Companion

364

Impulse-Control Disorders

12, 92,244,338,

345, 346, 373

see also Intermittent Explosive

Disorder

Impulsivity 94, 99,105

Inadequate Personality Disorder

289, 307, 370

Inhibition 99

Intermittent Explosive Disorder

345,346, 373

see also Impulse-Control

Disorders

International Classification of

Diseases (ICD)

defined 10,14

ICD-10 Personality Disorders

10,84, 267

anankastic 10, 327, 346

anxious 10,289

borderline type

10,245,264

list 10

dissocial 10,211,234

emotionally unstable

10.245.264

impulsive type

10.264

paranoid 137

Interpersonal Therapy (IPT)

63-64, 65, 69, 70,

89,128-129,178,

202-203, 226,

258, 280, 399,

318-9,339-40

Interpretation(s) peer

62

Interview Schedules

19

L

La belle indifference

189, 192

Language Disorders

170

Latency Stage 30

Learning Theory

166

Life Cycle Stages

28-30, 286

Bowlby’s 29

Erikson’s 28

Adult 384

Freud’s 30

Mahler’s 28

Piaget’s 28

Loosening of Associations

171

M

Magical Thinking

165,171, 173, 178, 179,251

Major Depressive Episode

see Depression and also

Mood Disorders

Malingering

219,220,

400


244,365

Mania/Hypomania

78,92, 120, 147,

193,218,219,

245,272,332,

372


Masochism/Masochistic

Personality 323, 324, 366-

367

types 366

Medication


Memory

Declerative 82,83

Procedural 82,83


(MSE) 19,93,122,148,

170-171,172,

194,220,246

Micropsychotic Episode(s)

120, 163, 183,

184, 194,239,

242,245, 246

Millon Clinical Multiaxial

Inventory-ll (MCMI-II)

18,84

Minnesota Multiphasic

Personality Inventory MMPI-II)

17

Mixed (Mood) Episode

120


Mnemonics

antisocial personality

210

avoidant personality

288

borderline personality

236

dependent personality

306

ego defenses

34

histrionic personality

186

mental status exam

93

narcissistic personality

266

obsessive personality

326

organic personality

368

paranoid personality

136

passive-aggressive personality

348

risk of violence

141

schizoid personality

114

schizotypal personality

162

Mood Disorders

12,92, 187,237,240, 244,

294, 307, 352, 364, 369,

372

with psychotic features

169

see also Cyclothymia

Depression, Dysthymia,

Mania/Hypomania, Mixed

Episode

Mood Stabilizers


Moral Insanity 211,234

Multiple Personality Disorder

(MPD) 362-365

N

Narcissism 267, 273

phallic 267

primary 267

secondary 267

types 274,277

Narcissistic

extension 270,275

injury 269,273,279

rage 269

401


Negativistic Personality

Disorder

see Passive-Aggressive


Neologism(s) 171

Neurologic Signs

soft/non-localizing

214

Neurosis/Neurotic Disorders

21,22,32,363

Neurotransmitters

dopamine 96

norepinephrine 96

serotonin 96

0

Object Constancy

173,240

Object Relations Theory

50, 52, 53, 54,

57,137,247

Obsession (defined) 327

Obsessive-Compulsive Disorder

78, 327, 338, 369

vs. OCPD 333


Oedipal Stage 30, 32, 36, 54,

191,195

Opiate Antagonists


Oral Stage/Orality

30, 190, 191, 195,247,

270,274,310,314

Organic Personality 368-369

Overvalued ldea(s) 168,171

P

Pan-anxiety 165,173, 237

Pan-neurosis 165,173, 237

Pan-sexuality 237

Panic Disorder 289,294,312

Paranoid-Schizoid Position

123, 137

Parapraxes 55,150

Passive-Aggressive Personality

Disorder 7, 8, 87, 264,

349, 367

Perception 105

disorders of 65, 92

treatment 94,99

Personality

changes in later life

384-385

defined 3,82

traits 5,8

process of change

389-390

Personality Change Due to a

Medical Condition

13

Personality Clusters

defined 6

Cluster A 6, 12, 17, 92, 174

Cluster B 6,12,17, 92,

187,240,244,

253,269,315

Cluster C 6,12,17, 87,92,

333,349


defined 4

development 6, 7

diagnosis 21

extreme forms of adaptive

behavior 5

general criteria 7

general features 4

longitudinal course

386

normal 16

NOS 7,8

persistence in the elderly

386

problems in applying to elderly

patients 382-383

severity criteria 9

Personality Disorders (note:

these entries are for listings outside

the individual personality chapters)

antisocial 8, 87, 97, 240,

244, 367, 373

avoidant 15,87,117,118,

122,125, 370

402


borderline 17,87,97, 101,

109, 110, 183,

184, 194, 307,

364

dependent 15,87,304,370

histrionic 17,87,307

narcissistic 15, 87, 160,373,

393-394

obsessive 15,87

paranoid 8, 15, 87

schizoid 8,87,88, 117,

303,304, 370

schizotypal 8,15,87, 88,97,

101,117, 120,

121

Personality Traits 8

changes with time 384

Pervasive Developmental

Disorders (PDD) 184

see also Asperger’s disorder

and Autism

Phallic Stage 30

Phenomenology 6, 69, 70

Phobic Disorders

208.312.369

social 159,163,289,

294,304


Pleasurable Interpersonal

Relationships (PIRs)

50, 51

Posttraumatic Stress Disorder

364.369


Primary Process

31,237

Pseudocommunity 140

Pseudohostile (family) 166

Pseudomutual (family) 166

Psychic Determinism 55, 336

Psychoanalytic Psychotherapy

see Psychodynamic

Psychotherapy

Psychodynamic Psychotherapy

55-57,69,70,89, 124-6

150-3, 174-5, 197-8,

222-3,249-51,276-8,296,

315-6, 336-7, 353

Psychological Testing

16,79

Objective Tests 16,17,18

Projective Tests 16,18

Psychological Symptoms 51

Psychometric Testing

see Psychological Testing

Psychopathy 211

Psychosomatic

defined 76,77

medicine 77

Psychotherapy 359-360,393-394

defined 26

goals 55, 66, 89, 387

Psychotic Disorders

12,92,244

see also Brief Psychotic

Episode, Delusional Disorder,

Schizoaffective Disorder,

Schizophrenia,

Schizophreniform Disorder

Psychotropic Medication

109, 110, 126-7, 153, 176,

202, 226, 257, 279, 297,

317,338,354,388

anticholingeric agents

100

antidepressants (general)

127,257,338,354

antipsychotic

see neuroleptics

anxiolytics

100, 127, 153,354

benzodiazepines (BZs)

99, 100, 127,226,

279,313,317

categories of 95

chemical imbalances 102

entity, as an 103

heterocyclic antidepressants

(HCAs) 100

introducing into therapy

102

limitations 101

monoamine oxidase inhibitors

(MAOIs)

403


99, 100, 194,202,

297

mood stabilizers 99,100,257

neuroleptics 99,127,153,176

226,257,317

opiate antagonists 100

rationale for use in treating

personality disorders

94-97

sedative/hypnotics

100,127

selection of agents

98-100

selective-serotonin reuptake

inhibitors (SSRIs)

99, 127, 153, 176,

202, 226, 257

separate providers 103-104

stimulants 100

symptom-focused treatment

95

timing in use 102

tricyclic antidepressants

(TCAs) 99,100

R

Rapproachement (subphase of

Mahler’s separationindividuation)

28,240,247

Rejection Sensitivity

193

Repetition Compulsion

54, 196,366

Resistance 31,57, 174, 198

Review Questions (answers are

on the following pages)

21,69, 109, 133, 159, 183,

207,233,263,285,303,

323, 345, 359, 393

Rorschach Test 18

s

Sadistic Personality Disorder

367

Satellite Existence

278

Schism 166,173

Schizoid 117,289

defined 115

Schizoaffective Disorder

120, 121


Schizophrenia 78,92,115,117,

120, 121,124, 126, 129,

137, 142, 146, 147, 165,

169, 175, 179,218,219,

245, 294, 364

borderline 163,170,184,

264

latent 163,170,245,

264

negative symptoms

115,117,121,

163, 371

positive symptoms

115,121,163,

167, 176

pseudoneurotic

170,237,245,

264

simple 163,170


Schizophrenic Spectrum of

Disorders 137,142,163,

165, 168,169

Schizophreniform Disorder

120,121


Schizotypal 163

Selective-Serotonin Reuptake

Inhibitors (SSRIs)


Self Disorders 12

Secondary Process 31

Sedative/hypnotics


Self

false 275

idealized 275

true 275

Self Psychology 267,277

404


Selfobject 274

Self-Defeating Personality

Disorder see Masochism

Separation-Individuation

28, 240, 247

Seven Factor Model 88

Sexual Disorders 194, 367

Signal Anxiety 32,195

Simple Deteriorative Disorder/

Simple Schizophrenia

127,245

Skews (family) 166

Skills Training

see Social Skills Training

Sniglets 171

Social Causation Hypothesis

166

Social Skills Training

69, 90, 128, 177,

297

Soft Signs

see Neurologic Signs

Somatization Disorder

208,219,244,309,312

see also Somatoform Disorders

Somatoform Disorders

187, 190,193,

208,312,369

see also Body Dysmorphic

Disorder, Conversion

Disorder, Hypochondriasis,

Somatization Disorder

Spectrum Disorders 12

Stimulants


Substance Use/Abuse Disorders

97,120,147,190,194,240

244,272,294, 352, 364

Superego 31,32

defective 221

harsh/punitive 335

lacunae 221

Symptom Versatility 11

Systematization 147

Tangential Speech/Tangentiality

171

Temperament 82, 94, 98,105,

118,142

dimensions 83, 84, 85, 86,

87, 88, 89

treatment geared towards

90

Temperament & Character

Inventory (TCI) 88

Thematic Apperception Test

(TAT) 18

Thought Content 171

Thought Form/Process 171

Trait Disorders 12

Transference

54,55, 166, 152,

175,199-200,224

eroticized 152,199

idealizing 277

mirror 277

twinship 277

Transitional Object(s)

103,241,247,

255,257,317

Tricyclic antidepressants (TCAs)


u

Unconscious 31,55,82,149

V

Vulnerability-Stress Model

27, 167

w


(WHO) 10, 14

405


The Author

Dave Robinson is a psychiatrist practic¬

ing in London, Ontario, Canada. His par¬

ticular interests are consultation-liaison

psychiatry and both undergraduate and

postgraduate education. A graduate of

the University of Toronto Medical School,

he completed a Residency in Family

Practice before entering the Psychiatry

Residency Program. He is a Lecturer in

the Department of Psychiatry and an In¬

structor in the Department of Family

Practice at the University of Western

Ontario in London, Canada.

The Artist

Brian Chapman is a resident of Oakville,

Ontario, Canada. He was born in Sus¬

sex, England and moved to Canada in

1957. His first commercial work took

place during W.W. II when he traded

drawings for cigarettes while serving in

the British Navy. Now retired, Brian was

formerly a Creative Director at

Mediacom. He continues to freelance

and is versatile in a wide range of me¬

dia. He is a master of the caricature,

and his talents are constantly in demand.

He doesn’t smoke anymore. Brian is an

avid swimmer and trumpeter. He performs regularly (playing the trum¬

pet) in the Toronto area as a member of three bands. He is married to

Fanny, a cook, bridge player and crossword puzzle solver extraordinaire.

Rapid Psychler Press was founded in

1994 with the aim of producing textbooks

and resource materials that further the use

of humor in mental health education. In

addition to textbooks, Rapid Psychler spe¬

cializes in producing CD-ROMs, slides

and overheads for presentations.

Rapid

Psythler

Press

406

• library

JH

\W Amazing Research.

Amazing Help.

http://niWibrary.nih.gov

10 Center Drive

Sethesda,

301-496-1080

provides a comprehensive, practical a

of the DSM-IV personality disorders. T

and therapeutic principles relevant to

pathology are detailed in the introdu

this, a separate chapter with up to t

voted to each DSM-IV personality disorder, i ms edition nas oeen

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new material. Disordered Personalities is richly illustrated and

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ISBN 0-9682094-4-0

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