Definition of Personality Trait

Enduring patterns of perceiving, Click to edit Master subtitle stylerelating to, and thinking about the environment and oneself that are exhibited in a wide range of social and personal contexts

Definitional Features of Personality Disorder

Click to edit Master subtitle style Enduring pattern of inner

experience and behavior that deviates markedly from the expectations of the individuals culture and is manifested in at least two of the following areas:

Definitional Features of Personality Disorder

The pattern is manifested in at least two of the following areas: cognition, affectivity, interpersonal functioning, or impulse control (Criterion A) The enduring pattern is inflexible and pervasive across a broad range of personal and social situations (Criterion B) Leads to significant distress or impairment in social, occupational, or other important areas of functioning (Criterion C)

Definitional Features of Personality Disorder

The pattern is stable and of long duration, and its onset can be traced back to adolescence or early adulthood (Criterion D) The pattern is not better accounted for as a manifestation or consequence of another mental disorder (Criterion E) The pattern is not due to the direct physiologic effects of a substance or a general medical condition (Criterion F)

Three Clusters of Personality Disorders

Cluster A (odd eccentric)

Paranoid Schizoid Schizotypal

Three Clusters of Personality Disorders

Cluster B (dramatic-emotional)

Antisocial Borderline Histrionic Narcissistic

Three Clusters of Personality Disorders

Cluster C (anxious-fearful)

Avoidant Dependent Obsessive-compulsive

The Challenge of Working With Personality Disorders

Patients typically come for therapy with presenting problems other than personality problems They require more work within the session Longer duration of treatment Greater strain on the therapists skills and patience Greater difficulty in treatment compliance

Red Flags for Identifying Personality Disorders

A patient or significant other reports that the patient has always done that or has always been that way The patient is not compliant with the therapeutic regimen Therapy progress seems to have come to a complete stop for no apparent reason Patients often will seem unaware of the effect their behavior has on others Patients problems appear to be acceptable and natural for them

Becks Theory of Personality Disorders

Certain behavioral patterns or strategies that had adaptive value in evolutionary terms, become maladaptive in todays society when these strategies become exaggerated

Becks Theory of Personality Disorders

A strong relationship exists between the cognitive patterns on the one hand and the affective and behavioral patterns on the other

Definition of Schemas

Click to edit Master subtitle style Schemas are relatively stable information processing structures that operate in a feed-forward system to guide the processing of information. They are not themselves conscious, although they can be recognized, evaluated, and their interpretations tested.

Characteristics of Schemas

They integrate and attach meaning to events They can be described in terms of valence or level of activation They can be of a highly idiosyncratic content

Characteristics of Schemas

They vary according to their function When particular schemas are hypervalent, the threshold for activation of the constituent schemas is low

Becks Theory of Personality Disorders

Each personality disorder has its own profile that can be characterized by core beliefs about the self and others and compensatory strategies associated with those core beliefs

Becks Profile of Personality Disorders

Personality Disorder
Avoidant

View of Self
Vulnerable to rejection, Inept, Incompetent

View of Others

Main Belief

Main Strategy

Becks Profile of Personality Disorders

Personality Disorder
Avoidant

View of Self

View of Others

Main Belief

Main Strategy

Vulnerable to Critical rejection, Superior Inept, Incompetent Demeaning

Becks Profile of Personality Disorders

Personality Disorder
Avoidant

View of Self

View of Others

Main Belief

Main Strategy

Vulnerable to Critical rejection, Superior Inept, Incompetent Demeaning

Its terrible to be rejected; If people know the real me, they will reject me

Becks Profile of Personality Disorders

Personality Disorder
Avoidant

View of Self

View of Others

Main Belief

Main Strategy

Vulnerable to Critical rejection, Superior Inept, Incompetent Demeaning

Its terrible to be Avoids evaluative rejected; If people situations know the real me they will reject me

Becks Profile of Personality Disorders

Personality Disorder
Paranoid

View of Self
Righteous Innocent Noble Vulnerable

View of Others

Main Belief

Main Strategy

Becks Profile of Personality Disorders

Personality Disorder
Paranoid

View of Self
Righteous Innocent Noble Vulnerable

View of Others
Interfering Malicious Abusive motives

Main Belief

Main Strategy

Becks Profile of Personality Disorders

Personality Disorder
Paranoid

View of Self
Righteous Innocent Noble Vulnerable

View of Others
Interfering Malicious Abusive motives

Main Belief
Be on guard, Dont trust, Motives are suspect

Main Strategy
Accuse or Counter-attack

Becks Profile of Personality Disorders

Personality Disorder
Paranoid

View of Self
Righteous Innocent Noble Vulnerable

View of Others
Interfering Malicious Abusive motives

Main Belief
Be on guard, Dont trust, Motives are suspect

Main Strategy
Accuse or Counter-attack

Becks Profile of Personality Disorders

Personality Disorder
Dependent

View of Self
Needy Weak Helpless Incompetent

View of Others

Main Belief

Main Strategy

Becks Profile of Personality Disorders

Personality Disorder
Dependent

View of Self
Needy Weak Helpless Incompetent

View of Others
Nurturant Supportive Competent

Main Belief

Main Strategy

Becks Profile of Personality Disorders

Personality Disorder
Dependent

View of Self
Needy Weak Helpless Incompetent

View of Others
Nurturant Supportive Competent

Main Belief
Need people to survive; Need steady flow of support, encouragement

Main Strategy

Becks Profile of Personality Disorders

Personality Disorder
Dependent

View of Self
Needy Weak Helpless Incompetent

View of Others
Nurturant Supportive Competent

Main Belief

Main Strategy

Need people to survive; Cultivate dependent Need steady flow of support, encouragement relationships

Becks Profile of Personality Disorders

Personality Disorder
Obsessivecompulsive

View of Self
Responsible Accountable Competent Fastidious

View of Others

Main Belief

Main Strategy

Becks Profile of Personality Disorders

Personality Disorder
Obsessivecompulsive

View of Self
Responsible Accountable Competent Fastidious

View of Others
Irresponsible Casual Incompetent Self-indulgent

Main Belief

Main Strategy

Becks Profile of Personality Disorders

Personality Disorder
Obsessivecompulsive

View of Self
Responsible Accountable Competent Fastidious

View of Others
Irresponsible Casual Incompetent Self-indulgent

Main Belief
I know whats best Details are crucial People should do better, try harder

Main Strategy

Becks Profile of Personality Disorders

Personality Disorder
Obsessivecompulsive

View of Self
Responsible Accountable Competent Fastidious

View of Others
Irresponsible Casual Incompetent Self-indulgent

Main Belief

Main Strategy

I know whats best Apply rules Details are crucial Perfectionism People should do better, Evaluate try harder Control Criticize

Becks Profile of Personality Disorders

Personality Disorder
Narcisstic

View of Self
Special, unique Superior Deserve special rules

View of Others

Main Belief

Main Strategy

Becks Profile of Personality Disorders

Personality Disorder
Narcisstic

View of Self

View of Others

Main Belief

Main Strategy

Special, unique Inferior Superior Admirers of me Deserve special rules

Becks Profile of Personality Disorders

Personality Disorder
Narcisstic

View of Self

View of Others

Main Belief
Since Im special I deserve special rules Im better than others

Main Strategy

Special, unique Inferior Superior Admirers of me Deserve special rules

Becks Profile of Personality Disorders

Personality Disorder
Narcisstic

View of Self

View of Others

Main Belief
Since Im special I deserve special rules Im better than others

Main Strategy
Use others Transcend rules Manipulate

Special, unique Inferior Superior Admirers of me Deserve special rules

Becks Profile of Personality Disorders

Personality Disorder
Schizoid

View of Self
Self-sufficient Loner

View of Others

Main Belief

Main Strategy

Becks Profile of Personality Disorders

Personality Disorder
Schizoid

View of Self

View of Others

Main Belief

Main Strategy

Self-sufficient Intrusive Loner

Becks Profile of Personality Disorders

Personality Disorder
Schizoid

View of Self

View of Others

Main Belief
Others are unrewarding Relationships are undesirable

Main Strategy

Self-sufficient Intrusive Loner

Becks Profile of Personality Disorders

Personality Disorder
Schizoid

View of Self

View of Others

Main Belief

Main Strategy

Self-sufficient Intrusive Loner

Others are unrewarding Stay Away Relationships are undesirable

Cognitive Therapy for Personality Disorder

Background Click to edit Master subtitle style

Therapeutic Assumptions

Therapy will often evoke anxiety because the patient is being asked to change who they are Patients with personality disorders often come to therapy with presenting issues other than personality problems Patients with personality disorders are more difficult to treat Therapy must take a tripartite approach Schema work takes a much more central role in CT with personality disorders A much greater emphasis is placed on the client-therapist relationship

Problems in Collaboration

Therapist or patient may lack the skill to be collaborative Patients beliefs regarding the potential failure in therapy Patients beliefs (fears) regarding the effects of changing on significant others or himself Poor socialization to the cognitive therapy model Frustration due to lack of progress

Cognitive Techniques

Guided discovery Labeling of inaccurate inferences Collaborative empiricism Examining explanations of others behavior Scaling Reattribution training Deliberate exaggeration Decatastrophizing

Behavioral Techniques

Click to edit Master subtitle style

Goals of Behavioral Techniques

Alter self-defeating compensatory behaviors Skill building (e.g., assertiveness) Behavioral experiments designed to weaken maladaptive beliefs

Specific Behavioral Techniques

Role playing Use of imagery Reliving childhood experiences Assisting in decision-making

Borderline Personality Disorder

Click to edit Master subtitle style

Significance of BPD

2% of general population meet for BPD 11% of outpatients and 19% of inpatients meet criteria for BPD (Widiger & Francis, 1989) Of those meeting for some personality disorder, 33% of outpatients and 63% of inpatients meet for BPD 70-75% of BPD patients have a history of selfinjurious acts

Significance of BPD Cont.

Estimates of suicide rates for BPD patients are approximately 10% 74% of BPD referred patients are women

Diagnostic Features of BPD

Hypersensitivity to abandonment Pattern of unstable and intense interpersonal relationships Unstable self-image or sense of self Marked impulsivity Recurrent suicidal behavior Affective instability Chronic feelings of emptiness Inappropriate or intense anger or difficulty controlling anger Transient stress-related paranoid ideation or dissociative symptoms

CBT for Borderline Personality Disorder (Linehan)

Click to edit Master subtitle style

Linehan Model
E m I n E o t i o n R e g v a l i d a t i n g m ( A u E l a t i o n n v ir o D n m y

o t io n a l V u l n e r a b i l f f e c t i v e I n s t a b i l i t y ) e b r s S ne al f l o i lI i nt y s t a b C o g n i t i v i l I i nt y s t a b i l i

B e h a v I i no t r e r p I n s t a b i l I i nt y s t a

Components of Emotional Dysregulation

Emotional vulnerability

High sensitivity to emotional stimuli Intense response to emotional stimuli Slow return to emotional baseline once emotional arousal has occurred

Components of Emotional Dysregulation

Deficits in emotion modulation strategies

Ability to inhibit inappropriate behavior related to strong negative or positive emotions Ability to act in a way that is not mood-dependent Ability to self-soothe any physiological arousal that the strong emotion has induced Ability to refocus attention in the presence of strong emotion

Features of the Invalidating Environment

During development, people respond to the communication of the child's preferences, thoughts, and emotions with either nonresponsiveness or more extreme negative consequences An invalidating environment emphasizes the inhibition of emotional expressiveness

Role of the Invalidating Environment

Persistent discrepancies between a childs private experience and what others in the environment respond to as her experience provide the fundamental learning environment for many of the behavioral problems associated with BPD

Consequences of the Invalidating Environment

Child fails to learn how to label emotion or modulate emotional arousal Child fails to learn to tolerate distress or form realistic goals and expectations Child learns that extreme emotional reactions will sometimes provoke a helpful environmental response Child fails to learn to trust her own internal experiences and hence looks for external cues about how to think, act, and feel

Linkage of Emotional Dysregulation and BPD Behavioral Characteristics

The behavioral characteristics of borderline individuals (i.e., self-mutilation, suicide attempts) can be conceptualized as the effects of emotional dysregulation and maladaptive emotional regulation strategies

Linkage of Emotional Dysregulation and BPD Behavioral Characteristics

Emotional lability leads to unpredictable behavior and cognitive inconsistency, thus interfering with identity development The chaotic relationships seen with BDPs is understandable given the persons difficulties in controlling impulsive behaviors and negative emotions

Areas of Divergence From Standard CBT

Emphasis on acceptance and validation of behavior as it is in the moment DBT emphasizes the importance of balancing the technology of change with the technology of acceptance

Areas of Divergence From Standard CBT

Emphasis on treating therapy-interfering behaviors of both client and therapist Emphasis on the therapeutic relationship as essential to treatment Emphasis on dialectic processes

Characteristics of the DBT Treatment

Applies many standard CBT principles and techniques Attempts to reframe suicidal and other dysfunctional behaviors

Characteristics of the DBT Treatment

Adopts a problem-solving focus Encourages exposure to fear-eliciting stimuli

Characteristics of the DBT Treatment

Gives some attention to cognitive change techniques

Characteristics of the DBT Treatment

Emphasizes strategies for validating client's thoughts, feelings, and actions

Characteristics of the DBT Treatment

Emphasis on modifying current maladaptive behaviors before ameliorating long-standing interpersonal conflicts or the effects of early trauma and abuse Combines therapy into two conceptual components psychosocial skills training and motivational issues

Major Modes of Treatment in DBT

Individual psychotherapy Group skills training Telephone consultation Case consultation for therapists

Specific Skill Training Modules in DBT

Emotional regulation skills

Understanding emotions and their reactions Observing emotions Experiencing emotions Reducing emotional vulnerability through exercise and reducing alcohol/drugs

Specific Skill Training Modules in DBT

Interpersonal effectiveness skills

Specific Skill Training Modules in DBT

Distress tolerance skills

Distraction techniques Self-soothing procedures Realistically evaluating the pros and cons of tolerating events Acceptance strategies

Specific Skill Training Modules in DBT

Mindfulness skills

Paying attention to the ebb and flow of emotional experience Paying attention to thoughts in the moment Paying attention to action urges Practice labeling them correctly Practice accepting them w/o trying to suppress them

Efficacy Data

(Linehan, 1991;1993) Click to edit Master subtitle style

CBT Treatment of Avoidant Personality Disorder

Renneberg et al (1990) Click to edit Master subtitle style

Study Overview

17 patients were administered an intensive 4 day group treatment program consisting of (1) group systematic desensitization; (2) Behavioral rehearsal; (3) self-image enhancement

Major Findings

50 45 % of patients meeting Jacobsen Criteria 40 35 30 25 20 Improved Recovered

Data from Renneberg et al (1990). Behavior Therapy, 21, 363-367.

CBT Treatment of Avoidant Personality Disorder

Alden (1989) Click to edit Master subtitle style

Design

4-arm randomized clinical trial (constructive strategy design)

Graduated exposure Graduated exposure + Interpersonal skill training Graduated exposure + Interpersonal skill training + Intimacy Focus Wait-list control

Subjects

76 subjects (42 men, 34 women) all unmarried Meeting DSM-III criteria based on clinical interview Must score above the 75% on Millons AVPD scale No current substance abuse or psychotropic medication

Treatments

10 weekly group sessions (2-2.5 hour duration) Each group had 6-7 participants 6 masters-level therapists (2 therapists per group)

Results

Patients in all three active treatments improved significantly compared to the wait-list There were no significant differences between the three active treatments suggesting skill training did not add to the efficacy of graduated exposure

Results Cont.

Significant others rated the patients improvement as noticeable; Clinical significance analyses revealed that while treated patients improved 1 SD during treatment, their scores did not move into the range of a normative sample

Effectiveness of Psychotherapy for Personality Disorders: A Quantitative Review

Perry et edit Master Click to al (1999) subtitle style

Description of Included Studies

15 studies examining treatments for personality disorders that included pre-to posttreatment data Of these only 6 were randomized studies and 9 were uncontrolled treatment studies 5 focused on BPD, 1 schizotypal, 1 avoidant, and 8 mixed

Description of Included Studies Cont.

Treatment Modalities

7 studies psychodynamic 4 studies CBT 2 Interpersonal group psychotherapy 1 Supportive psychotherapy

Major Findings

Drop-out rates varied considerably and averaged 21.8% Drop-outs were positively associated with longer treatments Mean pre- to posttreatment effect sizes were 1.11 for self-report measures amd 1.29 for observer-rated measures These did not differ for the different types of treatment