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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?
Cluster A
oddness and eccentricity
Cluster B
dramatic and emotional
Cluster C
anxious
Other Specified (AKA NOS)?
"General Personality Disorder"
But the client does not meet criteria for any one specific personality disorder
Impairment of Personality Functioning:
Specific Pathological Personality Traits
Includes only six of the DSM-IV PDs
Personality Disorder - Trait Specified
"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
Behavioral Patterns (Linehan, 1993)
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
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
feeling misunderstood or unappreciated
lack of empathy or consideration of
partners' feelings leads to conflict
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