Personality Disorders. Neurotic-Borderline-Psychotic Cluster A- Psychotic- odd/eccentric Paranoid,...
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Transcript of Personality Disorders. Neurotic-Borderline-Psychotic Cluster A- Psychotic- odd/eccentric Paranoid,...
Personality Disorders
Neurotic-Borderline-Psychotic
Cluster A- Psychotic- odd/eccentric Paranoid, Schizoid, Schizotypal
Cluster B- Borderline- dramatic/emotional Antisocial, Borderline, Histrionic,
Narcissistic Cluster C- Neurotic- anxious/fearful
Avoidant, Dependent, OCPD
Personality Disorders ARE
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 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 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….
If overestimates threat of underestimates- help form more realistic appraisal of coping
If coping lacks, help build it Cognitive errors:
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 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 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 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
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 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 Acute discomfort with close relationships
Difficulty with social cues and interactions Anxious around others
Cognitive and perceptual distortions 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
Cognitions 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
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
GOALS: 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 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 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 COG Distortions:
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 me-Importance of others
How to interact therapeutically with APD
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 Will try to enlist therapist as ally against others or con
therapist into being impressed by cl’s insights and reform
TX APD 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 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
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 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 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 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 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 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 self-
exploration
Goals for the Histrionic PD 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)
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
fragmented- help 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)
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 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
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 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).
Help to think in more middle ground. Help to make comparisons intrapersonally. Help to find similarities with others
COG: Cl comes up w/ evidence for alt beliefs (DTR) 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
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
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):
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 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 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 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 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 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 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 self-reliance and mutual dependence
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)
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 Force ambivalence and anxiety out of consciousness and express
passively (thus reactive to E) or impose strict rules
Cog Distortions of OCPD Cog distortions-OCPDs like CBT
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 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 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
Remain warm and kind, as they are used to people becoming frustrated with them
Know that unfamiliar situations are more difficult for them and this includes therapy
Address vulnerability to shame
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 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)