Transcript Personality Disorders - Santa Barbara Therapist

Personality Disorders
Neurotic-Borderline-Psychotic
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Cluster A- Psychotic- odd/eccentric
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Cluster B- Borderlinedramatic/emotional
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Paranoid, Schizoid, Schizotypal
Antisocial, Borderline, Histrionic,
Narcissistic
Cluster C- Neurotic- anxious/fearful
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Avoidant, Dependent, OCPD
Personality Disorders ARE
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Chronic- dating back to childhood or
adolescence
Enduring Patterns across situations
(2) cog, affective, interpersonal, or
impulse control
Often ego-syntonic
Coded on Axis II
Paranoid PD
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Pervasive distrust/suspiciousness or others as malevolent
(exploit, harm, deceive)
Difficult to get along with/difficulties having close relationships
due to argumentativeness, hostile aloofness, or complaining
Hypervigilent, guarded, defensive- appear cold- but internally
labile
Elicits hostility in others-thus confirming expectations
Need to be self- sufficient and Autonomous
Need to control those around them
PROJECTION
Seek to confirm negative beliefs
BE CAREFUL TO ASSESS CULTURAL ISSUES (ex. Refugees)
Cognitions of the Paranoid PD
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Cog “Others can not be trusted and will try and hurt
you”, but do not confront directly because it will be
seen as a personal attack, so….
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If overestimates threat of underestimates- help form more
realistic appraisal of coping
If coping lacks, help build it
Cognitive errors:
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Over Generalizations
Dichotomous thinking
Reason backward from beliefs to evidence to reinforce
beliefs
INTRODUCE an element of doubt, NOT challenging beliefs
How to interact with the
Paranoid PD
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If you get the client to trust you- you’re done 
Allow interpersonal space, time between sessions, due to high
anxiety provoked in sessions
Never directly confront about delusions-help cl explore and
support them
Explain every move made and be straightforward and clear,
allowing cl to control moves
Move slow, show a quiet formal genuine respect
Limit reflections, simple nods suffice- reflections may cause fear
in the patient
Educate about assertion vs aggression
Determine triggers and help to avoid when unable to tolerate
adequately. Help remove env. Irritants
Therapist must not fall into Transference and CT
Issues in treating the
Paranoid PD
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OVERARCHING GOAL: Loosen up the extreme constriction and inflexibility that pervades all
domains
Help identify the possible rewards from relationships
PROJECTION- increase self-efficacy
When they withdraw in self-protective way-encourage them to gather further information
before reevaluating assumptions about others
Help to be other focused
Communication skills training, role playing, immediate feedback to help diminish
hypersensitivity to social evaluation and eliminating behaviors that invite criticism
Help change from identification with the aggressor to differentiation from the aggressor
Explore benefits of being alone vs relationships
Increase empathy
Turn blame on others to self-examination
Teach frustrations are a normal part of life (they ruminate about past wrongs done to them)
As defenses loosen up, vulnerability, inferiority and worthlessness will rise and depression
may result. Here a shift in tx is necessary
Meds
Schizoid PD
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Detachment from social relationships and restricted range of
expressed emotions in interpersonal settings
Do not want or enjoy close social interactions as opposed to
Avoidant PD- who want social interaction, but are afraid
Indifferent to praise or criticism
Intellectualization is used
Passively detached from environment
Appear to lack capacity to experience emotional pleasure or
pain
Do not tend to obtain gratification from self or others
FLAT and COLORLESS
Interacting with Schizoid PD in
Therapy
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Reliable, stable therapeutic relationship
that mirrors the client
Therapist must be more active at first
CT-frustration, helplessness, boredom
Cls may not value therapy
Goals in treating the Schizoid PD
GOALS
* Therapist must assess level of tolerance for social
relatedness and desire of client
 Enhancing Pleasure, expressive abilities, and energy
level
 Helping them be minimally active (Prevent total
isolation that may lead to reality break, but don’t
push for too much activity-they can’t tolerate it)
 Increasing affect, perceptual awareness, and
responsiveness to environment (so they don’t
withdraw into themselves)
 Help clarify thought process
Treating the Schizoid
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Behavior Therapy may be used to teach,
reinforce, role play, in vivo exposure, audio &
videotaping of social skills (careful
assessment of reinforcers is necessary as
they don’t respond to much
DTR- to clarify and attend to vague cognitions
and emotional experiences
Explore functional and dysfunctional aspects
of isolation
Educate family and sig other on acceptance
of Schizoid lifestyle while helping them set up
mild socialization opportunities
Schizotypal PD
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Acute discomfort with close relationships
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Cognitive and perceptual distortions
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Difficulty with social cues and interactions
Anxious around others
Ideas of reference (benign event has special
meaning)
Believe they have special powers to sense events,
mind read, magical thinking
Often suspicious of others
Eccentric behavior
Cognitions of the Schizotypal PD
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Cognitions
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Ideas of reference-unrelated events are related to
him
Paranoid ideation
Magical thinking-I can read your mind or control
events, you can do this too.
Experience of illusions – sees people in shadows
Emotional reasoning- emotions are facts
Personalization- responsible for external events
Assessment and how to interact with the
Schizotypal PD
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Assess are they more avoidant or Schizoid in nature
Therapy should be well structured, supportive and move at the client’s
pace so as not to cause undue anxiety and regression. Due to cls
beliefs they can read minds or telepathically cause events, checking in
on their experience of therapy is important
SUPPORTIVE THERAPY!!! After establishing rapport, continue to
support, but help reframe gently
You are the cl’s reality testing observing ego, your goal is to increase
cls pleasure in living and reduce anxiety (building up better defenses)
Give Advice about social interactions, dress, speech, mannerisms.
They project, so watch transference and CT
DO not analyze dreams, free associations, use neutral stance etc. This
will cause regression and worsen the disorder
Goals in treating the Schizotypal PD
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GOALS:
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Enhance self-worth and help to recognize
positive attributes
Teach more adaptive functioning
(repeatedly- as they have trouble
generalizing)
Reduce social isolation (therapy itself is a
reality testing function reducing some
effects of the reality distorting isolation)
TX SCHIZOTYPAL PD
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USE ideas of reference, magical thinking, and daydreaming;
along with lack of human contact and feedback; which impede
on accurately interpreting their environment
Social skills training and environmental management. Help to
do as much as they can for themselves.
Teach to evaluate thoughts by environmental evidence vs
feelings
Help pt to disregard thoughts that won’t disappear w/ cognitive
coping “There I go again, even though I am thinking this
thought- it does not mean it’s true”
Track and test predications
Find practical ways to help cl improve life
Medications can help with some symptoms
Antisocial PD
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Disregard for and violation of other’s rights
Deceitful and Manipulative-enjoy “getting over” on others and POWER
Must have symptoms of conduct disorder prior to age 15
Tend to be impulsive and are irresponsible
Little to no remorse
Said to “burn out” in middle age, but may be due to
deaths, imprisonment, and learning to channel
personality style in less public and flagrant ways
Consequences rarely play a part in their decision
making, and acting out is a regulatory mechanism,
impulses are directly expressed
Usually in tx due to ultimatum
Cognitions of APD
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COG Distortions:
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Wanting something or wanting to avoid something
justifies my actions-Justification
My thoughts and feelings are completely accurate
just because they occur to me-thinking is believing
I always make good choices-personal infallibility
I know I am right because I feel right about what
I do- feelings make facts
Others are irrelevant unless it affects meImportance of others
How to interact therapeutically with
APD
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Avoid power struggles at all costs
Openly acknowledge the vulnerability of therapy to
manipulation by the anti social to reduce opposition.
Remove self from evaluator role
Best if th is self-assured, reliable, relaxed and
nondefensive, clear personal limits, strong sense of
humor, NOT wishy washy or “touchy feely” MORE
FIRM and NURTURNING
CT- fear, charmed, coldness/hatred of client
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Will try to enlist therapist as ally against others or con
therapist into being impressed by cl’s insights and reform
TX APD
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GOAL: Help cl see how his/her behaviors hurt him (are a disadvantage
to him) in the long run
Identify APD behaviors as a disorder causing long term consequences
to the afflicted individual. Therapy framed as an initial experimental
trial to look at situations that might be interfering with the cls
independence and success in getting what he or she wants
Use choice review exercises: Problem sit is listed and possible
behavioral responses listed and rated in relation to their consequenses
Behavioral techniques may work in the setting, but don’t generalize
Cooperative activities with other antisocials with severe consequences
may help (Wilderness camps)
Cognitive work to help move cl from concrete operational thinking to
more formal thought
Prognosis of APD developing concern for others is slim
Borderline PD
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Instability in personal relationships, self-image, affects, and
impulsivity
Do WHATEVER to avoid perceived or real abandonment
Often fear engulfment as well (push/pull)
Idealize and devalue
Splitting
Borderline, while difficult, are probably more amenable to
change and reorganization than many other PDs
Desire gratifying relationships, and flexibility of personality are
strengths that work toward Tx
Goals for BPD
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Goal: balancing polarities: They are
both passive and active, self and other
focused…just one at a time (not
integrated) And when one is not
working they shift to the other, thus
feeling like they don’t know who they
are, ruining relationships and feeling
empty and confused
How to interact with BPD
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START therapy with clear explicit boundaries, clear
goal of helping the client to be more independent
and that limits will help in this goal. Therapist should
then be responsive and supportive WITH IN THOSE
LIMITS (Frame)
Make clear that getting better does not equal being
thrown out of tx
Remember: A real alliance (not just an idealized one)
takes time
Begin supportive and then move to supportive
confrontation of splitting, poor choices, etc.
BE CONSISTENT
TX BPD
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Remember that BPD will have several other symptoms of other disorders and
PDs. Underneath is a dichotomous thinking, unstable sense of self, and frantic
need to avoid abandonment and engulfment. Keep this in mind to focus on
undercurrents and not get lost in “symptoms”
Make a few concrete goals that can be followed week to week (due to cls lack of
stable self and difficulty staying focuses or having consistency)
Help build compassion for self, help in self soothing and self-protection skills
Help cl see counter productive nature of behaviors
Help cl tolerate anxiety that causes the switching from one extreme behavior to
another. If they can contain the anxiety, they can choose a better response
Help cl define self and form a more solid identity
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Reducing vacillations between extremes helps cl to form stable identity
Confront all good/ all bad…again helping cl to integrate splits
Help connect behavior to early history, psychodynamic work can be very helpful,
validate cls experience, predict “regressions” when cl succeeds as normal
DBT- see book, Use peer Group work
Psychopharmacology
Histrionic PD
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Excessive emotionality and attention seeking behavior
Feel uncomfortable and unappreciated when they are not the center of
attention-Demand the center of attention
Shallow and rapidly shifting emotions, often sexually provocative,
speech is impressionistic and global (do not focus on facts or details)
Highly suggestible
Often play “a role” in interpersonal relationships
Move quickly away from conflict, to new relationships-thus not forming
deep supportive networks
Feel incapable of handling a large number of life’s demands and need
someone truly competent and powerful to do so for them
Use REPRESSION and FANTASIES OF FUSION WITH A POWERFUL
OTHER and DISTRACTION to avoid dysphoria/anxiety
Use DISSOCIATION and CHANGING PERSONAS when one fails to avoid
stress- MIRROR THEM TO PROMOTE COHESION
Histrionics often marry compulsives
How to interact with HPD
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Join with the clients observing ego against self
defeating part of client (build up super ego)
Start with Skills training, CBT, DTR, exploratory
therapy, behavioral experiments (they obsess about
external events-help them turn inward) cognitively
first as it may be less threatening
Help client focus more on details (ask for details)
Actively recommend alternative behaviors
Actively address transference
Use client’s need for approval to reinforce selfexploration
Goals for the Histrionic PD
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Establish SPECIFIC tx goals to keep patient
motivated
OVERARCHING GOAL- correct the tendency of
Cl to fulfill all their needs by focusing on
others to exclusion of self (done to ensure
powerful other is always available and
admiring them) which leaves no energy to
focus on internal states
How to reach the goal for HPD
(notice they all promote a focus inward to meet needs)
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Help them to give up active control over others actions and reactions (increasing passivity
to experience and enjoy whatever occurs)
Help them to slowly explore and focus on thoughts and feelings
Help them to tolerate and cope with less satisfying aspects of relationships and tolerate not
being “center stage” in order to gain long term intimacy
Help see long term gains of keeping seduction and flirtation to appropriate relationships
Teach more appropriate skills to meet needs: communication and assertiveness
Help them differentiate when their theatrical drama can be appropriate and when to contain
it
Help them tolerate BOREDOM & ANXIETY
Help develop a personal identity, since they are defined by others. May seem fragmentedhelp integrate with consistent feedback and pulling together of events and history
Reinforce all independent and assertive behavior by the client (thus promoting active vs
reactive behavior, reducing manipulation and a focus inward on detemining needs)
Relaxation/physical activity to reduce anxiety
Encourage them to take emotional risks
Confronting dependency with and acceptance that it can not be satisfactorily fulfilled is a
sign of huge progress
More Specific Techniques for HPD (and other
disorders that increase focus inward)
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Have cl make list of everything they know about self
(basics too- favorite color, food)
Address fear of rejection by having cl focus on
previous lost relationships and how they have
survived
Talk about need to have ALL needs met by significant
powerful other and if this occurred one would lose all
of self
Do not use playful banter- this increases cl’s belief
they must entertain and be on display
DO NOT BECOME A SAVIOR
Narcissistic PD
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Grandiosity, need for admiration, lack of empathy,
unique/special (may feel uniquely inadequate as well)
FRAGILE self-esteem
Attach to idealized others
Sense of entitlement
Perceived or real criticism will plummet them into
despair or rage
Tend to marry other Narcissists, dependents, or
masochistics
How to interact with NPD
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Always begin with good supportive working alliance
Apologize for Narcissistic injuries and process
Reach them thru their pain
Point out lacks of empathy in client and work to improve
empathy and behaviors
Psychodynamic restructuring- confront conscious and
unconscious anger, process neg/pos transference toward
therapist, address use of splitting, projection, and projective
identification (Kernberg) or adopt a sympathetic and accepting
stance, while addressing need for patient to accept personal
limitations (Kohut)
If feelings of emptiness and sensitivity to rejection are
interfering with therapy consider medications to reduce
Cognitions of NPD
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COGNITIVELY: tendency to overvalue self is due to faulty comparisons
with others, whose differences from self are overestimated. Will also
do this in opposite direction and experience depression if defenses
don’t kick in (all or nothing thinking).
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Help to think in more middle ground.
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Help to make comparisons intrapersonally.
Help to find similarities with others
COG: Cl comes up w/ evidence for alt beliefs (DTR)
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Everyone has flaws
One can be human like everyone else and still be unique
collegues can be resources, not just competitors
limiting focus on evaluation by others and better management of affective
reactions to evaluation
enhanced awareness of feelings of others
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increase empathy
eliminating exploitive behavior
TX of NPD-Once a patient accepts that unattainable ambitions and
maladaptive behaviors must be given up in favor of more realistic cognitive
and interpersonal behaviors- a huge part of the work is done
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Overarching goals: Help cl accept their weaknesses
and deficiencies and increase other-orientedness
Help to connect to early interactions to “free them
up” to modify them. “I’m angry, I deserved that
award” “How might your parents react to your not
receiving the award?” INTERNALIZATIONS
Responses focus on cl’s disappointment vs blaming of
others (cls externalize):
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You’ve tried so hard, and your wife still complains VS
You’ve tried so hard, and you feel devastated when things
don’t work as perfectly as you thought they would
TX NPD
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Adjustment of grandiose fantasies to more
realistic ones (Tend to fantasize a lot, do not
try to stop this, just readjust it) Help to focus
on pleasure from activity in fantasy vs.
audience evaluation -this becomes a
rehearsal for life
Help to evaluate when evaluation is not
important, how to request specific feedback
from others, & thought stopping
Group can be used, but not always the best
option due to narcissistic wounding
Avoidant PD
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Socially inhibited, feel inadequate, hypersensitive to
negative evaluations and hides/withdraws (vs
Narcissist who splits)
People are experienced as critical and disapproving
unless tons of nurturing, acceptance and support are
shown
Want relationships and belonging DESPERATELY, but
are too fearful to engage (vs Schizoid who has no
interest in relationships)
Interaction with Avoidant PD
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Therapeutic relationship is very important because
avoidant client will only report what will keep the
therapist from thinking poorly of them
High empathy and support from therapist is needed,
as well as a SAFE HAVEN
Start supportive, but then more
confrontive/interpretive/uncovering (Insight oriented
work on anxiety provoking fantasies and childhood)
Remember: Insight is not progress…behavioral
change is!
Tx of APD
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Help establish internal reference points for sense of self
Skills Training: Social skills, assertiveness, increased social contact,
Self-monitoring of own withdrawal behavior, DTR, hierarchy of
activities, anxiety reduction skills, giving up triangular relationships, risk
taking.
Help them learn: Anxiety is a signal to check maladaptive thoughts
Increase Cls active focus on pleasurable stimuli, decrease avoidance of
potentially painful stimuli
Help them understand the amount of energy they spend avoiding and
processing nonexistent personal assaults or “stupid” behavior on
their part
Help differentiate between real, imagined, and incidental threats in
normal living
Medication to reduce anxiety
Group, family and couples therapy
Dependent PD
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Need to be taken care of, tend to be
submissive/clingy and have fears of separation
Feel unable to function without the help of others
Require high advise and reassurance from others
Difficulty expressing opinions and needs due to fears
of losing the other
Conflicted about obtaining autonomy because this
will lead to abandonment/ and they don’t know how
to connect to others as autonomous
Hate to be alone- others define self
Interactions with DPD: Helping to
build a self
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Use therapeutic relationship to explore dependent
dynamics (help client to self-activate sessions, ask for
needs to be met)
Start with more structure and provision of
dependency needs in therapy and move cl slowly
toward more autonomy in session
More severe clients may need to transition from
parental dependency to less severe marital
dependency w/ therapist being a transitional object
Help cl see parents more realistically
Address fears that autonomy/assertiveness will cause
them to lose others (resistance in therapy)
Treatment of Dependent PD: Interdependence (not total
independence) is the goal with the flexibility to more between selfreliance and mutual dependence
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Countering their belief that their fate is dependent on others
Help cl develop active involvement in need satisfaction, without excessive
support from others
Increase self-perceptions of adequacy and competence/trust in/caring for self
Promote self-control, independent thinking, independent personality (replacing
internalized representations of others with a more mature, realistic one of their
own) Reducing Identification
Teach not to wait passively for needs to be met
Explore how when short term gain of comfort come from clingy behaviors/ long
term relational problems are likely
Teach anxiety reducing techniques since autonomous behavior will temporarily
increase anxiety
Role play, model, or conduct anxiety hierarchy of ind/assertive behavior
Explore gradiations between dependency and independency
DTR to help with catastrophying and self-critical thoughts
Problem solving and conflict management techniques, Assertiveness training,
communication skills, role playing, self-management
OCPD Conflict: Rage at being controlled (passively acts
out emotions) vs fear of being punished (compliance)
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Preoccupied with orderliness, perfectionism, and mental and
interpersonal control at the expense of openness, flexibility and
efficiency
Attend to rules, details, lists so that the overarching goal is lost
Poor time management (due to detail orientation-think thesis)
Perfectionist and self-imposed HIGH standards
Don’t want to “waste time” and may be overly devoted to work or tasks
Self-critical
May hoard
Reluctant to delegate tasks, RIGID, stubborn, there is a “correct way”
to do things (Shoulds)
Appear to have resolved conflicts thru obedience, but are struggling at
a deeper level to restrain their defiance thus they
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Force ambivalence and anxiety out of consciousness and express passively
(thus reactive to E) or impose strict rules
Cog Distortions of OCPD
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Cog distortions-OCPDs like CBT
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There are right and wrong behaviors, decisions, emotions
Failure is intolerable
I must be perfectly in control of my environment and myself
making mistakes leads to punishment
self-criticism is helpful in preventing other’s disapproval and
motivating myself
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Explore fear of giving up worry and self-criticism, as they
believe this motivates and keeps them “doing what they are
supposed to do” confront how it actually does the opposite
(sometimes resulting in numbing out and procrastination)
Interactions with OCPD
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Cl will want structure, but sessions should be open with spontaneous
communication. This is likely to cause T and CT, including rage and anger
toward self, therapist and process. If cl believes anger to be “not ok” they may
become busy at work and begin missing sessions. Th should use cls intellectual
curiosity to explore behavior in a trusting E
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Remain warm and kind, as they are used to people becoming frustrated with
them
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Know that unfamiliar situations are more difficult for them and this includes
therapy
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Address vulnerability to shame
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Ask over and over “how do you feel?” and when they reply with a thought, say
“That helps me understand what you think, but how do you feel”
TX OCPD: See self and other at the
same time
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You want to “shake up” their structure and help them be more flexible. Help see how they
may have internalized critical and demanding parents, thus developing empathy for self as
a child. Psychodynamic exploratory work of childhood, dreams and fantasies can help cl
access repressed aspects of self and “loosen up” self
Help client give up desire for harmonious understanding with caregivers
Help them establish an identity that that differentiates their feelings and desires from those
they perceive as expected of them
Help them bring repressed anger and fear of disapproval to surface
Help them realize expectations of others and needs of self are both valid
Help decrease concerns with outcomes and help to make decisions based on personal
needs and desires
Help desensitization to avoided situations, highly structured behaviors and rituals
RELAXATION TECHNIQUES- convince them they are not a “waste of time” by “trying it out”
Warn of relapse, as cls will want to do therapy perfectly
Explore sexuality-issues here due to control and rejection (reframe as differences in desire)
Acknowledge benefits of OCPD, but also note the creativity blocking and inefficient aspects
of it
Once wishes are acknowledged as acceptable, then perfectionism is left to content with
Medications to reduce anxiety can be helpful
Group therapy is not a good option (due to other’s frustrations with them)