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A personality disorder involves enduring behavior that deviates from what is expected in their culture. What are the 3 categories of personality disorders?
Cluster A: Odd & Eccentric (Schizoid, Paranoid, Schizotypal)

Cluster B: Dramatic, Eratic, & Overemotional (antisocial, borderline, histrionic, narcissistic)

Cluster C: Anxious & Fearful (dependent, avoidant, obsessive compulsive)
What is compromised/altered in a person diagnosed with a personality disorder?
2 or more:
cognition
affect
interpersonal functioning
impulse control
(thinking, feeling, behaving, & perceiving)
A Personality Disorder is all of the following EXCEPT:
a. inflexible
b. enduring
c. distressful to the individual
d. all of the above
c. distressful to the individual

It is distressful to those around them
What is sociocentric personality structure?
When identification is centered in the group so that the individual is subordinate to the group and lack personality outside of it. An example of how culture can impact which traits we adopt/value
What is egocentric personality structure?
Personality is centered in the self and thus the person sees themself as autonomous. In this case culture values traits promoting autonomy and devaluing dependence.
How do hierarchies within a culture impact us?
determine whether the individual or the group is more im portant
what traits to stigmatize
how we deal with stigma
What does

Axis II: w/borderline features

mean?
there are several symptoms suggesting some borderline symptoms
What are the properties of psychological defenses?
-they manage instinct & affect
-are unconscious
-are discrete from each other
-often indicate certain kinds of psychiatric difficulties
-are adaptive as well as pathological
What are some narcissistic psychological defenses?
Denial, distortion, primitive idealization, projection, projective identification, splitting
What are some of the immature psychological defenses?
acting out, identification, projection, regression, somatization, passive-aggressive
What are some of the neurotic psych defenses?
controlling, displacement, dissociation, inhibition, intellectualization, isolation, rationalization, reaction formation, repression, sexualization, undoing
What are the more mature psychological defenses?
altruism, anticipation, humor, sublimation
What are the features of Cluster A: Odd & Eccentric PDs?
Paranoid, Schizoid, Schizotypal,
-overlap w/psychotic disorders
-considered to be in the schizophrenic spectrum of disorders
-genetic &/or environmental factors that are related to more serious conditions (i.e., schizophrenia or schizoaffective) may be present to a lesser degree
What are the features of Cluster B: Dramatic, Erratic, & Overemotional PDs?
Borderline, histrionic, narcissistic, anti-social
-overlap w/mood & impulse control disorders
- considered to be disorders w/externalizing symptoms
What are the features of Cluster C: Anxious & fearful PDs?
Dependent, obsessive compulsive, avoidant
- overlap with anxiety disorders
- considered to be disorders w/internalizing symptoms
Paranoid Personality Disorder
A. Distrust/suspicious of others. Interprets motives as malevolent. 4 or more:
1) suspect w/o evi that others are exploiting, harming, or deceiving
2) Doubt loyalty of others
3) Reluctant to confide
4) Reads hidden demeaning/ threats into benign remarks
5) bears grudges
6) Quick to react/counterattack to perceived attacks
7) Worries about fidelty of partner

B. R/O Delusional & schizo conditions
Diff than Delusional b/c general suspiciousness, not a small set of well-developed delusions
Schizoid PD
A. Detachment from social relationships & restricted range of emotional expression in interpersonal settings. 4 or more:
1) Neither enjoys or desires close relationships
2) Chooses solitary activities
3) Little interest in sexual experiences
4) Takes pleasure in few, if any activities
5) Lacks close friends or confidants
6) indifferent to praise/criticism
7) emotional coldness/ detached/ flat affect
B. R/O other disorders & GMC. if criteria met prior to onset of Schizophrenia add Premorbid SPD
Schizotypal PD
A. Social/interpersonal deficits including acute discomfort with/inability for close relationships & by cog + perceptual distortions/ eccentricities. 5 or more:
1) ideas of reference 2) odd beliefs/ magical thinking
3) unusual perceptual experiences 4) odd thinking & speech
5) suspicious/ paranoid ideation 6) inappropriate/ constricted affect
7) Bx/ appearance that is odd, eccentric, peculiar
8) lack of close friends/ confidants 9) excessive social anxiety
B. R/O another disorder
Histrionic PD
A. Pervasive pattern of excessive emotionality & attention seeking. 5 or more of the following:
1) uncomfortable when not center of attention
2) inappropriate sexually seductive/ provocative Bx
3) Rapidly Shifting & shallow expression of emotions
4) Uses physical appearance to draw attention
5) shallow & impressionistic speech
6) self-dramatization
7) suggestible
8) Considers relationships to be more intimate than they really are
Narcissistic PD
A. Pervasive pattern of grandiosity, need for admiration, and lack of empathy. 5 or more:
1) sense of self-importance
2) preoccupied w/fantasies of unlimited wealth or power, brilliance, beauty, etc
3) believes that he is special and unique, and can only assoc w/other special and unique people
4) requires excessive admiration
5) sense of entitlement
6) Interpersonally exploitative
7) lacks empathy
8) envious of others
9) arrogant, haughty, behaviors or attitudes
Borderline PD
A. Pervasive pattern of unstable relationships, self-image, and affect, and markedly impulsive. 5 or more:
1) frantically avoids real or imagined abandonment
2) unstable/intense interpersonal relationships (idealization/devaluation)
3) identity disturbance
4) Impulsivity in 2 areas
5) recurrent suicidal bx
6) affective instability
7) emptiness
8) intense anger
9) transient stress related paranoid ideation
Antisocial PD
A. Pervasive pattern of disregard for and violation of others rights, since age 15. 3 or more:
1) failure to conform to social norms
2) deceitfulness
3) Impulsivity, failure to plan ahead
4) irratibility or aggressiveness
5) disregard for safety of self or others
6) consistent irresponsibility
7) lack of remorse
B) AT least 18 yrs of age
C) evi of conduct disorder with onset prior to age 15
D) R/O other disorders
Avoidant PD
A. Pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative eval. 4 or more:
1) avoids occupational act. w/a sig amount of interpersonal contact
2) unwilling to be involved w/people unless certain of being liked
3) restraint within interpersonal relationships
4) preoccupied w/being criticized or rejected
5) inhibited in new interpersonal situations
6) views self as socially inept
7) reluctant to take risks or engage in new activities
Dependent PD
A. Pervasive & excessive need to be taken care of that leads to submissive & clinging bx and a fear of separation. 5 or more:
1) diff. making everyday decisions
2) needs others to assume responsibilty
3) difficulty expressing disagreement
4) diff. initiating projects or doing things
5) excessive lengths to obtain nurturance and supp
6) feels uncomfortable or helpless when alone
7) seeks a new relationship when another one ends
8) preoccupied w/fears of being left to take care of things by him or herself
Obsessive Compulsive personality Disorder
A. Preocc w/orderliness, perfectionism, & mental & interpers control; inflexibility, inhibited openness & efficiency. 4 or more:
1) Preocc w/details, lists, rules, order, org, or schedules, & major pt of activity is lost
2) shows perfectionism that interferes w/task completion
3) excessive devotion to work/ productivity at expense of fun & friends
4) Overconscientious, scrupulous, inflexible re: morality/ethics/values
5) Unable to disregard worn out or worthless objects w/o sentimental value
6) reluctant to delegate tasks
7) miserly spending style
8) rigidity and stubborness
How does someone with Paranoid PD present?

Defense Mechanisms?
Holds grudges w/o justification, expects to be exploited, sees threats and personal attacks where they don't exist, fears betrayal, questions spouse's fidelity w/o justifiable reason
- Attempts to appear unemotional
- Common defense mechanism: PROJECTION, denial, splitting, reaction formation

Holds grudges, abrasive, hostile

Usually labile, but try to project that nothing bothers them
What are the psychodynamic & CBT techniques used for those w/Paranoid PD?
1. Psychodynamic: trust needs to be established & do NOT question paranoid ideas or overanalyze

2. Cognitive: use action to establish trust by improving their coping skills
Paranoid PD -

Transference & Countertransference
Transference: usually negative & see therapist as trying to expose them (projection, projective ID)

Countertransference: anxious/hostile & strong w/eventual dislike for client
How does someone w/ Schizoid PD present?

Defense Mechanisms?
usually enter b/c of anxiety or depression;

Clipped responses w/indifference to praise & criticism; relationships/sex are of little to no interest; emotionally cold, detached, & restricted

Defense: intellectualization, schizoid fantasy, projection
What are the psychodynamic & CBT techniques used for those w/ Schizoid PD?
Psychodynamic: From paranoid-schizoid position; respond well to therapeutic limits (time, setting, ethics) and usually present b/c of Axis: I issues; desire relationships

CBT: limited self-disclosure & social skills & assertiveness training
Schizoid PD-

Transference & Countertransference
Transference: generally appreciative & cooperative w/in therapeutic relationship

Countertransference: boredom, impatience, derision, & giving prematurely negative prognosis

SSRIs might help process
How does someone w/ Schizotypal PD present?

Defense Mechanisms?
Discomfort w/ close relationships, suspicious & guarded, constricted or inappropriate affect, odd beliefs/thoughts/speech, & eccentric appearance & Bx;

Usually present b/c of an acute stressor (possibly triggering micropsychotic episodes) or family member

Defense Mech: ideas of reference, schizoid fantasy/depersonalization, magical thinking, projective, splitting (primitive or narcissistic)
Schizotypal PD-

Transference & counter transference
Transference:detachment & withdrawal to test therapist's concern

Countertransference: counterdetachment, avoid unintentionally ridiculing!
What are the psychodynamic &CBT techniques used for those w/Schizotypal PD?
Stuck in oral stage b/c object constancy not achieved

Psychodynamic: supportive focus on "here & now" & nonjudgmental stance w/minimal attempts at interpretation

CBT: focus on increasing social appropriateness & evaluation of automatic assumptions

Group therapy & SSRIs may help
How does someone w/ Histrionic PD present?

Defense Mechanisms?
Sexually/provocative inappropriate, dramatic, superficial, paucity of detail, shallow emotions & so loquacious that closed-ended questions are necessary

Defense Mechanisms: repression, regression, dissociation, sexualization, denial
What are the Psychodynamic & Cognitive approaches to Histrionic PD?
Psychodynamic: fixated at oral & oedipal; correct perception that you know all & encourage openness; explore resistance instead of challenging

Cognitive:Set systematic agenda, look at long-term cost of impulsivity, assertiveness training, role-playing w/element of rejection

Group therapy is okay if realize help-rejecting complaints aren't useful; meds less useful
Histrionic PD:

Transference/Countertransference
Transference: reenact oedipal conflicts (adoration/competition); eroticized transference to manage anxiety (egodystonic in healthier patients)

**Only make interpretations if it turns into resistance & then use 3 way connection

Countertransference: flattery/attraction to client's interest & sexual overtures, voyeuristic enjoyment of fantasies, disgust at disclosures
What are some features you might expect to see in someone with Narcissistic PD?

Defense Mechanisms?
Male; Need to be admired, talks at you, grandiose self-importance, interpersonally exploitative, overvalues others before finding weakness, COLD anger

Defense: Splitting, projection, introjection, idealization/devaluation, identification, projective identification (help deal w/envy)
What are the types of Narcissistic PD that Robinson IDs? Describe
Type 1: Fits DSM (arrogant, oblivious, disinterest in others feelings)

Type 2: hypervigilant, thin-skinned, seemingly altruistic, self-effacing, appears to divert attention from self; almost looks like antithesis of what you'd expect; play martyr role
What do people w/NPD usually present with?

What are the psychodynamic and cognitive approaches for individuals with Narcissistic PD?
Underdeveloped superego due to overindulgent/misunderstanding parents; depression/illness threatening grandiosity

Psychodynamic: focus is on self-acceptance w/o encouraging grandiosity, non-questioning approach in order to make up for parental empathetic failures

Cognitive: systematic desensitization & emph on enjoying activities

Avoid Group Therapy
Narcissistic PD:

Transference/ Countertransference
Transference: projects own flaws onto you, envy, idealization/devaluation, little interest in reason for reactions

Countertransference: seduction, irritability, hostility, boredom
What are some of the features you might expect in a person w/Antisocial PD?

Defense Mechanisms?
prev diagnosis of conduct disorder before age 15, frequent lies, no superego, unhonored obligations, can't plan, ignores safety, aggressive, malignant grandiosity (deliberately use others)

Defenses: controlling (for primary & 2ndary gain), dissociation, projective ID, acting out
What are the Psychodynamic & Cognitive approaches to Antisocial PD?
Psychodynamic - lack meaningful attachment & exhibit primitive envy so no superego; Tx only if they show remorse, evi of compassion, 1 attachment; Tx must be direct & rigid not empathetic

Cognitive - exercises on dis/advantages of responses & impact on self & others

Bx therapy may work best
Antisocial PD-

Countertransference/Transference
Transference - projective identification, controlling

Countertransference - attempts to prove helpfulness/good intentions can lead to hostility, contempt, moral outrage, hate; fear & resignation
What Axis I disorders are each of the personality clusters associated with?
Cluster A - Schizophrenia & other psychotic, Delusional Disorders

Cluster B - substance abuse, mood disorders, somatization

Cluster C - anxiety disorders
When is ASPD activity most prevalent?
In early adulthood

Decreases over the years
How might a client with Borderline PD present?
Can present better than they really are; past rptd crises, marked deval of past relationships, therapists, & otr attempts at help; very verbal, intense affect that changes quickly

Usually come in b/c of: depression, dissociative episodes, paranoia, substance abuse,
What are the defense mechanisms associated with Borderline PD?

Which PD is it most commonly comorbid with?
Defense Mechanisms: splitting, projective identification, dissociation, denial

Comorbidity: ASPD though having a parent w/ a PD has greater impact than any Axis I pathology
When does Mahler say that development was interrupted in an individual with BPD?
Mahler - 18 months during separation-individuation & parental engendering of separation fears; thus object permanence not attained & stuck in oral stage & have identity diffusion
Borderline PD:

Transference/Countertransference
Transference:when living out unsolved struggles from early dvlpmnt; idealization/devaluation

Countertransference- breaking boundaries, wanting to terminate Tx
Which personality disorders are often found in those with ADHD, learning disorders, and neurological soft signs?
Borderline PD

Antisocial PD
What is the psychodynamic take on BPD?
Psychodynamic: consistent reinforcement of parameters of Tx; empathize w/them when splitting happens & soft interp of their use of projective identification
What is the cognitive take on BPD?
Good w/ DBT, group therapy, possibly inpatient

-modification of dichotomous thinking helps curb impulse fulfillment
How might you expect someone with Dependent PD to present?

Reason for referral?
Female, meek, seeks approval, sensitive to questions about submissiveness; subordinates self; frumpy clothes

Reason for referral: MDD, agoraphobia, panic disorder
Dependent PD

Transference/Countertransference
Transference - idealization, see you as nurturing figure

Countertransference - to push them or run for the hills
What defense mechanisms are associated with Dependent PD?

What psychosocial phase are they stuck at?
Defenses: idealization, reaction formation, projective identification, inhibition, somatization, regression

Phase: oral stage; hunger for attachment
What are the psychodynamic and cognitive approaches to Dependent PD?
Psychodynamic: model patients w/longer idealization of therapist; goal is to alter dependent Bx

Cognitive: guided discovery & Socratic questioning, hwk & an agenda

Good: group So-So: meds ONLY for Axis I
How might you expect someone with OCPD to present?

What brings them in?
Emotional constriction, pedantic/detailed, dominate interview, overly objective

Reason for referral: mid-life depression, somatoform or illness from stress,
OCPD-

Transference/Countertransference
Transference- project superego (demanding/judgmental parent), irritability, oppositional, see therapist as having high expectations

Countertransference - boredom at intellectualization; temptation to badger/ridicule their affective restriction
What defense mechanisms are associated w/OCPD?

What psychosocial phase are they stuck at?
Defenses: isolation, intellectualization, moralization, rationalization, undoing, reaction formation, displacement

Phase: anal
What are the psychodynamic & cognitive approaches to OCPD?
Psychodynamic
-Tx must be accepting & emph feelings to limit intellectualization
- show reaction formation in the last thing they say
- goal is to alter superego/ease shame

Cognitive- explore/alter assumptions

Good: group therapy; Not: meds
How might you expect someone with Avoidant PD to present?

What usually leads them to seek treatment?
M=F; underemployed, hyperalert to disapproval; open if see guarantee of acceptance; anxious

Seek Tx due to: anxiety disorder, substance abuse

(overlap w/ DPD, social phobia, panic disorder w/agoraphobia; brain injury a common trigger)
What defense mechanisms are associated w/Avoidant PD?
Defenses: repression, inhibition, isolation, displacement, projection, avoidance
What are the psychodynamic and cognitive approaches to Avoidant PD?
Psychodynamic: supportive-expressive approach

Cognitive: CBT is good here; focus on avoidant process using Socratic questioning to reduce dysphoria

Bx: exposure therapy, role playing, relaxation training, assertiveness training

Good: group, SSRIs, MAOIs, TCAs
Avoidant PD

Transference/Countertransference
Transference: magical help, pleasers, avoid confrontation, seek acceptance

Countertransference: collusion w/guarantee of acceptance patient seeks & fear of hurting/offending
What are the 2 types of avoidant personalities that Robinson describes?
Type A: constitutionally overanxious; more likely to have had a normal attachment history; benefit from Bx interventions, social skills training, & exposure Tx

Type B: Narcissistically vulnerable; more likely to come from intolerant or shaming parents w/neg attachmnt experience; Rx trad psychotherapy; Similar to hypervigilant/thin-skinned Type 2 NPD