Personality Disorders  EPC 695B
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Personality Disorders EPC 695B

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Personality Disorders EPC 695B

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Personality Disorders

EPC 695B


All humans have personality traits.

These are well-ingrained ways in which individuals experience, interact with, and think about everything that goes on around them.


Personality Disorders are collections of traits that have become rigid, and work to individual’s disadvantage, to the point that their personality disorders

impair functioning

or cause distress.


All of the DSM-IV-TR personality disorders are patterns of behavior and thinking that have been present since early adult life and have been recognizable in the client for a long time.


Personality disorders are probably dimensional, not


This means that their components (the traits) are present in normal people, but are accentuated in those with the disorders in question.



A lasting pattern of inner experience and behavior that

markedly deviates

from norms of the client's culture.

The pattern is manifested in at least


of these



. Cognition (how the client perceives and interprets self, others, and events) b. Affect (appropriateness, intensity, lability, and range of emotions) c. Interpersonal functioning d. Impulse control






(p. 689)



This pattern is fixed and affects many personal

and social situations.


pattern causes clinically important



impairs work, social, or personal functioningThis pattern has lasted a long time, with roots in adolescence or young adulthood.The pattern is not better explained by another mental disorder.The pattern is not directly caused by a GMC or by the use of substances, including medication.

Generic Criteria

for Personality Disorders (con’t.)


These general criteria are extremely important. They identify vital points that are central to the diagnosis of any personality disorder.

To summarize, a personality disorder is:Lifelong


Affects many areas

of the client's life,

Causes problems

, and

Is not

the product of another illness.

 Generic Criteria - Summary


Let’s look together at the handout: Morrison’s

Quick Guide to the Personality Disorders


See additional handouts:Diagnosing Personality DisordersPersonality Disorders





To make a specific


- a semi-structured interview can be used,

augmented by a self-report personality inventory





interviews guide the


through a series of questions that assess all of the potential personality disorders. Example: SCIS-II by Spitzer, Williams & Giffon (Helps to avoid impressions that rely on only one or two symptoms rather than the full criteria set.) b. Millon Clinical Multiaxial Inventory II (MCMI-I) is a self-


measure. Self report inventories




more personality disorder pathology than

reported by clinical interviews. Thus, the inventories are only suggestive of possible diagnoses and alternatives.

Assessment of Personality Disorders


Personality disorders are more vulnerable to error of diagnosis than Axis I disorders.

Diagnostic errors occur most often when the therapist fails to adhere to the diagnostic criteria or when the therapist has a gender or cultural bias.

For example: The counselor may only

see one key symptom and make or rule

out a diagnosis without carefully looking for the entire cluster of symptoms required to meet DSM criteria.

Assessment of Personality Disorders (con’t.)


For example:

A study

by Morey and Ochoa (1989) found that, when a client with a borderline personality disorder had a symptom of


sexual interest, the client was not diagnosed correctly because clinicians believe that clients with borderline personality disorder are sexually


Assessment of Personality Disorders (con’t.)


A study by Ford and Widiger (1989) also found that failure to adhere to criteria made it more likely that the clinician would be influenced by gender and cultural background of client.

For example, clinicians making diagnoses of histrionic and antisocial personality disorder were affected in their diagnoses by the sex of the client (women seen as histrionic, men as antisocial), but when asked to assess, using given criterion symptoms, they were not biased by client sex.

Assessment of Personality Disorders (con’t.)


1. If a client has an Axis I diagnosis, but

a personality

disorder is the main reason the client has come for evaluation,

(Principal Diagnosis) should be

attached to

the Axis II diagnosis.

Axis I


312.32 Kleptomania

Axis II 301.6 Dependent Personality Disorder (Principal Diagnosis) 2. A frequently used defense mechanism can be indicated on the Axis II line: Axis II 301.0 Paranoid Personality Disorder; frequent use of projectionSee DSM-IV-TR, p. 811: Defense Mechanism and Coping Styles

Coding Notes


 3. If your client's personality disorder preceded a psychotic disorder (most often Schizophrenia), the diagnosis

might read:

Axis I 295.10 Schizophrenia, Disorganized Type, Continuous, With Prominent

Negative Symptoms

Axis II 301.22 Schizoid Personality Disorder


Coding Notes (con’t.)


Please look at handout:

Correlation between Axis II Personality Disorders

and Axis I Mental Disorders


Now look at: Profile of Characteristics

of Personality Disorders

in your packet




Central characteristic: unjustified distrust and


of others.

Because the client fears exploitation, s/he



confide in others

– even those who have earned his/her trust. c. Client reads unintended meaning into benign comments and actions. d. Client will interpret specious

occurrences as


result of deliberate intent and will

harbor resentment

for a long time,




e. These clients are rigid, often litigious, and have an especially urgent need to be self-sufficient.

301.0 Paranoid Personality Disorder


f. To others, these clients appear to be cold, calculating, and guarded people who avoid both blame and intimacy.


When interviewed, they may appear tense and have trouble



This disorder is especially likely to create occupational

difficulties; these clients are so aware of rank and power that they frequently have trouble dealing with superiors




i. Although it is far from rare (about 1% of the general population), it rarely comes to clinical attention. Usually diagnosed in men. Its relationship (if any) to the development of Schizophrenia, Paranoid Type, remains unclear.301.0 Paranoid Personality Disorder


Treatment Options




beliefs about



Behavioral Therapy



Withholding negative feedback Case: Useful Work (DSM-IV-TR Casebook, p. 211)301.0 Paranoid Personality Disorder


Indifferent to the society of other peopleLifelong loners, who show a restricted emotional range; they appear unsociable, cold and


Unusually succeed at solitary jobs others find difficult to tolerate

May daydream excessively, become




, and often do not marry or even have long-lasting romantic relationships

Do retain contact with reality

Disorder is relatively common, affecting perhaps a few percent of the general population

Men are at greater risk than women.301.20 Schizoid Personality Disorder


Treatment OptionsSupportive TherapyPharmacotherapyCognitive reorientation therapy

Group Therapy

Countertransference: As watch film, see what feelings he engenders in you.

Film: Jerry - Schizoid Personality Disorder

301.2 Schizoid Personality Disorder


From early age have lasting interpersonal deficiencies


severely reduce capacity for closeness with others.


has distorted or eccentric thinking, perceptions,


behaviors that can make

these clients seem



feel anxious when with strangers and have almost no close friends.d. May be suspicious and superstitiousPeculiarities of thought include magical thinking and belief in telepathy or other unusual modes of communication.May talk about sensing a "force" or "presence," or have speech characterized by vagueness, digressions, excessive abstractions, impoverished vocabulary, or unusual use of words.

301.22 Schizotypal Personality Disorder


g. May eventually develop Schizophrenia.


Many are depressed when first come to clinical


Eccentric ideas and style of thinking also place these clients at risk for becoming involved with cults.

Gets along poorly with others and, under stress, may briefly become psychotic.

Many marry and work.

Occurs as often as Schizoid Personality Disorder

301.22 Schizotypal Personality Disorder


Overlapping Diagnoses: Axis I: Paranoid Schizophrenia; Mood Disorder;


Axis II: Borderline; Schizoid


Treatment Options


Supportive Therapy


Underestimating importance of treatment to client. Why would that happen?


Wash Before Wearing (DSM-IV Casebook, p. 289) 301.22 Schizotypal Personality Disorder


Chronically disregard and violate rights of other people; these individuals cannot or will not conform to the norms of society.

Some are engaging con-artists; others may be graceless thugs.

Women are often prostitutes.

Seem superficially charming, but are aggressive and irritable.

This personality disorder affects nearly every life area: In addition to substance use, there may be fighting, lying, and criminal behavior of every conceivable sort: theft, violence, confidence schemes, and child and spouse abuse.

Claim to have guilt feelings, but do not appear to feel genuine remorse for this behavior.

301.7 Antisocial Personality Disorder


Claim to have guilt feelings, but do not appear to feel genuine remorse for this behavior.

Manipulative interactions with others make it difficult to decide whether or not complaints are genuine.

About 3% of men, but only 1% of women have this disorder.

Accounts for 3 out of every 4 penitentiary prisoners.

More common among lower class populations and runs in families; probably both genetic and environmental.

Disorder decreases possibly with increasing age. Individual mellows out after 30; however, still are substance users.

Death by suicide or homicide is sometimes their lot.

Can't get this diagnosis if antisocial behavior occurs only in the context of substance abuse. Crucial to learn whether clients have engaged in illicit acts when not using substances.

Only one-half of children with anti-social background eventually develop the full adult syndrome.


301.7 Antisocial Personality Disorder


Overlapping Diagnoses Axis I Major Depression; Substance abuse

Axis II Borderline; Narcissistic

Treatment Options:

Morrison: No known effective treatment

Others have said:



Behavioral (i.e., token economies, assertiveness training; education);

Cognitive Therapy

Countertransference: Watch your feelings when you see the film.

Gullibility SuspiciousnessFilm: Antisocial Personality Disorder (Tape 3) George #8 301.7 Antisocial Personality Disorder


This concept was devised about the middle of the 20th century. Clients were originally (and sometimes still are) said to be on the borderline between neurosis and psychosis.

The existence of this disorder is disputed by many clinicians.

As the concept has evolved into a personality disorder, it has achieved remarkable popularity, perhaps because so many clients can be shoe-horned into its definition.

About 1-2% of general populations may legitimately qualify for this diagnosis.

These clients have a pattern of instability throughout adult live.

The most over-used diagnosis in the DSM-IV. Many of these clients really have Axis I disorders that are more readily treatable, such as Major Depressive Disorder, Somatization Disorder, and Substance-related Disorders.

Often appear in crisis of mood, behavior, or interpersonal relationships.

301.83 Borderline Personality Disorder


Many feel empty and bored; they attach themselves strongly to others, then become intensely angry or hostile when they believe that they are being ignored or mistreated.

Impulsively try to harm or mutilate selves.

These are cries for help, anger, or attempts to numb selves.

Can have brief psychotic episodes, but resolved so quickly that these are seldom are confused with psychoses like schizophrenia.

With all the mood swings, it is difficult for the client with this diagnosis to achieve fell potential

Truly miserable and about 10% commit suicide.

Antecedents: abandonment; abuse


301.83 Borderline Personality Disorder


Overlapping Diagnoses Axis I Major depression; Dysthymic Disorder; Adjustment Disorder

Axis II Histrionic; Narcissistic; Schizotypal; Antisocial

Treatment Options

Expressive psychodynamic therapy;

Object Relations;

Supportive Psychotherapy;

Brief psychotherapy;

Cognitive-behavior therapy

 In therapy, it is important to:

Address client’s disappointments,

Confront behavior (“When you sleep with every man you date, I wonder what is happening with you.”) Understand that behavior is often a result of loneliness and abandonment issues in childhoodKnow that you will be overvalued and undervalued, as well as loved and hated.Countertransference Feelings: Guilt, Rage, Wanting to rescue and reject client Case: “Empty Shell,” p. 237 301.83 Borderline Personality Disorder


Have long-standing excessive emotionality and attention-

seeking that seeps into all areas of lives.

Satisfy need to be on center stage in two main ways: (a)

their interests and topics of conversation focus on their own desires and activities; and (b) their behavior, including speech, continually calls attention to themselves.

Over-concerned with physical attractiveness.

Express themselves so extravagantly that it seems like a

parody of normal emotionality.

May be promiscuous or have a normal sex life, others may have

difficulty with frigidity or impotence.

Moods seem shallow.

Low tolerance for frustration may spawn temper tantrums. 301.50 Histrionic Personality Disorder


Quick to form new friendships, also quick to become demanding.

Have trouble with tasks that require logical thinking such as doing mental arithmetic.

May succeed in jobs that set premium on creativity and imagination.

This disorder is not well studied, but if quite common.

May run in families.

Classical client is female, but disorder can occur in men.

301.50 Histrionic Personality Disorder


Overlapping Diagnoses

Axis I: Mood Disorders; Somatization Disorder


II: Borderline; Narcissistic





Behavioral; Psychodynamic; Supportive; Group;Countertransference Seductive Indifference


Case: My Fan Club (DSM-IV-TR Casebook, p. 84). Case encompasses

both Histrionic and Narcissistic Personality Disorders.

301.50 Histrionic Personality Disorder


Lifelong pattern of grandiosity (in behavior and in fantasy), thirst for admiration, and lack of empathy.

Permeates most aspect of lives.

Client feels s/he is unusually special.

Commonly exaggerate accomplishments to make self seem bigger than life.

(These traits are true only of adults. Children and teenagers are naturally self-centered; this doesn't imply ultimate personality disorder)


Despite grandiosity, have fragile self-esteem and often feel unworthy.

301.81 Narcissistic Personality Disorder


Sensitive about own feelings, but have little apparent understanding of the feelings and needs of others and may feign empathy.

Because they tend to be concerned with grooming and value youthful looks, they may become increasingly depressed as they age.

Disorder was very poorly studied. Now studied more; people not come for therapy

Most clients are men.

There is no information about family history, environmental antecedents, or other background material. Perhaps mirroring was imperfect. Not seen as person - who child really is. False Self.


301.81 Narcissistic Personality Disorder


Overlapping Diagnoses Axis I Major depression; Adjustment disorder with depressed mood

Treatment Options

Psychodynamic Object Relations

Brief Supportive Therapy Client-centered

Behavioral Cognitive


In therapy, it is important to:

Use metaphors; e.g., cold

Interpret behavior (“When you act so coldly with your wife after she doesn’t understand you, I think that has roots in your childhood when your mother was so distant when you didn’t please her.”)

Use visualization; e.g., crevice

Countertransference: Please the client, Anger, Retaliation 301.81 Narcissistic Personality Disorder


Feels inadequate and is socially inhibited and

overly sensitive to criticism.

Present throughout adult life; however, avoidant

traits are common in children and do not necessarily imply eventual personality disorder.

c. Self-effacing and eager to please others.

Can lead to social isolation, as he/she may misinterpret innocent comments as critical.

Hangs back in social situations.


Avoidant Personality Disorder



Tends to have few close friends.

Comfortable with routine.

Sparse research. Uncommon and almost no

information about sex distribution and family pattern.


. This disorder may be associated with a

disfiguring illness or condition.

Not often seen clinically, for client tends to come for evaluation only when another illness supervenes.


Avoidant Personality Disorder



Overlapping Diagnoses

Axis I: Anxiety

disorder; Dysthymia; Major depression;


Disorder with Depressed Mood.

Axis II: Dependent

; Passive-aggressive

Treatment Options


(systematic desensitization; assertiveness training

) Cognitive Paradoxical (Prescribing avoidant behaviors; prescribing rejections)PsychodynamicImportance of therapeutic relationshipCountertransference Case:Pushing the



Case: The

Jerk (







Avoidant Personality Disorder



Feels the need to be taken care of.

Desperately fears separation

Client’s behavior can become so submissive and clinging that it may result in others' taking advantage or rejecting the client

Feels helpless and uncomfortable when client is alone.

Needs much reassurance, so has trouble making decisions.

May tolerate considerable abuse (even battering)

DPD may occur commonly, but it has not been well studied.

Afraid of independence, because then others will reject him/her

Found more often among women than men.

Some writers believe that it is difficult to distinguish this diagnosis from Avoidant Personality Disorder.

301.6 Dependent Personality Disorder


Overlapping Diagnoses

Axis I: Anxiety disorders; Mood disorder


II: Histrionic; Narcissistic; Avoidant; Schizotypal


Treatment Options


(Assertiveness Training; Exposure to anxiety situations


Cognitive therapy

Family and marital therapyGroup therapyPsychodynamic therapyCountertransferenceGuiltOver-protectiveness


Case: Blood

is Thicker Than Water (DSM-IV Case book, p. 179)

301.6 Dependent Personality Disorder


a. Perfectionistic and preoccupied with orderliness; needs to exert

interpersonal and mental control.

b. Many with this personality disorder have no actual obsessions

or compulsions at all, though some eventually develop OCD.

c. Rigid perfectionism often results in indecisiveness, preoccupation with detail, and insistence that others do things their way.

d. Sometimes savers, refusing to throw away even worthless objects they no longer need.

e. List makers who allocate their own time poorly, workaholics who

must meticulously plan even their own pleasure.

f. May resist authority of others, but insist on their own.

g. May be perceived as stilted, stiff, or moralistic.

h. Condition is fairly common. Diagnosed more often in males than females. i. Probably runs in families

301.4 Obsessive-Compulsive Personality



Overlapping Diagnoses Axis I Mood

Disorders; Anxiety Disorders

Axis II Avoidant

; Dependent


Treatment Options

Behavioral (

In vivo

exposure; compulsive rituals; obsessive ruminations)

Cognitive (thought-stopping; cognitive restructuring)

Paradoxical approaches (to oppositionalism)SupportivePsychodynamic (problems collaborating with intellectualizing defenses; resistance; focusing on affect; use of humor).Countertransference BoredomPower strugglesCollusionCase: The Workaholic (DSM-IV Case book, p. 147)Therapist Compulsivity 301.4 Obsessive-Compulsive Personality Disorder


Used for clients who have insufficient features for a better-defined personality disorder, but who appears to have long-standing personality traits that have cause difficulties in many life areas.

Can also be used for other personality disorders that have not yet received official DSM sanction.

Many individuals have long-standing personality traits, but these traits cut across several personality disorders and they don’t completely meet the criteria for any one of them.

Case: Stubborn Psychiatrist (DSM-IV Case book, p. 166)

301.9 Personality Disorder NOS