Cluster B Personality Types, the Dramatic-Erratic Group: Overview and Focus on Borderline - PowerPoint Presentation

Slide1

Cluster B Personality Types, the Dramatic-Erratic Group: Overview and Focus on Borderline Personality

What is Borderline Personality Disorder (BPD)?

What approaches and interventions work with BPD?

Self care working with BPD.

Slide2

What is Cluster B: Dramatic-erratic group?

Four distinct personality types organized by descriptive similarities. These similarities separate this group from Cluster A (odd-eccentric) and Cluster C (anxious-avoidant)

General requirements for all personality subtypes to meet criteria for disorder:

Cultural-norm deviation (cognition, affectivity, interpersonal, impulse control)

Pattern is inflexible and pervasive

Clinically significant distress

Stable, long duration

Not accounted for by other (medical, substance, mental health)

Slide3

Cluster B

Antisocial Personality Disorder

Histrionic Personality Disorder

Narcissistic Personality Disorder

Borderline Personality Disorder

Slide4

Antisocial Personality

General population: 3% male, 1% female

Clinical population: 3% to 30% (setting dependent)

Core feature: disregard for, and violation of, the rights of others

At least 18 years old

Evidence of Conduct Disorder onset before age 15

Does not occur exclusively during the course of schizophrenia or manic episode

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Antisocial Personality, p.2

Failure to conform to social norms: law

Deceitfulness

Impulsivity

Irritable/aggressive

Reckless disregard

Irresponsibility

Lack of remorse: indifferent or rationalizing

Slide6

Histrionic Personality

General population: 2% - 3%

Clinical population: 10% - 15%

Core feature: pervasive and excessive emotionality and attention-seeking

Uncomfortable when not the center

Inappropriately seductive, provocative

Rapid and shallow emotion

Uses physical appearance

Slide7

Histrionic Personality, p.2

Excessively impressionistic, lacking detail (shallow)

Self dramatization

Easily suggestible

Considers relationships to be more intimate than they actually are

Slide8

Narcissistic Personality

General population: less than 1%

Clinical population: 2% - 16%

Core feature: grandiosity, need for admiration, lack of empathy

Self-important

Preoccupied with fantasy

Believes self to be special

Requires excessive admiration

E

ntitlement

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Narcissistic Personality, p.2

Interpersonally exploitive

Lacks empathy

Envious of others; believes others are envious of him/her

Arrogant, haughty

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Borderline Personality

General population: 2%

Clinical population: 10% - 20%

Core feature: instability of relationships, self image, and emotional expressivity, marked impulsivity

Frantic efforts to avoid real or imagined abandonment

Intense, unstable relationships (idealization

 devaluation)

Identity disturbance

Impulsivity in 2: spending, sex, use, reckless driving, binge eating

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Borderline Personality, p.2

Recurrent suicidal behaviors (acts with or without intent, threats) or self-mutilation

Affective instability due to marked reactivity of mood

Feelings of emptiness

Inappropriate, intense anger or inability to control anger

Transient stress-related paranoia or severe dissociative experiences

Slide12

Getting more specific

Millon, Disorders of Personality DSM-IV and Beyond

BPD is one of 3 “structurally defective” personality types (schizotypal, paranoid)

Adaptive inflexibility

Self-perpetuating vicious circles

Tenuous emotional balance

Slide13

BPD: The Unstable Pattern

Argues for the lack of utility of the term “borderline” as it does not describe the clinical presentation

Ambivalent personality

Erratic personality

Impulsive personality

Quixotic personality

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Millon’s diagnostic domains

Expressive behavior: spasmodic

Interpersonal conduct: paradoxical

Cognitive style: capricious

Self-image: uncertain

Object-representations: incompatible

Regulatory mechanisms: regressed

Morphologic organization: split

Mood/temperament: labile

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Millon’s subtypes

Discouraged

:

sad, depressed, submissive, fear-based, insecure, helpless/hopeless alternates with brief periods of cheer, anger outbursts, resentment, fury

Impulsive:

capricious, superficial, seductive, evasive, worry turns to agitation, turns to gloom, hypomanic, what was once exciting is now bleak

Slide16

Subtypes, p.2

Petulant

: extreme unpredictability, defiant, disgruntled, discontent, sullen, pessimistic, resentful of the love they feel for others, swing from rage to pleading for forgiveness

Self-destructive

: perpetual vacillation, vent anger

intropunitively

(not externally), fear of autonomy, tries to please others (deferential, ingratiating) but do not perceive reciprocity, feel incapable, self harm and suicide

Slide17

BPD: Common co-morbidities

Substance use

Mood disorders

Eating disorders

PTSD

AD/HD spectrum

Other PDs

Slide18

Approaches to working with BPD

Assess for co-morbid conditions with plan to treat

Integrated care is optimal

Individual, group, psychiatry, case management

Assess risk and prioritize safety planning when needed

Encourage family engagement

DBT

Manipulation?

Schema Therapy

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What is manipulation?

Preplanned or cunning attempt to get someone to do something they ordinarily would not do, often with nefarious intent

.

It is a logical fallacy to assume that because you feel a certain way, the other person intended for you to feel that way.

Slide20

Dialectical Behavioral Therapy

Marsha

Linehan

Chief dialectic: validate and hold out the expectation for change

Mindfulness: wise mind, emotion mind, rational mind

Distress tolerance skills

Interpersonal effectiveness skills

Emotion regulation skills

Formal, informal/modified, inpatient, outpatient

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Goals

S

upportive

, empathic stance with validation of past traumas, help

the person connect

present to the past when

tolerable.

P

oor

self-image aggravates the problem. Clearly establish the goal – independent functioning (“responsible autonomy” –

Linehan

) at the beginning of treatment, maintain firm

boundaries.

T

herapy

starts with short term achievable goals (increase/decrease) followed by mid- to long-term process goals (family of origin, cognitive restructuring, trauma recapitulation (remembrance and mourning – Herman).

Slide22

Goals

H

elp the person

identify their paradoxical interpersonal conduct and how it leads to what they fear the most

(eg rage

at separation creates the abandonment that they are trying to avoid) which is driven by splitting with a nonintegrated emotional

functioning &

black-white

cognitive style.

Group is an excellent opportunity to offer rich interpersonal learning to try new skills, observe others, and not

over-focus

on a primary therapist as in the typical individual therapy session.

Slide23

Self Care

Caseload

management

Risk assessment and management

Stay out of the drama (G. Lester)

Rescuer

Victim

Persecutor

Be the Scientific Observer: observe, describe, observe, describe, do not become part of the experiment you are watching. Have a hypothesis and plan to be wrong and figure out how to use the new information

Slide24

Self care

Use supervision

Learn more about BPD and about

flyfishing

Do not personalize: stay cognitively loose, flexible, resist like/dislike

Your feelings are natural, normal, and a tool for you, learn how to use them

Be prepared for requests for self disclosure

Be consistent

Be a role model

Find the funny