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Personality Disorders

Persons with paranoid personality disorder are hypersensitive. They expect trickery and disloyalty from other people. And then they try to avoid all surprises by anticipating them. In an interview people will be intense and guarded and overly serious. They have difficulty expressing warm emotions and tolerating feeling anything that is being dependent on another person. Including feelings of being dependent on the clinician. They are keenly aware of power and rank. They will often seize upon irrelevant details to confirm suspicions. And what happens is that they paranoid people generally do not see the forest for the trees. They will do this about their treatment as well as other aspects of their life. They have very poor judgment in matters relating to their specific fears. Often their judgment is not so impaired in other areas and so can be quite misleading. Itís often only when you get the paranoid person to talk about his or her fears you begin to see the disordered thinking and paranoid personality disorder, parnoid personality disorder, paranoia 

DSM IV talks about a pervasive and unwarranted tendency to interpret the actions of other people as deliberately demeaning or threatening, and so you can see that you need four out of the seven criteria - you expect to be exploited or harmed being able to bear grudges. Quite a few people who are violent towards spouses in particular, fulfill the criteria for paranoid personality disorder.

The etiology of the paranoid personality disorder is unknown. Some psychoanalytic theorists have suggested that people who would be objects of irrational and unpredictable parental rage may adopt paranoia as a realistic stance in childhood but then be unable to modify that stance in adulthood. The incidence of paranoid personality disorder is unknown because many of these people never present for treatment. The diagnosis is made more frequently in men than in women, and it is more frequently made in biological relatives of

Treatment. It is important initially to be as open and straightforward as you can in your dealings with paranoid individuals. Use humor quite sparingly because it is so easily misunderstood. It is important to maintain a very professional manner, not to be overly warm, because this can exacerbate someoneís paranoid fears about

Schizoid personality. Schizoid individuals are socially withdrawn, introverted, eccentric. When schizophrenic individuals have chronically disoriented thinking and schizoid individuals do not. The hallmark of schizoid personality is the avoidance of human contact. Schizoid people structure their lives in order to avoid human contact. They become quite involved in their own private fantasy world, often to the exclusion of life around them. I donít know if any of you are familiar with the

Schizotypal individuals have oddities of perception and communication and usually poor work histories. People often say you can tell a schizotypal walking down the street from across the street because they are just odd. Schizoid individuals often just look quiet and

Treatment. Individual psychotherapy is quite difficult. But for most schizoid individuals who do present for therapy, as they begin to trust the therapist they also begin to share their fantasy lives, which can be quite vivid. Group psychotherapy has not been useful for schizoid individuals. There is no specific role for medication that has

Schizotypal personality disorder. This is similar to schizoid personality with the additional features of strange or eccentric looking, having oddities of perception and communication, odd word usages. Schizotypal personality disorder is the one personality disorder that we know to be genetically linked to schizophrenia. In fact it was created out of the Danish adoption studies found a group of people with this symptom cluster who were much more heavily concentrated in the biological relatives of schizophrenics. These are people who have milder forms of psychotic-like symptoms, derealization, ideas of reference, perceptual illusions. Many of them will feel that they have special powers. Thereís the woman with the crystal ball. In an interview, schizotypal people will be withdrawn like schizoid individuals, but their speech

Differential diagnosis. You want to think about schizoid personality disorder; schizoid individuals donít show the oddities of speech and perception and the quasi-psychotic-like symptoms. The schizotypals are not frankly psychotic in the way that schizophrenic individuals are. Borderline personality disorder surprisingly

Histrionic personality disorder is the grandchild of the diagnosis of hysteria. Hysterical people are typically imaginative, often with well-developed emotional intuition. They tend to look at the world in over impressionistic terms rather than focusing on details, so they tend to be headline readers. They gravitate toward activities that donít necessarily involve concentration for long hours on facts and details, but they are often very creative and colorful. Histrionic personality disorder is really hysteria run amok. Itís hysterical personality traits carried to an extreme that is maladaptive. Histrionic individuals can be quite colorful and outgoing. They are

In terms of treatment, insight-oriented psychotherapy seems to be the treatment of choice for histrionic individuals. Both individual and group therapy have been found to be useful. Essentially the therapist works on helping histrionic individuals clarify what they genuinely feel, clarify ways in which they lose functioning, in

Narcissistic personality disorder. Narcissus was by legend a beautiful Grecian youth who fell madly in love with his own reflection when he happened to see it reflected in a pool one day. Narcissism refers to self-love, and loving self regard is something that is both desirable and necessary in ones inner world. It is only when the absorption of the self impairs oneís ability to form lasting relationships do we call it pathological. And crippling self-doubt and insecurity that is involved in

Treatment of narcissistic personality disorder. Individual and group psychotherapies are the treatments of choice. Usually psychodynamic in orientation. Cohat sees narcissism as a developmental defect that results from inadequate parenting. So for Cohat the therapists job is to encourage people to reveal their untamed grandiose self, to really reveal all their grandiose fantasies and to allow an idealized view of the therapist because someone needs to have those views of self and the therapist for a long time, and then gradually weather the disappointments that come inevitably when the therapist fails the patient. So interpretations for "Cohatians" will be that

The treatment is fraught with difficulties because of this vacillation between idealizing others and devaluing others. And the bouts of rage that ensue when the therapist is seen as disappointing. So the aim of therapy is to provide a consistent, caring relationship and help people develop more realistic concepts of self. There have been

Antisocial personality disorder. The most salient diagnostic feature of antisocial personality disorder is a repeated violation of the rights of other people and the normal society. You may also put it in more formal terms, sociopaths is used to describe these people and psychopath is also used at times. People with this disorder are not usually patients. They are more often found in courts and prisons and welfare offices, sometimes in government. Usually if people do come to mental health

Antisocial people look unreachable and untreatable, and as I said, when their behavior is rigidly contained many of them will respond to interpersonal therapies but they are extremely sensitive to criticism and rejection. Peer support is often very effective in helping antisocial people understand more about their denial of their own destructive behavior. One of the things that we are all tempted to do is to rescue charming sociopaths from the consequences of their behavior and this is absolutely contraindicated. So one of the things that is an absolute condition of any treatment in any evaluation, even in the emergency room, is that the antisocial individual is responsible for whatever they have done and that your job is not to help to mitigate the consequences. That has been no clear role for psychotropic medication in antisocial personality disorder but these people often abuse medication, including benzodiazepines.

Borderline personality disorder is characterized by a pattern of intense, unstable, interpersonal relationships. This intensity and instability is one of the hallmarks of the disorder and one of the most discriminating features. Borderline individuals often have intense and persistent anger. They can be quite ragefull and demanding and they struggle with intense dependent longings and also hostility toward the people on whom they are dependent. So actually there was a book a few years ago about borderline personality disorder and the title was, "I Hate You. Donít Leave Me".

Borderline personality disorder individuals are very adept at blackmailing other people to do their bidding and many of you are quite familiar with this; the patient who is about to leave at the end of a Friday afternoon session and puts a hand on the doorknob and says, "Oh, by the way. I have a stash of pills and I think Iíll probably kill myself so I wonít see you next week." Many borderline individuals are overwhelmed by anger and frustration. They have low frustration tolerance. And often it is the

Treatment then must involve treatment of affective disorders as well as treatment of the borderline disorder so that one cannot simply treat the symptoms of borderline personality without addressing affective disorders. Also, when we treat the affective disorder someone will often look much less dysfunctional in terms of their personality functioning. This is easier now that the antidepressants that we have are not so easy to overdose on. Using the SSRIís is much more reassuring to the

Avoidant personality disorder is extreme sensitivity to rejection. So people with this sensitivity stay away from relationships, not because they donít want relationships but because they are so frightened of rejection when they get into them. Usually they will only enter into relationships when they are guaranteed of uncritical acceptance. Avoidant people usually lack self confidence. They attempt to bolster their self confidence by seeking unusually supportive companions. They

In terms of treatment, psychotherapy is the treatment of choice but itís quite difficult because people are so sensitive to rejection. But therapy can help people ease the harshness of their own self-criticism and see the ways that they project their self-criticism onto other people and they then expect their relationships to be fraught with pain. Cognitive therapy can be useful in helping people to uncover these underlying false assumptions about themselves and the world. Group therapy can demonstrate

Dependent personality disorder is essentially again one of those disorders that some people would argue is simply a trait. But people with dependent personality disorder structure their lives so that other people will take responsibility for their welfare. So they will try not to function on their own but to seek out bosses, lovers, and friends who will tell them what to do and allow them to be passive. They avoid making decisions, including intimacy, socially, what job to take, even what to wear.

In terms of differential diagnosis, dependent traits are quite common in a variety of the other personality disorders; borderline, histrionic, avoidance, passive-aggressive and schizoid. It is not difficult to distinguish self-defeating personality disorder from dependent personality disorder because self-defeating doesnít exist anymore, but passive-aggressive traits can sometimes be confused with dependent traits. The goal of the passive-aggressive behavior is quite different. Itís often to express hostility thatís unacknowledged whereas in dependent behaviors the goal is to abdicate responsibility and ask someone to take responsibility. Agoraphobia may be mistaken for dependent personality disorder, but the agoraphobic is much more active in demanding that other people take responsibility. The agoraphobic says, "I canít drive to work, you have to drive me to work because I canít be alone. I canít go shopping in the super market alone." The dependent person canít do things because of a perceived sense of inadequacy. The agoraphobic canít do things because of an overwhelming fear of anxiety and panic. In some areas therapy can be quite helpful to dependent people, in terms of helping them examine the effects of their dependency and passivity on others as well as on themselves. Itís important that the therapist respect the patientís need for dependent relationships early on and not try to disrupt them, because this can lead to a abrupt decompensation. Group therapy, assertiveness training, cognitive therapy can all help address these problems of abrogation of responsibility, of self assertion and low self-esteem.

Obsessive-compulsive personality disorder. Certainly the terms obsessive and compulsive are used on a variety of ambiguous ways in psychiatry. They are often used to describe the classic preoccupation with unwanted thoughts and compulsive behaviors. They are used to describe a personality style and they are used to describe a specific personality disorder. Obsessive-compulsive personality disorder is not obsessive-compulsive disorder. It does not involve as exclusive, intrusive, unwanted thoughts and compulsive behaviors. Thatís not what we are talking about. They are disorders of a very different character and how you treat them of course is very different. So in fact the fact that they have such very similar names is

In terms of the differential diagnosis, Iíve already said itís important to differentiate this from obsessive-compulsive disorder, basically by unwanted thoughts and compulsive behaviors. Obsessive-individuals may show features of other personality disorders, particularly schizoid and paranoid personality. Psychotherapy is basically the treatment of choice. There is little role for medication except for symptom relief for depression or anxiety. Often these people will seek psychotherapy on their own. Psychotherapy is long and slow. When Elizabeth Zetzel, who is a famous psychoanalyst from the first generation in this country, was asked how obsessional people get better in therapy.

The next category is personality disorder, not otherwise specified. Of course we have no idea what that is. Itís a wastebasket very often used for people with interpersonal dysfunction that we canít characterize and here we have a therapist writing in his notebook, "Just plain nuts."

Let me just say briefly some final thoughts on treatment. First of all, there are just a few principles Iím going to list. One is; itís important to focus on personís behavior and not on his or her explanations of the behavior. So the doctor is saying to this patient, "Running away from your problems does not count as exercise." Itís very important to focus on behavior and not listen to excuses, for most of these people. Other recommendations include maintaining a collaborative stance with people with personality disorder. They try to move you out of that stance into being someone to fight with, who takes care of them, who seduces them. There are a variety of things and itís very difficult to maintain your stance as an expert and as a collaborator. Pay close attention to your own rescue fantasies because many of these people