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DSM-5 Personality Disorders

What do we mean by "Personality Disorder"?

"An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the 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."

What are some unique features

of personality disorders?

  • Long-standing, beginning in late adolescence or early adulthood

  • Stable over time and across situations

  • Impaired sense of self-identity

  • Failure to develop adequate interpersonal functioning

Cluster A

oddness and eccentricity

Cluster B

dramatic and emotional

Cluster C

anxious

Other Specified (AKA NOS)?

"General Personality Disorder"

  • Cognition (USO)
  • Affectivity (Range, intensity, etc.)
  • Interpersonal functioning
  • Impulse control

But the client does not meet criteria for any one specific personality disorder

Impairment of Personality Functioning:

  • Self
  • Identity
  • Self-Direction
  • Interpersonal
  • Empathy
  • Intimacy

Specific Pathological Personality Traits

  • Negative Affectivity
  • Detachment
  • Antagonism
  • Disinhibition
  • Psychoticism

Includes only six of the DSM-IV PDs

  • Antisocial
  • Avoidant
  • Borderline
  • Narcissistic
  • Obsessive-Compulsive
  • Schizotypal

Personality Disorder - Trait Specified

  • Rate level of impairment (0-4) on identity, self-direction, empathy, and intimacy.
  • Select the personality trait domains that apply, or specific facets within those domains.
  • Titanium is not set up to do this.

"It's all about ME!"

Diagnostic criteria (DSM-5 = 301.81)

The Diagnostic and Statistical Manual of Mental Disorders fifth edition, DSM-5, a widely used manual for diagnosing mental disorders, defines narcissistic personality disorder as:

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 others are envious of him or her

9.shows arrogant, haughty behaviors or attitudes

Unprincipled (antisocial features)

Amorous or Exploitive Egotist (histrionic features)

Compensatory (negativistic/avoidant features)

Elitist (pure)

Causes?

Narcissistic "Wounds": Neglect and abuse result in a

child defending against low self-

worth and shame by developing a

fantasy of self as special, gifted, superior,

and deserving of fame, praise and accolades

Oversensitive Emotional Temperament: Vulnerability to shaming

Parental Shortcomings: Overindulgence, overpraise, lack of corrective

feedback lead to the core of the child's identity

is superiority and infallibility and create

an expectation that s/he will be idolized by all.

Cultural Factors:

Roadblocks in Therapy:

Highly defended

Distorts reality to fit grandiose self-image

Problem lies in others

Can't empathize

Low insight

Treatment Strategies (Millon, et al., 2004; Benjamin, 1996)

Gentle, consistent, accurate empathy reflecting painful emotional experience while facilitating insight into causes.

Modeling: Taking responsibility for mistakes, being comfortable with imperfection, avoiding externalizing blame

Cognitive strategies geared toward reducing grandiose thoughts

Interpersonal interventions geared toward increasing empathy and care for others (e.g. emotionally connecting, identifying emotions in others, acknowledging the importance of how others feel).

"I Hate You, Don't Leave Me!"

Diagnostic criteria for 301.83 Borderline Personality Disorder

(cautionary statement)

A pervasive pattern of instability of interpersonal relationships, self-image, 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

Millon's Subtypes

  • Discouraged
  • Impulsive
  • Petulant
  • Self-Destructive

Behavioral Patterns (Linehan, 1993)

  • Emotional vulnerability

  • Self-invalidation

  • Unrelenting Crises

  • Inhibited grieving

  • Active passivity

  • Apparent competence

Causes?

Developmental problems regarding object constancy and separation/individuation

Invalidating environments and emotional sensitivity/vulnerability

Early Trauma/Loss

Genetic Predisposition for neurobiological

problems

Interaction of multiple factors

Therapeutic Strategies

DBT

validation, problem solving, skills training

Schema-Focused Cognitive Therapy

change abandonment schemas through

emotive, interpersonal, cognitive, and behavioral

interventions

Medications

antidepressants (SSRI, MAOI), mood stabilizers,

antipsychotics

Interpersonal Process Groups

corrective emotional experience, interpersonal

learning, dealing with loss, reality testing

Therapeutic Roadblocks

  • Splitting

  • Feeling intimidated and overwhelmed by the emotional intensity and destructive behaviors

  • Feeling overly responsible

  • Low professional self-esteem

  • Brief Therapy Models

Therapeutic Tips

Avoid victim blaming

Focus on effectiveness of behaviors rather than character

Avoid pejorative descriptors

Reframe destructive behaviors as attempts to solve a problem

Remember that emotional pain in combination with a lack of problem-solving skills lead to many destructive behaviors.

Try not to take anger personally; it is a cover for hopelessness, anxiety, hurt, desperation

Keep in mind the client's emotional vulnerability, despite appearances (e.g. prickly hostility)

Keep your empathy skills handy

Communicate clearly about personal limits

Teach “therapy-enhancing behaviors”

Bibliography and Resources

I Hate You---Don’t Leave Me, by J.J. Kreisman and H. Straus. New York:

Penguin, 2010.

Borderline Personality Disorder Demystified: An essential guide for

understanding and living with BPD, by R. Friedel. Cambridge, MA:

Da Capo, 2004.

Cognitive Therapy for Personality Disorders: A Schema-Focused Approach,

by J. Young. Sarasota, FL: Professional Resource Press, 1994.

Personality Disorders in Modern Life (2nd ed.), by T. Millon, S. Grossman,

S. Meagher, C. Millon, and R. Ramnath. New York: Wiley, 2004.

The Theory and Practice of Group Psychotherapy (5th ed.), by I. Yalom and M.

Leszcz. New York: Perseus, 2005.

Cognitive-Behavioral Treatment of Borderline Personality Disorder, by M.

Lineham. New York: Guilford, 1993.

Essentials of PAI Assessment, by L. Morey. New York: Wiley, 2003.

The Drama of the Gifted Child: The search for the true self (Rev. ed.), by

A. Miller. New York: Perseus, 1996.

Diagnostic and Statistical Manual of Mental Disorders (4th ed., Text Rev.), by

The American Psychiatric Association. Washington, D.C.: American

Psychiatric Association, 2000.

Paranoid

Schizoid

Schizotypal

Borderline

Summary of Borderline Features (Morey, 2003)

Affective Instability

extreme reactivity and intensity, poor modulation,

rapid changes

Identity Problems

emptiness, lack of purpose, shifting goals/interests

Negative Relationships

ambivalent, intense, feeling abandoned or victimized

Self Harm

impulsivity around suicidal behaviors, destructive tension-reducing

behaviors

Narcissistic

Millon's Subtypes

Therapist Countertransference

  • interpersonal difficulties

feeling misunderstood or unappreciated

lack of empathy or consideration of

partners' feelings leads to conflict

  • depression or anxiety

fantasy undeniably different from reality

ego is deflated

feelings of emptiness, failure

Why would someone with NPD come to therapy?

"It's all about ME!"

Histrionic

Antisocial

Avoidant

Obsessive-Compulsive

Dependent

Pattern of experience and behavior affects

at least two of the following:

DSM-5 Alternative Model

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