Personality DisordersPersonality Disorders

Neurotic Beh

-Anxiety-based-No distortions in reality-Recognizes problem-No great personality disorganization

Psychotic

-Gross distortions in reality (e.g., perception)-Some personality disorganization-Does not recognize problem

Bo r d e r l i n e

Neurotic BehaviourNeurotic Behaviour

““Doing the same thing over and over Doing the same thing over and over expecting a different outcome” expecting a different outcome”

““You yourself produce the thing you fear You yourself produce the thing you fear thethe

most”most” Deals with anxiety-based disorders Deals with anxiety-based disorders

including:including:– Generalized AnxietyGeneralized Anxiety– PanicPanic– Obsessive ComplusiveObsessive Complusive– PhobiasPhobias– Others that have anxiety as a basisOthers that have anxiety as a basis

Neurotic BehaviourNeurotic Behaviour

Maladaptive behaviour pattern Maladaptive behaviour pattern that that does notdoes not involve gross involve gross distortions in reality or marked distortions in reality or marked personality disorganizationpersonality disorganization

Person recognizes that behaviour Person recognizes that behaviour is unacceptable or irrational (ego is unacceptable or irrational (ego dystonic dystonic apart from the ego) apart from the ego)

Neurotic AnxietyNeurotic Anxiety

Central component of anxiety disorders Central component of anxiety disorders and anxiety-based disordersand anxiety-based disorders

No obvious danger or threatNo obvious danger or threat Event or stimulus is, objectively, minor Event or stimulus is, objectively, minor

or insignificant (e.g., mouse, thunder, or insignificant (e.g., mouse, thunder, shopping mall, etc.)shopping mall, etc.)

Neurotic Paradox INeurotic Paradox I

Neurotic evaluates innocuous Neurotic evaluates innocuous events as anxiety provoking events as anxiety provoking inordinate anxiety responseinordinate anxiety response

Deals with anxiety in defensive Deals with anxiety in defensive fashion, usually avoidance fashion, usually avoidance reduces anxiety in short termreduces anxiety in short term

Neurotic Paradox IINeurotic Paradox II

This defensive behaviour results in This defensive behaviour results in self-defeating behaviour:self-defeating behaviour:– Does exactly opposite of what is Does exactly opposite of what is

healthy or adaptivehealthy or adaptive

Neurotic Paradox Neurotic Paradox OutcomesOutcomes

Blocks personal growthBlocks personal growth Relationship problems (especially Relationship problems (especially

intimacy)intimacy) Anxiety focus of lifeAnxiety focus of life Lack of energy and enthusiasmLack of energy and enthusiasm Egocentric concernsEgocentric concerns

Neurotic Paradox ProcessNeurotic Paradox Process

Maximize pleasureMaximize pleasure Minimize painMinimize pain Immediate Effect: Reduce AnxietyImmediate Effect: Reduce Anxiety Long Term: Don’t resolve the Long Term: Don’t resolve the

actual problemactual problem E.G. Doug, the Graduate StudentE.G. Doug, the Graduate Student

Neurotic Styles: Neurotic Styles: CharacteristicsCharacteristics

Deficit in behavioural repertoire Deficit in behavioural repertoire (Inhibition)(Inhibition)

Behaves in an inflexible and Behaves in an inflexible and exaggerated manner exaggerated manner oppositeopposite to to the deficient behaviourthe deficient behaviour

Behaviour does not fully contain Behaviour does not fully contain the anxietythe anxiety

Neurotic StylesNeurotic Styles

Aggression/Assertion InhibitionAggression/Assertion Inhibition Responsibility/Independence Responsibility/Independence

InhibitionInhibition Compliance/Submission InhibitionCompliance/Submission Inhibition Intimacy/Trust InhibitionIntimacy/Trust Inhibition

Aggression/Assertion Aggression/Assertion InhibitionInhibition

Person uncomfortable with aggression Person uncomfortable with aggression and/or assertion and avoids situations and/or assertion and avoids situations where need to engage in this behaviourwhere need to engage in this behaviour

Irrationally clings to cooperative stanceIrrationally clings to cooperative stance Thought to result in problems such as Thought to result in problems such as

hypertension,ulcers, migraines, other hypertension,ulcers, migraines, other stress-related disordersstress-related disorders

Potential sudden aggressive outburstsPotential sudden aggressive outbursts

Responsibility/Independence Responsibility/Independence InhibitionInhibition

Person has aversion to autonomyPerson has aversion to autonomy Avoids situations where they are in Avoids situations where they are in

charge or in control other others or charge or in control other others or themselvesthemselves

Appear incompetent in simple Appear incompetent in simple tasks to “pull” direction by otherstasks to “pull” direction by others

Poor relationships, helplessness, Poor relationships, helplessness, depressiondepression

Compliance/Submission Compliance/Submission InhibitionInhibition

Neurotic is often the “rebel” and Neurotic is often the “rebel” and avoids submission to authorityavoids submission to authority

Need to be non-compliant (i.e., Need to be non-compliant (i.e., self-reliant, independent, free-self-reliant, independent, free-thinking, to a fault)thinking, to a fault)

Intimacy/Trust InhibitionIntimacy/Trust Inhibition

Retreats from closeness and Retreats from closeness and withdraws from people who want withdraws from people who want deeper relationshipsdeeper relationships

All relationships short-term to All relationships short-term to avoid intimacyavoid intimacy

End relationships at crucial points End relationships at crucial points in the establishment of intimacy in the establishment of intimacy (not just romantic relationships, (not just romantic relationships, friendships too)friendships too)

Interpersonal Interpersonal ConsequencesConsequences

Some will result in depending too Some will result in depending too much on others that results in much on others that results in others feeling “used and others feeling “used and manipulated”manipulated”

Unpredictable demands on others Unpredictable demands on others that results in others feeling angry, that results in others feeling angry, frustrated, guilty, etc.frustrated, guilty, etc.

Interpersonal Aspects of Interpersonal Aspects of Neurotic Styles INeurotic Styles I

Extremely sensitive to acts, Extremely sensitive to acts, opinions, feelings of othersopinions, feelings of others

Lack of spontaneity (stilted, Lack of spontaneity (stilted, controlled, mechanical)controlled, mechanical)

Superficial relationships if anySuperficial relationships if any Relationships often stormyRelationships often stormy Private life is one of turmoil and Private life is one of turmoil and

inner tormentinner torment

Interpersonal Aspects of Interpersonal Aspects of Neurotic Styles IINeurotic Styles II

Don’t have large networks of Don’t have large networks of enduring relationshipsenduring relationships

Speculation that some Speculation that some complementary “hooking up” is complementary “hooking up” is match made in hellmatch made in hell– Two people with aggression/assertion Two people with aggression/assertion

inhibitioninhibition– One with responsibility/independence One with responsibility/independence

style and one with style and one with compliance/submsission stylecompliance/submsission style

Personality DisordersPersonality Disorders

When behaviour patterns become When behaviour patterns become inflexible and maladaptive to the inflexible and maladaptive to the point of causing distress or point of causing distress or social/occupation impairment can social/occupation impairment can say have Personality Disorder say have Personality Disorder

Personality DisordersPersonality Disorders

Don’t stem from reactions to stress Don’t stem from reactions to stress but from gradual development of but from gradual development of inflexible and distorted personalityinflexible and distorted personality

Maladaptive ways of perceiving, Maladaptive ways of perceiving, thinking, relating to worldthinking, relating to world

Personality DisordersPersonality Disorders

Excessively rigid patterns of Excessively rigid patterns of behaviour or ways to relating to behaviour or ways to relating to others that prevents people from others that prevents people from adjusting to external demands adjusting to external demands and, thus, become self-defeating.and, thus, become self-defeating.

Have always been there for an Have always been there for an individualindividual

Personality DisordersPersonality Disorders

Mild: Function reasonably well, Mild: Function reasonably well, viewed as troublesome, eccentric, viewed as troublesome, eccentric, etc.etc.

Severe: Extreme or unethical Severe: Extreme or unethical behaviour, may be incarcerated.behaviour, may be incarcerated.

Quote From Lorna Benjamin Quote From Lorna Benjamin (1996)(1996)

““A great way to come down with a A great way to come down with a case of “medical student disease case of “medical student disease (syndrome)” is to read a survey of (syndrome)” is to read a survey of personality disorders”personality disorders”

Some Trait Pattern Some Trait Pattern ExampleExample SuspiciousnessSuspiciousness Self-regardSelf-regard Fear of RejectionFear of Rejection

Come to dominate reactions to Come to dominate reactions to new situationsnew situations

Repetitive maladaptive behaviourRepetitive maladaptive behaviour

Difference between DSM’s Difference between DSM’s Clinical Syndromes & PDClinical Syndromes & PD

Clinical SyndromeClinical Syndrome specific specific symptom clusters, time limited, symptom clusters, time limited, ego-distonic (viewed as separate ego-distonic (viewed as separate from self, unacceptable, from self, unacceptable, objectionable and alien)objectionable and alien)– E.g., depression, anxiety disorders, E.g., depression, anxiety disorders,

psychotic disorderspsychotic disorders

ContinuedContinued

Personality DisorderPersonality Disorder Individual Individual with PD are perceived as ego-with PD are perceived as ego-syntonic (e.g., personality issues are syntonic (e.g., personality issues are acceptable, unobjectionable and acceptable, unobjectionable and part of the self). Tend to blame part of the self). Tend to blame others for problems in their lives. others for problems in their lives.

Difficulties with Diagnosis of Difficulties with Diagnosis of Personality DisorderPersonality Disorder

Need to infer traits to make diagnosis, Need to infer traits to make diagnosis, do not have specific behaviours do not have specific behaviours clinician can judgeclinician can judge

Disorders and criteria are relatively Disorders and criteria are relatively new, therefore not as much research new, therefore not as much research has been done on themhas been done on them

Great deal of overlap among the Great deal of overlap among the disordersdisorders

Hard to draw a line between disorder Hard to draw a line between disorder and normal behaviourand normal behaviour

Personality Disorder Clusters

Cluster One: Odd-Eccentric: – Behaviours similar to schizophrenia,

suspiousness, withdrawal, peculiar thinking

The Odd Eccentric PD Group

1. Paranoid Personality Disorder2. Schizoid Personality Disorder3. Schizotypal Personality Disorder

Paranoid Personality Paranoid Personality DisorderDisorder

Reverend Jim JonesPeople’s Temple

Paranoid Personality Paranoid Personality DisorderDisorder suspicious of other’s motivessuspicious of other’s motives interprets actions of others as interprets actions of others as

deliberately demeaning/threateningdeliberately demeaning/threatening expectation of being exploitedexpectation of being exploited see hidden messages in benign see hidden messages in benign

commentscomments easily insulted/ bears grudgeseasily insulted/ bears grudges appear cold and seriousappear cold and serious

Paranoid Personality Disorder Paranoid Personality Disorder Example Example

Undergraduate student/patient Undergraduate student/patient who followed who followed

Schizoid Personality Schizoid Personality DisorderDisorder

Theodore Kaczynski: Unabomber

SchizoidSchizoid

indifferent to relationshipsindifferent to relationships limited social range (some are limited social range (some are

hermits)hermits) aloof, detached, called lonersaloof, detached, called loners no apparent need of friends, sexno apparent need of friends, sex solitary activitiessolitary activities seem to be missing the “human part”seem to be missing the “human part”

SchizotypalSchizotypal

peculiar patterns of thinking and peculiar patterns of thinking and behaviourbehaviour

perceptual and cognitive perceptual and cognitive disturbancesdisturbances

magical thinkingmagical thinking not psychoticnot psychotic

– perhaps a distant “cousin” of perhaps a distant “cousin” of schizophreniaschizophrenia

Personality Disorder Clusters

Cluster Two: Dramatic-Emotional: – Behaviours are so dramatic,

emotional, or erratic that it is almost impossible to have truly giving and satisfying relationships

– More commonly diagnosed than other PD’s

The Dramatic-Emotional PD Group

1. Antisocial Personality Disorder (Dissocial)2. Borderline Personality Disorder3. Histrionic Personality Disorder4. Narcissistic Personality Disorder

Antisocial Personality Antisocial Personality DisorderDisorder

pattern of irresponsibility, recklessness, pattern of irresponsibility, recklessness, impulsivity beginning in childhood or impulsivity beginning in childhood or adolescence (e.g., lying, truancy)adolescence (e.g., lying, truancy)

adulthood: adulthood: – criminal behaviourcriminal behaviour– little adherence to societal norms, little adherence to societal norms, – little anxietylittle anxiety– conflicts with othersconflicts with others– callous/exploitivecallous/exploitive

Difficulties in establishing secure Difficulties in establishing secure identityidentity

DistrustDistrust Impulsive and self-destructive Impulsive and self-destructive

behaviorbehavior Difficulty in controlling anger and Difficulty in controlling anger and

other emotionsother emotions

Borderline Personality Borderline Personality DisorderDisorder marked instability of mood, marked instability of mood,

relationships, self-imagerelationships, self-image intense, unstable relationships intense, unstable relationships uncertainty about sexualityuncertainty about sexuality everything is “good” or “bad”everything is “good” or “bad” chronic feeling of “emptinesschronic feeling of “emptiness recurrent threats of self-harm/ recurrent threats of self-harm/

“slashers”“slashers”

Single White Female (Jennifer Jason Single White Female (Jennifer Jason Leigh) or Fatal Attraction (Glen Leigh) or Fatal Attraction (Glen Close).Close).

Narcissistic Personality Narcissistic Personality DisorderDisorder grandiose, sense of self-importancegrandiose, sense of self-importance lack of empathylack of empathy hyper-sensitive to criticismhyper-sensitive to criticism exaggerate accomplishments/ exaggerate accomplishments/

abilitiesabilities special and uniquespecial and unique

– entitlemententitlement– below surface is fragile self-esteembelow surface is fragile self-esteem

Armand HammerArmand Hammer

“There has never been anyone like me, and my likes will never be seen again.”

Armand Hammer - AgainArmand Hammer - Again

“The brilliance of my mind can only be described as dazzling. Even I am impressed by it.”

Focus on Borderline PDFocus on Borderline PD

Borderline Personality Borderline Personality DisorderDisorder Therapist “killers” (not really killers)Therapist “killers” (not really killers) Very difficult to treatVery difficult to treat Tend to be avoided by many Tend to be avoided by many

cliniciansclinicians Takes lots of training and Takes lots of training and

experience to treat effectivelyexperience to treat effectively Lots of turmoil in treatmentLots of turmoil in treatment

Borderline Personality Borderline Personality Disorder: Four Core ElementsDisorder: Four Core Elements

Difficulties in establishing secure Difficulties in establishing secure self-self- identityidentity

Distrust & SplittingDistrust & Splitting Impulsive and Self Destructive Impulsive and Self Destructive

BehaviourBehaviour Difficulty in controlling anger and Difficulty in controlling anger and

other other emotionsemotions

Borderline Examples: From Borderline Examples: From TherapistTherapist

First experience with BPD under First experience with BPD under my supervisionmy supervision

Identity DisturbanceIdentity Disturbance

In terms of identity disturbance, she relied In terms of identity disturbance, she relied heavily on a sort of reflected identity from heavily on a sort of reflected identity from others and saw herself as she believed others others and saw herself as she believed others saw her. saw her.

With respect to her poor ego boundaries and With respect to her poor ego boundaries and the melding of her identity with my own, one the melding of her identity with my own, one particularly surprising thing she said to me particularly surprising thing she said to me was that she had googled my name on the was that she had googled my name on the internet and found out that I had won a internet and found out that I had won a presitious academic award. She said she felt presitious academic award. She said she felt really sad because she did not have an award really sad because she did not have an award herself. herself.

Distrust and SplittingDistrust and Splitting

She vascillated quite wildly between She vascillated quite wildly between idealizing me (including telling me that idealizing me (including telling me that she loved me and at times wanted us to she loved me and at times wanted us to sit together on the couch so I could hold sit together on the couch so I could hold her) and devaluing me (lots of anger in her) and devaluing me (lots of anger in session, and a fairly caustic email that session, and a fairly caustic email that said "Ain't it so nice and easy. Tell you said "Ain't it so nice and easy. Tell you what M***, go out and get ourself what M***, go out and get ourself abused, loose that charming smile of abused, loose that charming smile of yours and come back and tell me who's yours and come back and tell me who's mentally ill", which was followed shortly mentally ill", which was followed shortly after by an apologetic one.)after by an apologetic one.)

ContinuedContinued

It was difficult for me to predict from It was difficult for me to predict from week to week whether she would tell week to week whether she would tell me I was dirt  or idealized. She was a me I was dirt  or idealized. She was a good example of someone who used good example of someone who used splitting defenses where she saw splitting defenses where she saw other people (me in particular) in all other people (me in particular) in all good or all bad terms and made good or all bad terms and made rapid shifts between these two rapid shifts between these two positions.positions.

Affective Instability Affective Instability

Affective instability (went along with the wild Affective instability (went along with the wild swings between this sort of coy, coquettish swings between this sort of coy, coquettish behavior and the pronounced anger in behavior and the pronounced anger in session), but also exhibited shallow affect and session), but also exhibited shallow affect and incongruent affect. incongruent affect.

For example, she often smiled or giggled when For example, she often smiled or giggled when she told me about her difficulties and began to she told me about her difficulties and began to ocassionally exhibit sadness in session by ocassionally exhibit sadness in session by crying. However, a little later in therapy she crying. However, a little later in therapy she told me that in fact the tears were fake and told me that in fact the tears were fake and that she was using them because she felt that she was using them because she felt closer to me when I responded to her tears.closer to me when I responded to her tears.

More on DistrustMore on Distrust

She had a long history of interpersonal She had a long history of interpersonal problems and difficulty connecting with problems and difficulty connecting with people. She was quite paranoid about people. She was quite paranoid about what others thought of her and this was what others thought of her and this was quite evident in her comments about her quite evident in her comments about her co-workers whom she felt were against co-workers whom she felt were against her (and, frankly, she may have been her (and, frankly, she may have been right) and in her desire to see her chart right) and in her desire to see her chart in the hopes that it would finally reveal in the hopes that it would finally reveal the intense dislike for her that she the intense dislike for her that she imagined I felt.imagined I felt.

Termination: Always Termination: Always difficultdifficult

We spent about 2 months preparing for and We spent about 2 months preparing for and discussing termination and it still went poorly. discussing termination and it still went poorly. She was angry and her parting gift to me was She was angry and her parting gift to me was a plant that contained a set of tiny clay pots a plant that contained a set of tiny clay pots (sort a decorative thing) partially submerged (sort a decorative thing) partially submerged in the soil. She gave the clinic secretary the in the soil. She gave the clinic secretary the same thing, but she was careful to say "this same thing, but she was careful to say "this one is for the secretary, and this one is for one is for the secretary, and this one is for you", when I looked at the two later, the one you", when I looked at the two later, the one that she gave me had the tiny clay pots that she gave me had the tiny clay pots smashed, while Geraldine's were intact. A final smashed, while Geraldine's were intact. A final parting message.parting message.

Self-Destructive BehaviourSelf-Destructive Behaviour

Drug abuseDrug abuse Suicide threatsSuicide threats Lots of promiscuityLots of promiscuity